Mira Vista Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Mount Vernon, Washington.
- Location
- 300 South 18th Street, Mount Vernon, Washington 98274
- CMS Provider Number
- 505315
- Inspections on file
- 44
- Latest survey
- March 11, 2026
- Citations (last 12 mo.)
- 25
Citation history
Health deficiencies cited at Mira Vista Care Center during CMS and state inspections, most recent first.
A resident experienced an acute neurological change with symptoms such as facial droop, slurred speech, arm weakness, and visual problems, but staff did not immediately notify the responsible party and did not document timely follow-up with the physician as previously instructed. Facility policy required prompt physician contact based on urgency and notification of the resident representative for changes in condition, yet progress notes lacked evidence that either emergency contact was informed when the change was first identified, and there was no documentation that the physician was called back within the specified timeframe. The resident was later transferred to a hospital, where an acute stroke was confirmed, and staff interviews acknowledged that such symptoms constituted a critical situation requiring concurrent physician and family notification.
Deficiencies were found in infection control practices, including improper PPE use and inadequate signage for residents on transmission-based precautions. Staff entered rooms of residents with infectious conditions, such as C. difficile, norovirus, ESBL, and those with PEG tubes, without donning required PPE or following organism-specific hand hygiene protocols. Observations and staff interviews revealed inconsistent understanding and implementation of facility policies and posted instructions.
Two residents prescribed antidepressant medications did not receive required monitoring for target behaviors, side effects, or depressive symptoms. One resident experienced a serious medication side effect and was started on a new antidepressant without appropriate monitoring or care plan updates. Staff confirmed that monitoring measures and non-pharmacological interventions were not implemented for either resident.
The facility did not consistently follow physician orders for medication administration, including required blood pressure and heart rate checks, resulting in multiple instances where medications were given outside of prescribed parameters or without proper documentation. Staff interviews confirmed expectations for monitoring and documentation, but records showed repeated omissions and lack of routine auditing, affecting several residents with heart failure and hypertension.
Dietary staff did not follow required hand hygiene protocols when changing gloves and failed to wear beard nets as required by facility policy, resulting in unsanitary food preparation conditions.
Surveyors found that two residents' medical records were incomplete and not systematically organized. One resident's chart lacked required documentation for a significant change PASSR evaluation, and another resident's care plan conference note was missing key interdisciplinary team input and essential care plan elements, including hospice services. Staff interviews confirmed delays and gaps in documentation.
A resident reported being left alone in a wheelchair for six hours, but the incident was not identified or reported as abuse or neglect, nor was it investigated according to policy. Additionally, a staff member had not completed required annual abuse and neglect training, indicating lapses in both grievance handling and staff education.
A resident with multiple health conditions reported being left alone in a wheelchair for six hours, resulting in soreness. Although the grievance was documented and addressed by an LPN and marked as resolved by the Administrator, there was no evidence of a formal investigation into the allegation of abuse or neglect, as required by facility policy. Staff interviews confirmed that such an incident should have been investigated, but no documentation of an investigation was found.
A resident with a history of antibiotic-resistant UTI and DVT was not scheduled for a recommended cystoscopy and infectious disease consult, leading to ongoing discomfort. The deficiency was due to miscommunication and lack of a formal scheduling policy, with staff unaware of the need for appointments until informed by a nurse practitioner.
The facility's policy failed to address safe storage of foods brought in by visitors, prohibiting personal refrigeration units in resident rooms and not allowing outside food in facility storage. This led to residents being unable to store uneaten perishable items, impacting their quality of life.
The facility failed to ensure a clean, comfortable, and homelike environment, with observations revealing stained carpets, broken blinds, damaged walls, and dirty floors across all units. The administrator acknowledged the poor condition and mentioned ongoing repairs but lacked specific plans for addressing these issues. This was a repeat deficiency from a previous survey.
The facility failed to maintain food safety standards, with a broken refrigerator seal, moldy pickles, and improper temperatures in storage units. The kitchen had cobwebs, debris, and spills, while the freezer had ice buildup and unidentified food. Staff acknowledged cleaning issues and unlogged maintenance needs, risking food contamination.
