Mirabella Seattle
Inspection history, citations, penalties and survey trends for this long-term care facility in Seattle, Washington.
- Location
- 116 Fairview Avenue N, Seattle, Washington 98109
- CMS Provider Number
- 505520
- Inspections on file
- 19
- Latest survey
- September 18, 2025
- Citations (last 12 mo.)
- 51
Citation history
Health deficiencies cited at Mirabella Seattle during CMS and state inspections, most recent first.
A resident with gastrointestinal conditions did not consistently receive prescribed Mylanta and lidocaine oral solution as ordered, with multiple missed doses documented and no physician notification when medications were unavailable. Nursing staff failed to follow the MAR and facility policy, leading to resident discomfort and incomplete documentation, as confirmed by interviews with nursing and pharmacy staff.
A resident with paraplegia, dependent on staff for transfers and requiring a mechanical lift, was left unsupervised on the edge of their wheelchair while a CNA left the room to seek help. The care plan and Kardex did not specify the required two-person assistance for mechanical lift transfers. During the CNA's absence, the resident fell and sustained a tibial fracture, highlighting a failure in supervision and documentation.
A resident sustained a tibial tuberosity fracture after an unwitnessed fall during a mechanical lift transfer when a CNA left the room to seek assistance. The facility's investigation did not include a summary of findings, root cause analysis, or a determination regarding abuse or neglect, as required by policy and regulation.
The facility allowed two contract CNAs to work without obtaining required nurse aide registry verification to confirm their competency and eligibility, as their files lacked documentation and the DON assumed the contract agency would provide this verification.
A facility failed to implement its abuse and neglect policies, leading to a deficiency in protecting a resident from misappropriation of property. The facility delayed reporting a missing ceramic figurine to the State Agency and allowed the suspected staff member to continue working during the investigation, contrary to policy requirements.
A resident's allegation of property misappropriation was not reported to the State Agency in a timely manner, as required by regulations. The resident suspected a night nurse of taking a ceramic figurine, and the report was delayed by ten days after being initially reported to the Social Services Director. This delay in reporting placed residents at risk for potential misappropriation or exploitation.
A facility failed to promptly investigate a resident's allegation of misappropriation of a ceramic figurine. The resident, who was cognitively intact, reported the missing item, but the Social Services Director delayed the investigation, initially trying to resolve it independently. The Director of Nursing confirmed the investigation should have been immediate and thorough, including resident interviews. This delay placed residents at risk of unidentified misappropriation and lack of protection from abuse.
The facility failed to complete accurate and timely PASRR assessments for four residents, leading to potential inappropriate placements. A resident's PASRR was completed seven days post-admission, while others had unmarked SMI despite diagnoses of depression and anxiety. Staff admitted to oversight, and the administrator expected adherence to regulations.
The facility failed to develop comprehensive care plans for several residents, leading to unmet care needs. A resident using oxygen since May 2024 did not have an oxygen care plan until June 2024. Another resident's care plan lacked documentation for side rail use, despite its necessity for mobility. Additional residents had missing care plans for oxygen use, restorative programs, and anticoagulant therapy, which were only addressed after staff reviews.
The facility failed to provide proper respiratory care for three residents, including improper storage and labeling of oxygen equipment and lack of signage indicating oxygen use. A resident with COPD had a nasal cannula on the floor, another with pneumonia used an unlabeled cannula, and a third resident's oxygen tubing was undated. Staff acknowledged these issues, which were against the facility's policy.
The facility failed to maintain temperature logs for a medication refrigerator, risking compromised medications. The refrigerator contained various medications, including a pneumococcal vaccine and blood sugar medication pens. Temperature logs were inadequately maintained, with significant gaps in April, May, and June. The DON confirmed the oversight and acknowledged the presence of these medications without proper temperature monitoring.
The facility was found to have expired food items in the kitchen and dry storage, and staff failed to follow hand hygiene protocols during food preparation. Expired items included a jar of dressing, a tray of clams, and jars of mustard. A kitchen cook did not wash hands after handling a thermometer and before preparing food, risking cross-contamination.
