Mountain View Post Acute
Inspection history, citations, penalties and survey trends for this long-term care facility in Ellensburg, Washington.
- Location
- 1050 E Mountain View, Ellensburg, Washington 98926
- CMS Provider Number
- 505263
- Inspections on file
- 44
- Latest survey
- February 23, 2026
- Citations (last 12 mo.)
- 35
Citation history
Health deficiencies cited at Mountain View Post Acute during CMS and state inspections, most recent first.
Three residents with left-sided paralysis and severe cognitive impairment did not consistently receive their prescribed ROM and splinting programs, as evidenced by missed documentation and improper splint application. Staff interviews revealed that restorative care was often not completed due to staffing shortages and lack of coverage, and one resident's splint was observed to be dirty with an odor. The DON confirmed awareness of these lapses, citing inadequate staffing as the cause.
Three residents requiring oxygen therapy were found with unclean oxygen concentrator filters and improperly stored oxygen tubing, including filters with visible dust and debris and tubing left on beds or floors without protective storage. Staff confirmed that weekly cleaning and secure storage in plastic bags were expected per facility protocol, but these procedures were not followed.
A resident with cognitive impairment and a history of anxiety and exit-seeking behaviors was not properly reassessed or monitored for elopement risk after exhibiting increased agitation and attempts to leave. Despite prior 1:1 supervision and frequent checks, staff discontinued enhanced monitoring without updating the care plan or risk assessment. The resident exited the facility unsupervised through a window, was found outside by staff from a neighboring facility, and sustained injuries requiring hospital care. Staff interviews revealed gaps in communication and documentation regarding the resident's elopement risk.
A resident with severe cognitive impairment and multiple diagnoses was administered injectable lorazepam for agitation without being given the option to refuse and without prior consent from their representative. The care plan lacked behavior management interventions, and there was no behavior monitoring documented. The DON confirmed that administering psychotropic medication without consent constituted a chemical restraint.
Staff did not follow facility policy for identifying and reporting potential abuse or neglect after a medication error involving an injected psychotropic medication for a resident with severe cognitive impairment. Despite the resident's representative raising multiple care concerns, the incident was not reported to the State Agency, and staff treated the concerns as educational rather than as possible abuse or neglect.
A resident with severe cognitive impairment experienced a medication error when a psychotropic medication was administered by injection due to a transcription error. The resident's representative raised concerns about care, but staff did not report the incident or the complaints to the State Agency, despite later acknowledgment by the DON that the incident constituted a reportable form of abuse.
A resident with severe cognitive impairment was given an injectable psychotropic medication without documentation of attempted non-pharmacological interventions or offering the oral form, and without obtaining consent from the resident's representative for the change in administration route. The nurse stated the resident could not refuse the medication due to a physician's order, and the DON confirmed this constituted a chemical restraint, violating professional standards.
The facility failed to provide consistent showering care for three residents dependent on staff for ADLs. A resident with moderate cognitive impairment missed multiple scheduled showers, while another resident reported receiving a shower only once every three weeks due to staff shortages. A third resident expressed discomfort from not receiving regular showers. Staff acknowledged a breakdown in the showering process.
A resident with a history of a fractured hip and hemiplegia experienced neglect when the facility failed to perform consistent skin assessments and address a developing necrotic area on the foot. Despite policies requiring weekly checks, staff did not document or communicate changes in the resident's condition, leading to hospitalization and partial amputation. Interviews revealed lapses in care, communication, and documentation among staff.
The facility failed to maintain resident hygiene and dignity, affecting five residents. A resident had long, dirty fingernails and had not been bathed as scheduled, while another had not showered for over a week, resulting in unkempt hair and split nails. A third resident, recovering from pneumonia, had not bathed since December, and a fourth shared a room with a strong urine odor. Additionally, a cognitively impaired resident ate with their hands due to lack of staff assistance, and staff cleaned the dining area while residents were still eating, which was deemed undignified.
Residents expressed concerns about call lights not being answered timely and food not being delivered hot, but the facility failed to follow its grievance policy. The Activities Director did not ensure grievances were logged and resolved, leaving residents unaware of the grievance process and without feedback on their concerns.