A resident with a history of stroke and vascular disease sustained a sunburn during an outing due to the facility's failure to identify sun exposure risks and provide adequate supervision. The resident's care plan lacked sunblock use guidelines, and staff did not offer sunblock, despite its availability. The facility also lacked a policy on sunburn prevention, and staff interviews were not conducted following the incident.
The facility failed to honor food preferences for two residents, impacting their quality of life. One resident was unable to store personal food items due to facility policy, while another resident's dietary preferences were not documented or considered, leading to dissatisfaction with the facility's food offerings.
The facility failed to assist two residents in formulating Advance Directives (AD), risking their right to have medical treatment preferences honored. One resident had an incomplete Durable Power of Attorney (DPOA) document, while another expressed interest in an AD and DPOA but received no follow-up. Staff were unaware of these deficiencies, contributing to the issue.
The facility failed to provide adequate assistance with ADLs for three residents, leading to unmet care needs. A resident with multiple medical conditions struggled to eat independently due to lack of adaptive equipment and staff assistance. Another resident with cancer and COPD was unable to reach their meal tray, and a third resident did not receive consistent oral hygiene care. Staff interviews revealed a lack of awareness and compliance with care plans, highlighting systemic issues in care provision.
Facility staff failed to follow infection control practices for two residents with urinary catheters. A resident's catheter bag was emptied without cleansing the spout, and hand hygiene was not performed between glove changes. Another resident's catheter tubing was observed dragging on the ground multiple times, despite care plan instructions to secure it. These actions increased the risk of infection.
A resident reported missing personal property, including cash, after being admitted to the hospital. Despite attempts to retrieve their belongings, the facility did not log any grievances, and staff interviews revealed a lack of communication and follow-up. Eventually, some items were found, but the cash was not mentioned, highlighting the facility's failure to address the grievance timely.
A resident was discharged to a hospital and denied re-admission to the facility without receiving a written transfer discharge notice or being informed of their appeal rights. The facility also failed to notify the State Long-Term Care Ombudsman. Staff cited drug use and disruptive behavior as reasons for non-readmission, while the resident was left without support in a distant facility.
A facility failed to provide a written bed hold notice to a resident or their representative upon transfer to a hospital, as required by policy. The resident's medical records lacked documentation of the notice, and interviews with staff revealed confusion about who was responsible for providing it. The resident confirmed not receiving any information about a bed hold.
A facility failed to follow physician orders for a hospice referral for a resident with multiple health issues, including chronic respiratory failure and a history of cancer. Despite a referral being made by an ARNP, it was not acted upon by social services, leaving the resident without requested hospice support. Interviews revealed a breakdown in the facility's process for handling hospice referrals.
Failure to Immediately Notify Physician and Family of Acute Neurological Change
Penalty
Summary
The deficiency involves the facility’s failure to immediately notify the resident’s responsible party and to update the physician timely when there was a significant change in condition for one resident who was later hospitalized with an acute stroke. The facility’s policy on change in condition, revised in April 2025, required the nurse to use clinical judgment to contact the physician based on urgency and to notify the resident representative of the change. The resident’s face sheet listed two emergency contacts. A progress note documented that at 5:30 AM on 01/04/2026 a change in condition was identified, the on‑call physician was notified, and instructions were given to monitor the resident and call back if the condition did not clear or worsened within 30 minutes. There was no documentation that the responsible party was notified at that time, nor that the physician was called back within 30 minutes as instructed. Later documentation on the same date at 10:11 AM by an RN showed the resident had acute neurological changes, including facial droop, slurred speech, left arm flaccidity, and visual problems. The note indicated the spouse arrived at 8:00 AM and was notified of the change in condition, and that the physician was notified that the family was declining transfer to the hospital, but it did not document immediate notification of either responsible party when the change was first identified. The note also recorded that the second emergency contact arrived at 9:00 AM and agreed to hospital transfer. An emergency room note from a local hospital at 9:40 AM confirmed an acute stroke. A CNA reported observing the resident at 6:00 AM with leaning to one side and inability to focus gaze and stated they summoned the RN, who assessed the resident at 6:10 AM. In interviews, the RN acknowledged that new onset arm weakness and visual problems would be a critical situation warranting physician and family notification and could not recall why the family was not called, while the Assistant DON confirmed that acute neurological changes should be a priority and that documentation did not show immediate family notification or that the physician was contacted again within 30 minutes as previously directed. The survey cited WAC 388-97-0320(1)(b-d).