The facility failed to implement a comprehensive water management program, review its Infection Prevention and Control Policy annually, and ensure proper hand hygiene and isolation precautions. Staff were unaware of the water management plan details, and the IPCP had not been reviewed since 2017. Observations showed staff neglecting hand hygiene and PPE use during room entry, including for a resident on CPAP therapy.
The facility failed to obtain informed consent for psychotropic medications for two residents. One resident was administered an anxiety medication without consent, and another resident was given an antidepressant without documented consent. Staff acknowledged the oversight and confirmed that consent should have been obtained prior to medication administration.
The facility failed to document advance directives for two residents, despite both residents stating they had them. Staff confirmed that these documents should be in the EHR, but they were not found. The absence of documentation was acknowledged by the Social Services Director and the Administrator, who expected adherence to the policy.
A facility failed to issue a Notification of Medicare Non-Coverage (NOMNC) at least two days before the end of Medicare coverage for a resident. The NOMNC was signed a day after coverage ended, and the Social Services Director could not provide evidence of timely communication with the resident's representative. The facility's policy requires adherence to Medicare guidelines, which was not met in this case.
The facility failed to provide written transfer or discharge notices to two residents and their representatives, as well as to the State Long-Term Care Ombudsman, when the residents were hospitalized. Staff interviews revealed that the required notifications were not provided, despite the facility's policy mandating such actions.
The facility failed to provide written bed hold notices to two residents who were hospitalized, as required by their policy. Despite verbal communication, there was no documentation or written notice provided, placing residents at risk for unwanted room changes upon readmission. The facility's Administrator expected adherence to the bed hold policy, which was not followed.
A resident's discharge status was inaccurately assessed, resulting in incorrect documentation in their clinical record. The nursing progress note indicated the resident was cleared to go home, but the MDS was coded for discharge to a hospital. The MDS coordinator acknowledged the error, and the DON expected the MDS to be accurate.
A facility failed to ensure proper G-tube management for a resident with dysphagia, as a nurse did not check the G-tube placement before administering medications, contrary to the facility's policy and physician orders. Interviews confirmed that staff were expected to perform this check, but it was not done, placing the resident at risk.
A facility failed to perform routine maintenance on side rails, placing a resident at risk for injury. The resident, who required assistance for bed mobility, used the side rails to aid in getting up. The Maintenance Manager was unaware of the side rails' presence, and the Administrator confirmed the lack of a maintenance process, despite the facility's policy requiring regular inspections.
Failure to Administer and Document Prescribed Medications as Ordered
Penalty
Summary
The facility failed to ensure that pharmaceutical services were provided to meet the needs of a resident with gastrointestinal diagnoses, including hiatal hernia and gastroesophageal reflux disease with esophagitis. The resident had intact cognition and was prescribed aluminum-magnesium simethicone (Mylanta) and lidocaine oral solution to be administered at specific times before meals and at bedtime. Review of the Medication Administration Records (MAR) for August and September showed multiple instances where these medications were not administered as ordered, and there was no documentation that the physician was notified when the medications were unavailable or not given. Staff interviews and record reviews revealed that nursing staff did not consistently follow the MAR or the facility's medication administration policy, which required adherence to the Seven Rights of medication administration and prompt notification to the physician and pharmacy when medications were unavailable. One nurse reported not administering the lidocaine solution because it was not found and did not notify the physician, believing the medication was not pertinent. There was also confusion regarding the storage location of medications, leading to missed doses. The pharmacist confirmed that the medications were compounded and that the MAR required separate documentation for each, but this was not consistently done. The resident reported experiencing discomfort and bloating when the medications were missed, which affected their ability to breathe, eat, sit up, and walk. Facility leadership, including the Resident Care Manager and Director of Nursing Services, acknowledged that staff should have notified the physician and administered the medications as ordered. The deficiency was identified through observation, interview, and record review, and was found to be in violation of facility policy and regulatory requirements.