Deficient Infection Control Practices and PPE Compliance
Penalty
Summary
Multiple deficiencies were identified in the facility's infection prevention and control practices, specifically related to the use of personal protective equipment (PPE) and appropriate signage for residents requiring transmission-based precautions. For a resident with recent norovirus and Clostridium difficile infections, the posted contact precautions signage did not specify the need for soap and water hand hygiene, which is required for enteric organisms. Staff interviews confirmed that signage should have included these organism-specific instructions, and observations revealed that contract staff entered the resident's room without donning PPE, stating they had not noticed the sign. Another resident with a newly placed PEG tube was ordered to be on Enhanced Barrier Precautions (EBP), but no EBP signage was displayed on the door during multiple observations. Staff were observed providing high-contact care, such as administering medication via the PEG tube, without donning appropriate PPE. Staff interviews confirmed that EBP should have been implemented upon the resident's admission, but this was not consistently followed. A third resident, readmitted with an ESBL-resistant infection, had contact enteric precautions signage posted, instructing staff to gown and glove upon room entry. However, staff were observed entering the room and handling items such as lunch trays without wearing PPE, stating they believed PPE was only necessary when providing direct care. Interviews with staff revealed a lack of understanding regarding the requirement to don PPE upon room entry, as indicated by the posted signage and facility policy.
Failure to Monitor Psychotropic Medication Use and Side Effects
Penalty
Summary
The facility failed to ensure that two residents received appropriate medication-specific monitoring for psychotropic medications, specifically antidepressants. One resident, with a history of depression and anxiety, was admitted and subsequently hospitalized after experiencing a side effect from their antidepressant medication, resulting in Syndrome of Inappropriate Antidiuretic Hormone (SIADH) and low sodium levels. Despite the resident's history and diagnosis, there was no depression symptom monitoring in place upon admission, and after a new antidepressant was started, there was no implementation of target behavior monitoring, side effect monitoring, or updates to the care plan. The resident had also initially denied depression symptoms but later disclosed ongoing depression, which was confirmed by a standardized screening tool, yet no monitoring was initiated following this disclosure. Another newly admitted resident with a diagnosis of depression was prescribed two different antidepressant medications without any associated behavior monitors, medication side effect monitors, or non-pharmacological interventions. Staff interviews confirmed that these monitoring measures were not in place for this resident. The lack of monitoring and care plan updates for both residents was acknowledged by facility staff, who stated that these components had been missed.
Failure to Adhere to Medication Administration Parameters and Documentation Standards
Penalty
Summary
The facility failed to follow professional standards of practice in medication administration for three residents with diagnoses including congestive heart failure (CHF) and hypertension (HTN). For one resident, there was no documentation that blood pressure (BP) or heart rate (HR) were monitored prior to administering eight of eleven doses of Carvedilol, despite physician orders requiring these checks. Staff interviews confirmed that vital signs should be checked and documented before administering medications with parameters, but records showed missing documentation for multiple doses. Another resident received Carvedilol and Hydralazine outside of the physician-ordered parameters on several occasions, with missing documentation of HR for five of nine doses and administration of medications when vital signs were outside the specified limits. Staff acknowledged the expectation to document and review vital signs before medication administration, but also stated that there was no routine audit for medications given outside parameters, and errors were only addressed if discovered incidentally. A third resident was administered Metoprolol and Midodrine outside of the established parameters, as evidenced by the medication administration record (MAR) showing doses given when systolic blood pressure was below or above the ordered thresholds. Staff confirmed that medications had been administered outside of parameters but were unable to fully review all relevant dates due to difficulties navigating the electronic record system. These failures to adhere to physician orders and document required assessments led to the identified deficiencies.
Failure to Ensure Sanitary Food Preparation and Staff Hygiene
Penalty
Summary
Facility staff failed to adhere to safe and sanitary food preparation practices in the kitchen, as observed during meal tray assembly. Specifically, two dietary staff members with beards were not wearing beard nets, contrary to the facility's dress policy requiring hair and beards to be effectively restrained with appropriate hair restraints, including beard nets. Staff N, the Dietary Supervisor, stated that beard nets were not necessary if beards were trimmed short, despite both staff members having facial hair. Additionally, multiple instances were observed where Staff N did not perform proper hand hygiene when changing gloves. Staff N was seen putting on gloves without washing hands prior to food preparation, removing gloves without washing hands, and repeatedly donning new gloves without handwashing in between tasks. In interviews, Staff N acknowledged the facility's process required handwashing before applying new gloves and when changing tasks, but did not follow these procedures during the observed meal preparation activities.
Incomplete and Disorganized Medical Record Documentation
Penalty
Summary
The facility failed to maintain complete, accurate, and systematically organized medical records for two residents. For one resident with a history of depression and anxiety, the electronic chart contained two Preadmission Screening and Resident Reviews (PASSR). The second PASSR indicated an evaluation was required for a significant change, but there was no documentation of such an evaluation in the resident's chart or in the progress notes. Staff interviews revealed uncertainty about the follow-up on the PASSR, and no notes were found regarding the required evaluation. For another resident admitted with hospice enrollment, the care plan documentation was incomplete. The care plan conference note indicated only social services attended, and key elements such as disease diagnosis, health and skin conditions, special treatments, medication reconciliation, and various care plans were left blank. There was also no documentation regarding hospice care services. Staff interviews confirmed that the care conference documentation was not completed in a timely manner, with the responsible staff still working on it ten days after the conference.
Failure to Identify and Report Abuse Allegation; Lapse in Staff Training
Penalty
Summary
The facility failed to identify and respond appropriately to a grievance that constituted an allegation of abuse or neglect for one resident. Specifically, a resident with diagnoses including orthostatic hypotension, cellulitis, dementia, and malnutrition reported being left alone in a transport wheelchair for six hours, resulting in significant discomfort. The grievance, documented by the facility, indicated the resident was left unattended from 1:00 PM to 7:00 PM. Despite this report, the incident was not escalated as an allegation of abuse or neglect, nor was it reported to the state agency or investigated as required by facility policy and regulatory standards. Interviews with staff revealed uncertainty about the process for handling such grievances, with some staff indicating they would notify a nurse or administrator, but no clear action was taken to treat the report as a potential abuse or neglect case. Additionally, the facility failed to ensure that all staff received annual abuse and neglect training as required. Review of training records showed that one staff member had not completed the required training within the past 12 months. Staff interviews confirmed that annual training was expected, but there was a lack of clarity regarding the last training dates. These failures in both grievance handling and staff training placed residents at risk for abuse, neglect, and associated harm.
Failure to Investigate Alleged Abuse/Neglect Following Resident Grievance
Penalty
Summary
The facility failed to conduct a thorough investigation into an allegation of abuse or neglect for a resident who reported being left alone in a wheelchair for six hours, resulting in extreme soreness. The resident, who had diagnoses including orthostatic hypotension, cellulitis of the left leg, dementia, malnutrition, and required assistance with personal care, filed a grievance stating they were left unattended from 1:00 PM to 7:00 PM. The grievance was documented and addressed by a Licensed Practical Nurse and marked as resolved by the Administrator, but there was no evidence of a formal investigation into the allegation as required by facility policy. Record review showed no documentation in the resident's progress notes regarding the grievance or any investigation on the relevant dates. Interviews with facility staff confirmed that such a report should have been escalated and investigated as a potential abuse or neglect case. Despite requests for further documentation, no additional information was provided to demonstrate that an investigation took place, indicating a failure to follow the facility's abuse prevention and investigation policy.
Failure to Schedule Recommended Medical Appointments
Penalty
Summary
The facility failed to coordinate and schedule necessary medical appointments and procedures for a resident who was readmitted after hospitalization for antibiotic-resistant urinary tract infection and deep venous thrombosis in both legs. The resident's Urology After Visit Summary recommended a cystoscopy evaluation and a referral to an infectious disease provider, but these were not scheduled 39 days after the recommendation. The resident continued to experience discomfort, as noted by ongoing complaints of burning when urinating. The deficiency was attributed to a lack of coordination and communication among staff. Staff B, an LPN/Supervisor, stated that scheduling was part of Staff C's duties, but the after-visit summary was misplaced, and Staff C was unaware of the need for scheduling until informed by a nurse practitioner. Despite attempts by the urology clinic to contact Staff C, no communication was received due to a change in phone. The facility lacked a formal policy for scheduling follow-up appointments, contributing to the oversight.