Failure to Provide Adequate Supervision During Mechanical Lift Transfer Results in Resident Injury
Penalty
Summary
The facility failed to provide adequate supervision and ensure safe transfer procedures for a resident with paraplegia who was dependent on staff for transfers and required the use of a mechanical lift. The resident's care plan and Kardex indicated the need for staff assistance with transfers and use of a Hoyer lift, but did not specify the required number of staff for mechanical lift transfers. On the day of the incident, a CNA attempted to apply a mechanical lift sling under the resident, who was left sitting on the edge of their power wheelchair. The CNA left the resident unsupervised to seek assistance, during which time the resident slipped from the chair and fell to the floor, sustaining a tibial fracture that required emergency room treatment. Interviews and record reviews revealed that staff were aware that mechanical lift transfers should be performed with two staff members, but this requirement was not documented in the resident's care plan or Kardex. The CNA involved in the incident did not ensure the resident was safely positioned or supervised before leaving the room, and the lack of clear documentation contributed to the unsafe transfer process. The resident reported being left partially off the cushion and unsupervised for approximately ten minutes before falling. Further interviews with staff, including the Resident Care Manager and Director of Nursing, confirmed that the care plan should have specified the need for two-person assistance during mechanical lift transfers. The absence of this information in the care plan and Kardex, combined with the CNA's actions, resulted in an avoidable accident that caused significant harm to the resident.
Failure to Conduct Thorough Investigation After Resident Fall
Penalty
Summary
The facility failed to conduct a thorough investigation following an incident in which a resident experienced an unwitnessed fall during a mechanical lift transfer, resulting in a tibial tuberosity fracture. The incident occurred when a CNA placed a Hoyer sling under the resident and left the room to get assistance, returning to find the resident on the floor. Documentation showed that the CNA involved would not be able to work at the facility due to not following protocol, but the investigation records lacked a summary of findings, root cause analysis, or a determination regarding the likelihood of abuse or neglect contributing to the incident. Interviews with facility leadership, including the Director of Nursing and Director of Health Services, confirmed that the investigation did not include a completed summary or a clear ruling out of abuse or neglect, contrary to both facility policy and regulatory requirements. The facility's own policies require prompt and thorough investigations, including gathering witness statements, root cause analysis, and a summary of findings, none of which were fully documented in this case.
Failure to Verify Nurse Aide Registry Status for Contract CNAs
Penalty
Summary
The facility failed to obtain registry verification to ensure that two contract Certified Nursing Assistants (CNAs), identified as Staff F and Staff G, met competency evaluation requirements before allowing them to work as nurse aides. Review of the April 2025 staffing schedule showed that both staff members worked multiple shifts at the facility. However, their employee files did not contain documentation from the nurse aide registry verifying their eligibility and qualifications. Further review of email communication confirmed that the Director of Health Services did not have registry verification for these staff members. During an interview, the Director stated that they assumed the contract agency would provide registry verification as part of their compliance package, but acknowledged that the facility should have received this verification prior to the staff working. The facility's policy requires verification of board registrations and certifications before new employees are permitted to work with residents, and prohibits employment of individuals with findings of abuse, neglect, exploitation, or mistreatment.
Failure to Implement Abuse and Neglect Policies
Penalty
Summary
The facility failed to implement its abuse and neglect policies and procedures effectively, leading to a deficiency in protecting residents from misappropriation of property. Specifically, the facility did not conduct a prompt and thorough investigation as required by their policy when Resident 1 reported a missing ceramic carriage figurine. The incident was initially reported to the Social Services Director on 02/07/2025, but the facility delayed reporting the incident to the State Agency until 02/18/2025, ten days later. This delay in reporting and investigation placed Resident 1 at risk for unidentified misappropriation and lack of protection from potential abuse. Additionally, the facility allowed the staff member allegedly involved in the incident to continue working during the investigation. Despite Resident 1 providing a description of the staff member suspected of taking the figurine, the facility did not remove the staff member from resident care as required by their policy. The Director of Nursing Services admitted to being unaware of the requirement to suspend the staff member during the investigation, which further contributed to the deficiency in protecting residents from potential abuse and exploitation.
Delayed Reporting of Property Misappropriation Allegation
Penalty
Summary
The facility failed to report an allegation of misappropriation of property in a timely manner to the State Agency, as required by federal and state regulations. The incident involved a resident who reported that their ceramic carriage figurine had gone missing and suspected a night nurse might have taken it. The resident's representative initially reported the allegation to the Social Services Director on February 7, 2025, but the report was not forwarded to the State Agency until February 18, 2025, ten days later. This delay in reporting was acknowledged by the Social Services Director, who admitted to attempting to resolve the matter independently rather than following the proper reporting protocol. The facility's policy mandates that all allegations of abuse, neglect, exploitation, or mistreatment, including misappropriation of property, be reported promptly. The Director of Nursing Services confirmed that the allegation should have been reported immediately after it was brought to the attention of the Social Services Director. The failure to report the incident in a timely manner placed residents at risk for potential unidentified misappropriation or exploitation and a lack of protection from abuse.
Delayed Investigation of Misappropriation Allegation
Penalty
Summary
The facility failed to timely initiate and thoroughly investigate an allegation of misappropriation of property involving a resident's missing ceramic carriage figurine. The resident, who was cognitively intact, reported the missing item on 02/14/2025, although their representative had initially reported the allegation to the Social Services Director, Staff B, on 02/07/2025. Despite the facility's policy requiring immediate investigation upon notification of such incidents, the investigation was delayed, and the incident was only reported to the State Agency on 02/18/2025, ten days after the initial report. Interviews revealed that Staff B acknowledged the delay in addressing the allegation, admitting they initially attempted to resolve the matter independently. The Director of Nursing Services, Staff A, confirmed that the investigation should have been initiated immediately and included resident interviews, which were not conducted. This failure to act promptly and thoroughly placed residents at risk for potential unidentified misappropriation and lack of protection from abuse, as per the facility's policy and regulatory requirements.
Inaccurate and Delayed PASRR Completion for Residents
Penalty
Summary
The facility failed to ensure that four out of five residents had a completed and accurate Preadmission Screening Resident Review (PASRR) upon admission. This assessment is crucial for identifying individuals with serious mental illness (SMI) or intellectual disabilities to prevent inappropriate placement in nursing homes. Resident 20's PASRR was completed seven days after admission, contrary to the requirement for it to be done prior to or at the time of admission. Staff C, the Social Services Director, acknowledged the delay and admitted responsibility for completing the PASRR if it was not done by the hospital. For Residents 12, 10, and 21, the PASRR forms were inaccurately completed, failing to mark the presence of SMI despite their diagnoses of depression and anxiety. Staff C admitted to not catching these errors and stated that the forms should have been marked for SMI and referred for a Level II PASRR. The facility's administrator, Staff A, expressed an expectation for the PASRR forms to be accurate and for staff to adhere to regulations and facility policy.
Deficiencies in Comprehensive Care Planning
Penalty
Summary
The facility failed to develop person-centered comprehensive care plans for several residents, leading to unmet care needs. Resident 230, who had been using oxygen since late May 2024, did not have an oxygen care plan until late June 2024. This oversight was acknowledged by both the Resident Care Manager and the Director of Nursing, who confirmed that the care plan should have been initiated when the resident began using oxygen. Similarly, Resident 4's care plan lacked documentation for the use of side rails, which the resident used for mobility. Despite observations and staff interviews confirming the use of side rails, the care plan did not reflect this need. Staff members, including a Registered Nurse and the Director of Nursing, noted that an assessment, consent, and physician's order should have been completed and included in the care plan. Other residents, such as Resident 19 and Resident 21, also had deficiencies in their care plans. Resident 19, who required oxygen monitoring, did not have an oxygen care plan until late June 2024, despite using oxygen since early June. Resident 21's restorative nursing program was not included in their care plan, even though it was part of their routine care. Additionally, Resident 20's care plan initially omitted anticoagulant therapy, which was only added after a review. These omissions were recognized by staff, who noted that these elements should have been included in the residents' care plans.