Deficiency in Policy for Storing Outside Food
Penalty
Summary
The facility failed to ensure their policy regarding foods brought in from outside sources included provisions for safe storage and clear distinction from facility food. The policy, titled 'Resident/Personal Food Storage' and dated July 2024, allowed residents to receive food from visitors but prohibited personal refrigeration units in resident rooms due to electrical load concerns. Additionally, the policy did not permit the storage of outside food in facility pantries or refrigeration units, requiring that any perishable food not consumed on the day of opening be discarded. During an interview, the Administrator confirmed that residents were not allowed to store outside food in facility refrigerators and were required to dispose of uneaten perishable items, as personal refrigerators were not an option. This policy placed residents at risk of decreased quality of life by limiting their ability to have food items of their choice safely stored in the facility.
Facility Fails to Maintain Clean and Homelike Environment
Penalty
Summary
The facility failed to maintain a clean, comfortable, and homelike environment across all three units observed, as evidenced by stained carpets, broken blinds, damaged walls, and dirty floors. Observations on specific dates revealed dirty and sticky floors in resident rooms, scattered wrappers, and dirty paper towels. Additionally, the facility's hallways had missing baseboards, carpet seams pulling apart, and various dark stains on the carpets, including large stains near specific rooms. The wainscot in one hallway was marked with drip-like staining and scraped areas, and there were rips in the carpet in another hallway. Further observations noted broken blinds in several rooms, with some slats completely missing. Walls in certain rooms had large gouged areas and exposed sheetrock. During an interview, the facility's administrator acknowledged the poor condition of the carpets and mentioned that bids for new flooring had been obtained, but no replacement timeline was scheduled. The administrator also stated that repairs and housekeeping were ongoing but did not provide specific plans to address the other issues. This deficiency was a repeat from a previous survey conducted in July 2023.
Food Safety and Storage Deficiencies
Penalty
Summary
The facility failed to ensure that resident meals were prepared and stored in accordance with professional standards of food safety. During observations, the walk-in refrigerator was found with a broken door seal and a temperature of 45 degrees Fahrenheit, while the temperature log inaccurately recorded it as 38 degrees Fahrenheit. An opened and undated bucket of pickles with mold was found inside the refrigerator. The walk-in freezer had a three-inch layer of ice on the door and contained unidentified food with unclear dating. The freezer temperature was 9 degrees Fahrenheit. The kitchen preparation area was observed with cobwebs, debris, and black particles, and the flooring had black markings and discoloration. The unit refrigerator also had a temperature of 45 degrees Fahrenheit, with sticky spills and debris inside. Interviews with staff revealed that the kitchen was cleaned daily, but deep cleaning occurred only every six months. The Dietary Manager acknowledged the mold on the pickle bucket and the broken refrigerator seal, which had been reported to maintenance but not logged. The Maintenance Staff confirmed the broken seal and ice buildup, noting that the repair was not logged. The Administrator stated that the refrigerator seal was broken by a delivery person and was awaiting replacement. These deficiencies left residents at risk for food contamination and foodborne illnesses.
Failure to Prevent Sunburn During Resident Outing
Penalty
Summary
The facility failed to identify the risk of sun exposure and provide adequate supervision and interventions to prevent a sunburn for a resident who was cognitively intact but required assistance with dressing and had impaired range of motion. The resident, who had a history of stroke, high blood pressure, and peripheral vascular disease, sustained a first-degree sunburn on their forehead and arms during an outing. The resident's care plan did not address sunblock use or sunburn prevention prior to the incident, and the facility lacked a policy related to sunblock use or sunburn prevention. The Medication Administration Record (MAR) indicated that sunblock was only available from the 15th of each month, and the resident was not offered sunblock during the outing. Staff interviews revealed that the resident was not aware of the availability of sunblock, and there was no documentation of staff offering sunblock. The facility's incident report did not include interviews with staff who worked during the weekend of the incident, and there was no evidence of staff education on offering sunblock to residents. The Director of Nursing Services was unable to determine why the sunblock order was revised after the incident.