Failure to Maintain Proper Respiratory Care and Equipment
Penalty
Summary
The facility failed to provide necessary respiratory care and services in accordance with professional standards for three residents. Resident 5, who had chronic obstructive pulmonary disease, was observed with an oxygen concentrator in their room, but the nasal cannula was not stored in a bag when not in use and was found on the floor. There was no signage indicating oxygen was in use. Staff members acknowledged the lack of labeling and improper storage of the nasal cannula, which was placed on the resident despite being on the floor. Resident 19, who had pneumonia and congestive heart failure, was using oxygen via an unlabeled nasal cannula. Observations showed the nasal cannula touching the floor and not stored in a bag. Staff confirmed that the nasal cannula should have been labeled, stored properly, and not placed on the floor. The facility's policy required the nasal cannula to be changed every 72 hours and stored in a bag when not in use, which was not followed. Resident 230 had an order for oxygen supply due to shortness of breath. Observations revealed that the oxygen tubing was undated, and there was no signage indicating oxygen use on the resident's room door. Staff interviews confirmed that the tubing should have been dated and signage should have been present. The facility's policy was not adhered to, as there was no order for tubing change when the resident started using oxygen, and the lack of signage was justified by the facility not being a smoking facility.
Failure to Maintain Medication Refrigerator Temperature Logs
Penalty
Summary
The facility failed to maintain proper temperature logs for one of the three medication room refrigerators, specifically the medicine refrigerator, which contained various medications including a pneumococcal vaccine and medications for multiple residents. According to the facility's policy, medications requiring refrigeration should be kept at temperatures between 36°F and 46°F, with temperatures recorded at least once a day. However, the temperature logs for the medicine refrigerator were inadequately maintained, with only five temperatures logged from April 1 to April 24, one temperature logged from May 1 to May 24, and no temperatures logged from June 1 to June 26. During a joint observation and interview, the Director of Nursing, Staff B, confirmed that the temperature logs for June 2024 were not completed for 26 out of 26 days, and acknowledged that temperatures were not consistently checked in April and May 2024. The medicine refrigerator contained eight unopened medication pens for lowering blood sugar, a test for tuberculosis, three unopened boxes of tuberculosis testing solution, an opened pneumonia vaccine, and four unopened boxes of a medication that prevents blood clots. Staff B admitted that these medications were present on June 26 and should have been monitored for temperature compliance.
Expired Food and Poor Hand Hygiene in Kitchen
Penalty
Summary
The facility failed to maintain proper food storage and hand hygiene practices, which placed residents at risk for foodborne illnesses. During an inspection, expired food items were found in the kitchen refrigerator and dry storage room. A jar of thousand island dressing and a tray of clams were observed with expiration dates that had passed, and staff members were unaware or had not yet discarded these items. Additionally, three jars of mustard with expired labels were found in the dry storage room, and the head chef only discarded them after being prompted by the surveyor. Furthermore, the facility's staff did not adhere to hand hygiene protocols during food preparation. An observation revealed that a kitchen cook failed to wash hands after handling a thermometer and before donning gloves to prepare food. The cook also picked up a dirty rag without washing hands, which could lead to cross-contamination. The facility's hand hygiene policy emphasized the importance of handwashing to prevent infections, but it did not specifically address hand hygiene during food preparation. The administrator confirmed that expired food should be discarded and that staff are expected to follow the hand hygiene policy.
Deficiencies in Infection Control and Water Management
Penalty
Summary
The facility failed to implement a comprehensive water management program to monitor and control the growth of legionella and other waterborne pathogens. During an interview, the Facility Services Director admitted that the facility's water management plan lacked a flow diagram to identify potential growth areas for legionella. Additionally, there was no process in place for communicating the water management program to residents, staff, or others. The oversight of the water management system was left to a vendor, and there was no specific program for the skilled nursing unit. The facility also failed to review its Infection Prevention and Control Policy (IPCP) annually. The Resident Care Manager/Infection Preventionist was unaware of the frequency of IPCP reviews. A joint record review revealed that the IPCP was last revised in November 2017 and approved in February 2023, with the next review scheduled for February 2024. The Director of Nursing and the Administrator were both unaware of the review frequency, indicating a lack of oversight and communication regarding the IPCP. Furthermore, the facility did not ensure proper hand hygiene practices during room tray and activity flyer delivery. Observations showed that staff members failed to perform hand hygiene before and after entering rooms, including those with Enhanced Barrier Precautions (EBP). Additionally, the facility did not implement isolation precautions for Aerosolizing Generating Procedures (AGP) for a resident using CPAP therapy. Staff members were observed entering the resident's room without appropriate Personal Protective Equipment (PPE), and the Special Droplet/Contact precautions sign was not properly displayed.