Failure to Honor Resident Food Preferences
Penalty
Summary
The facility failed to honor and facilitate resident preferences for food storage and dietary choices, impacting two residents. Resident 43, who has been at the facility since 2021 and is cognitively intact, expressed frustration over the inability to store personal food items, such as salad dressing, in the facility's refrigerators. The facility's policy prohibits residents from storing personal food in facility refrigerators or having personal refrigeration units in their rooms, leading to the disposal of Resident 43's perishable items. This policy was confirmed by the facility's administrator, who stated that residents must consume perishable items immediately or dispose of them, as the facility does not allow storage of outside food items. Resident 28, admitted with conditions including high blood pressure and a broken leg, reported dissatisfaction with the facility's food, describing it as bland and lacking flavor. The resident stated they had not been interviewed about their food preferences since admission, and their electronic medical record lacked documentation of their dietary likes or dislikes. The dietary supervisor admitted to not having met with Resident 28 to discuss their preferences, despite the facility's protocol to do so within 72 hours of admission. This oversight resulted in Resident 28 not having their dietary preferences considered, as evidenced by an inaccurate menu without meal choices.
Failure to Assist Residents in Formulating Advance Directives
Penalty
Summary
The facility failed to obtain and/or offer assistance to residents and/or their representatives to formulate Advance Directives (AD) for two residents, which placed them at risk of losing their right to have their stated preferences and decisions honored regarding medical treatment and end-of-life care. Resident 26 was admitted with diagnoses including stroke, high blood pressure, and peripheral vascular disease. The facility had a one-page Durable Power of Attorney (DPOA) document for Resident 26 that lacked a date and signature. Staff involved in the admission process were not aware of the incomplete documentation, as the admission occurred before their employment. Resident 28, admitted with high blood pressure, atrial fibrillation, and a broken right leg, signed an Advanced Directive receipt indicating interest in formulating an AD. However, there was no documentation in the medical record regarding the formulation, coordination, or execution of an AD. Social Services staff acknowledged that Resident 28 expressed interest in an AD and a DPOA but had not followed up to develop these documents. This lack of follow-up contributed to the deficiency noted in the report.
Failure to Provide Adequate ADL Assistance
Penalty
Summary
The facility failed to provide adequate assistance with activities of daily living (ADL) for three residents, leading to unmet care needs and diminished quality of life. Resident 11, who has multiple medical conditions including Multiple Sclerosis and hemiplegia, was observed struggling to eat independently due to limited range of motion and lack of adaptive equipment. Despite the care plan indicating the need for one-person assistance during meals, staff did not provide the necessary help, leaving the resident to attempt eating without success. Additionally, Resident 11 reported not receiving regular showers or being turned in bed as required, which was corroborated by staff interviews. Resident 33, diagnosed with lung cancer, leukemia, and COPD, also experienced neglect in meal assistance. Observations showed that their lunch tray was out of reach, and they were unable to consume their meal without help. Despite the care plan indicating the need for setup assistance, staff failed to provide the necessary support, leaving the resident dependent on their roommate to voice their need for help. Staff interviews revealed a lack of awareness regarding the residents' needs for meal assistance, highlighting a systemic issue in the facility's care provision. Resident 28, with a history of high blood pressure and a broken leg, was found to have inadequate oral hygiene care. Despite being able to brush their teeth independently when sitting up, observations indicated that their hygiene products were not within reach and showed no signs of recent use. Staff interviews confirmed that oral care was not consistently offered or provided, contradicting the care plan's directives. This deficiency was noted as a repeat issue from the previous year, indicating ongoing non-compliance with care standards.
Infection Control Deficiencies in Catheter Care
Penalty
Summary
Facility staff failed to adhere to proper infection control practices during catheter care for two residents. Resident 222, who was admitted with Parkinson's disease, urinary retention, and a history of falls, was observed having their catheter bag emptied by a nursing technician without the spout being cleansed before or after the procedure. Additionally, the staff member did not perform hand hygiene between changing gloves. This oversight was acknowledged by the staff member, who admitted that an alcohol wipe should have been used to cleanse the spout. Resident 43, who has a long-term urinary catheter due to neurogenic bladder, was observed multiple times with their catheter tubing unsecured and dragging on the ground. This occurred both outside the facility and within the facility, as the resident self-propelled in their wheelchair. The care plan for Resident 43 included an intervention to secure the catheter to prevent kinking and accidental removal, but this was not followed, leading to the tubing dragging on various surfaces, which poses a risk for infection.