Failure to Obtain Informed Consent for Psychotropic Medications
Penalty
Summary
The facility failed to ensure informed consent for psychotropic medication was completed prior to administration for two residents. Resident 15 had a physician's order for an anxiety medication dated March 9, 2024, and began taking the medication on March 10, 2024. However, during a joint record review and interview on June 28, 2024, it was discovered that Resident 15 did not have a consent form for the medication. Staff D, the Resident Care Manager, acknowledged that the consent was missed, and Staff B, the Director of Nursing, confirmed that consent should have been obtained before the medication was administered. Similarly, Resident 20, who was admitted with multiple diagnoses including major depression, had an order for an antidepressant medication on January 24, 2024. During a joint record review and interview on June 28, 2024, it was found that there was no consent for the antidepressant in Resident 20's electronic health record. Staff D stated that they would typically obtain consent for psychotropic medications but could not locate it in the records. Staff B also confirmed that obtaining consent for the antidepressant was part of their process.
Failure to Document Advance Directives for Residents
Penalty
Summary
The facility failed to ensure that advance directives were obtained and readily available in the medical records for two residents. Resident 4, who was admitted to the facility, stated they had an advance directive, but a review of their Electronic Health Record (EHR) showed no documentation of it. Staff C, the Social Services Director, confirmed that if a resident had an advance directive, it should be scanned into the EHR, but no such documentation was found for Resident 4. Staff A, the Administrator, also expected a copy of the advance directive to be in the medical records if it existed. Similarly, Resident 21 stated they had an advance directive and that their Power of Attorney (POA) carried a copy. However, a review of Resident 21's EHR showed no documentation of their advance directive. Staff C acknowledged the absence of the document in the EHR and mentioned that they typically ask families to provide a copy. Despite being aware that Resident 21 had a POA, there was no paperwork to support it. Staff A reiterated the expectation that staff should follow the policy and have a copy of the advance directive if it existed.
Failure to Timely Issue Medicare Non-Coverage Notice
Penalty
Summary
The facility failed to issue a Notification of Medicare Non-Coverage (NOMNC) at least two calendar days before the end of Medicare coverage for a resident, as required by Medicare guidelines. The resident was admitted under skilled Medicare A benefits, and the NOMNC was signed a day after the coverage ended. The facility's policy mandates that such notices be delivered according to Medicare guidelines, which were not followed in this instance. During interviews, the Social Services Director claimed that the NOMNC was issued on time and that if a resident was unable to sign, the form would be emailed to their representative. However, the record review showed the NOMNC was signed late, and the Social Services Director could not provide evidence of the email communication with the resident's representative. The facility administrator confirmed the expectation that the NOMNC should be issued at least two days before the last covered day.
Failure to Provide Written Transfer/Discharge Notices
Penalty
Summary
The facility failed to provide a written transfer or discharge notice to residents and their representatives, as well as to the Office of the State Long-Term Care Ombudsman, for two residents who were hospitalized. This deficiency was identified during a review of the facility's policy and interviews with staff members. The policy, revised in November 2017, required that a transfer or discharge notice be issued as soon as practicable when an immediate transfer or discharge is necessitated by a resident's urgent medical condition. However, for Resident 230, who was sent to the hospital for further evaluation, there was no documentation in the Electronic Health Record (EHR) indicating that a written notice was provided to the resident, their representative, or the Ombudsman. Interviews with the Social Services Director, Resident Care Manager, and Director of Nursing revealed that they did not provide the required written notices, and the facility did not send a copy of the transfer notice to the Ombudsman. Similarly, for Resident 10, who was discharged to the hospital due to emesis and abdominal pain, there was no documentation in the EHR showing that the resident or their representative was notified in writing of the reason for discharge. Staff interviews confirmed that the required written notifications were not provided to the resident, their representative, or the Ombudsman. The Director of Nursing acknowledged that the facility had not been notifying residents and their representatives in writing of the reason for discharge, nor sending a notice to the Ombudsman, despite the facility's policy requiring it. The Administrator expressed an expectation for staff to follow the discharge/transfer policy.
Failure to Provide Written Bed Hold Notices
Penalty
Summary
The facility failed to provide written bed hold notices to residents who were hospitalized, as required by their policy. This deficiency was identified for two residents, Resident 230 and Resident 10, who were transferred to the hospital. The facility's policy, revised in January 2020, mandates that before a resident is transferred to a hospital or goes on therapeutic leave, the nursing facility must provide written information to the resident and their representative about the bed hold policy. However, in the case of Resident 230, there was no documentation in the Electronic Health Record (EHR) that a bed hold notice was offered when they were sent to the hospital for further evaluation. Resident 230 confirmed in an interview that they were not offered a bed hold notice. Staff C, the Social Services Director, admitted to discussing the bed hold verbally but did not provide a written notice, citing that the facility had no issues with readmitting residents. Similarly, for Resident 10, who was discharged to the hospital due to emesis and abdominal pain, there was no documentation in the EHR that a bed hold notice was provided. Staff C stated that the bed hold notice was communicated verbally but not documented, and no written notice was given to the resident or their representative. The facility's Administrator, Staff A, expressed that it was their expectation for staff to follow the bed hold policy, which was not adhered to in these instances. This failure to provide written bed hold notices placed residents at risk for unwanted room changes upon readmission.
Inaccurate Discharge Assessment for a Resident
Penalty
Summary
The facility failed to accurately assess a resident's discharge status, leading to incorrect information in the resident's clinical record. Specifically, Resident 28 was reviewed for hospitalization, and the nursing progress note indicated that the resident was cleared to go home safely. However, the discharge Minimum Data Set (MDS) was incorrectly coded for discharge to a Short-term General Hospital instead of the community. During an interview and joint record review, the MDS coordinator acknowledged the error and stated that the MDS should have been coded for community discharge. The Director of Nursing also expressed the expectation for the MDS to be accurate. This inaccuracy in the resident's assessment placed the resident at risk for unidentified care needs.
Failure to Check G-Tube Placement Before Medication Administration
Penalty
Summary
The facility failed to ensure appropriate treatment and services related to gastrostomy tube (G-tube) management for Resident 21, who was receiving nutrition through a feeding tube due to dysphagia and gastrostomy status. The facility's policy required checking the G-tube placement by visual inspection of aspirated stomach content prior to medication administration, as outlined in the resident's medication administration record (MAR). However, during an observation, Staff G, a Registered Nurse, did not check the G-tube placement before administering medications to Resident 21, which was against the facility's policy and the physician's order. Interviews with staff members, including Staff G, the Resident Care Manager, and the Director of Nursing, confirmed that the expected procedure was to check for G-tube placement before administering medications. Staff G admitted to not performing this check, and both the Resident Care Manager and the Director of Nursing stated that they expected staff to follow the MAR and physician orders regarding G-tube placement checks. This oversight placed Resident 21 at risk for medical complications and a diminished quality of life.
Failure to Conduct Routine Maintenance on Side Rails
Penalty
Summary
The facility failed to conduct routine maintenance to ensure the safety of side rails for one resident, identified as Resident 4, who was reviewed for accident hazards. The facility's policy, revised in August 2022, required regular inspections of bed frames, mattresses, and side rails to identify potential entrapment areas. However, the Maintenance Manager, Staff S, admitted that side rails were not routinely checked for safety and were only inspected when a resident was discharged or admitted. This lack of routine maintenance was confirmed during a joint observation with Resident 4, where bilateral side rails were found in the raised position, and Staff S stated they were unaware of any side rails in use. Resident 4, who required extensive assistance for bed mobility and transfers, used the side rails to aid in getting up from a lying position. Despite the resident's reliance on the side rails, the facility did not have a process for routine maintenance or documentation to ensure their safety. Interviews with the Administrator, Staff A, further confirmed the absence of a maintenance process for side rails, placing residents at risk for injury or entrapment due to the facility's oversight.
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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