Failure to Resolve Resident Grievance on Missing Personal Property
Penalty
Summary
The facility failed to resolve grievances related to missing personal property for a resident who was cognitively intact and had been admitted to the facility. The resident's inventory of personal effects included items such as a belt, cash, a hat, a necklace, a suitcase, shoes, and a knee brace. After being admitted to the hospital, the resident reported missing property, including cash and other personal items, to the State Hot Line. Despite the resident's attempts to retrieve their belongings, the facility did not log any grievances regarding the missing items in their grievance logs for May, June, and early July. Interviews with facility staff revealed a lack of communication and follow-up regarding the resident's missing items. The Interim Director of Nursing Services and Social Services Staff were aware of the situation but had not resolved it. The Business Office Manager indicated that a grievance form would not be completed if the resident had discharged. Eventually, the Director of Admissions found the resident's items in the Boiler room, including some of the missing items, but the cash was not mentioned. The facility's failure to address the resident's grievance in a timely manner placed residents at risk for unresolved missing personal property.
Failure to Provide Transfer Discharge Notice and Ombudsman Notification
Penalty
Summary
The facility failed to provide a written transfer discharge notice to a resident who was discharged to a hospital and subsequently refused re-admission to the facility. This deficiency involved a resident who was cognitively intact and had been admitted with multiple medical conditions, including type 2 diabetes, high blood pressure, and complications from a left below-knee amputation. The resident was sent to the hospital following a wound care clinic appointment due to issues with their amputation. Despite the facility's policy requiring written notice of transfer or discharge, the resident did not receive such notice, nor were they informed of their appeal rights. Interviews with facility staff revealed that the decision not to readmit the resident was made by the prior Director of Nursing Services, with input from the admissions department. The resident expressed confusion and distress over the refusal of re-admission, as they had no prior issues with the staff and were forced to relocate to a distant facility, away from their support system. Additionally, the facility failed to notify the Office of the State Long-Term Care Ombudsman about the discharge, further compounding the deficiency. The hospital case worker indicated that the facility cited drug use and disruptive behavior as reasons for the non-readmission, while a nursing supervisor mentioned the resident's demanding nature and medication hoarding as contributing factors.
Failure to Provide Bed Hold Notice
Penalty
Summary
The facility failed to provide a written bed hold notice to a resident or their representative at the time of transfer to a hospital or within 24 hours of the transfer. This deficiency was identified for one of the three residents reviewed for hospitalizations. The facility's policy, dated November 2016, requires that residents or their representatives be informed in writing of their right to a bed hold when transferred to a general acute care hospital. However, a review of the medical records for the resident in question showed no documentation of a bed hold notification being provided. Interviews with facility staff revealed a lack of clarity regarding the responsibility for providing the bed hold notice. The Director of Admissions indicated that nursing staff typically completed the bed hold form and forwarded it to medical records for uploading into the electronic medical record. However, the form was not found in the resident's records. Additionally, a Licensed Practical Nurse/Nurse Supervisor believed that Social Services would handle the bed hold notification after a resident was sent to the hospital. The resident confirmed that they did not receive any information or sign any documents regarding a bed hold.
Failure to Follow Hospice Referral Orders
Penalty
Summary
The facility failed to follow physician orders to obtain a hospice referral for a resident who was experiencing a change in condition. This oversight involved a resident who was admitted with multiple diagnoses, including adult failure to thrive, chronic respiratory failure, thrombocytopenia, a history of cancer, heart disease, depression, and anxiety. A hospice referral was made by an Advanced Registered Nurse Practitioner (ARNP) on 05/28/2024, which was intended to be placed in the Social Services box for further action. However, the referral was not acted upon, leaving the resident without the hospice support they and their spouse had requested. Interviews with facility staff revealed a breakdown in the process of handling hospice referrals. The ARNP, who initiated the referral, was unaware of why the order was not followed, despite having discussed hospice care with the resident and their spouse. The Social Services Manager stated they had not seen the referral in their box and therefore did not proceed with the hospice referral. The Interim Director of Nursing Services confirmed that the facility's process was to pass hospice referrals to social services for implementation but could not explain why this particular referral was not processed. This failure placed the resident at risk of not receiving necessary end-of-life support.
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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