The facility failed to properly review and validate PASARR assessments for four residents, leading to incomplete or inaccurate screenings for serious mental illness (SMI) or intellectual/developmental disabilities (ID/DD). This included missing or incorrect level 1 PASARR forms and the absence of required level 2 evaluations, placing residents at risk of inappropriate placement and care. Staff interviews revealed misunderstandings about the sufficiency of level 2 Invalidation Assessments without corresponding level 1 PASARRs.
The facility failed to develop and implement timely baseline care plans (BCPs) for several newly admitted residents, resulting in incomplete or missing initial goals and treatment plans. This deficiency affected residents with various medical conditions, including dementia and heart complications, and left them and their representatives uninformed about their care plans. Staff interviews revealed that a transition to a new system contributed to these omissions.
The facility failed to consistently review and revise care plans for five residents, leading to incomplete documentation of medical needs and interventions. Care plans lacked specific parameters for medical devices, medication updates, and safety measures. Additionally, care conferences did not consistently involve residents or their representatives, and nursing assistants were not included in the interdisciplinary team meetings.
The facility failed to provide adequate care for three residents, including a resident with mental health issues who did not receive necessary physician assistance, a resident with cellulitis whose IV line was not properly maintained, and a resident with paralysis who experienced skin breakdown due to inadequate monitoring. These deficiencies highlight significant lapses in care and monitoring protocols.
The facility failed to provide adequate restorative nursing services to maintain or improve ROM for four residents, leading to a deficiency. A resident with paralysis reported infrequent ROM exercises, while another dependent on staff for transfers noted inconsistency in their RA program. A third resident recovering from amputation stated their exercise program never started, and a fourth resident with a hip replacement experienced a decline in mobility without receiving prescribed exercises. Staff acknowledged the lack of program maintenance and review.
The facility failed to provide adequate nursing staff, resulting in deficiencies in resident care, including poor hygiene, inadequate medical monitoring, and insufficient restorative services. Residents reported not receiving regular showers, and staff interviews highlighted the reliance on agency staff with minimal orientation. The facility's outdated assessment of staffing needs contributed to the ongoing issues.
The facility failed to maintain proper cleaning and storage of oxygen equipment, risking infection transmission. Residents with severe cognitive impairments and respiratory issues had dirty oxygen concentrator filters, and one resident's humidifier was improperly placed on the floor. Staff interviews revealed non-compliance with scheduled maintenance and infection control practices.
The facility failed to maintain a safe and sanitary environment, with issues such as embedded dirt in hall floors, damaged tiles in the dining room, and grime in the laundry and utility rooms. Residents experienced discomfort due to temperature control issues and unclean conditions in their rooms. Staff interviews revealed that the facility was in need of repairs, with no current plans to address these deficiencies.
A facility failed to assess a wheelchair seat belt as a restraint for a resident with impaired cognition and mobility. The resident could not unbuckle the seat belt independently, and no evaluation was conducted to determine if it was a restraint or enabler. Staff interviews confirmed the oversight, and the facility's policy was not followed.
The facility failed to implement its abuse prevention policies, affecting four residents. A resident reported verbal abuse by an LPN, but no investigation was conducted. Another resident experienced rough handling by an RN, which was not logged or investigated. A third resident's refusal of care by a new NA was not properly addressed, and the NA continued working. Lastly, a resident was teased by an NA, but the incident was not reported to the state, and the NA was not removed from care duties.
A facility failed to notify the LTC Ombudsman of a resident's transfer to the hospital, as required. The resident, with heart complications and Parkinson's, was transferred without the necessary written notice. Staff interviews revealed a lack of awareness and process for such notifications.
A facility failed to issue a written notice of bed hold to a resident or their representative during a hospital transfer. The resident, with heart complications and Parkinson's, was transferred without the required notification, as confirmed by staff interviews and record reviews. The standard procedure of informing the resident or representative via phone and documenting it was not followed.
The facility failed to develop comprehensive care plans for two residents, leading to unmet care and safety needs. One resident with a urinary tract infection and catheter had improper catheter management and lacked a detailed care plan. Another resident with a history of substance abuse had no structured care plan addressing their condition, with staff acknowledging a lack of training in this area.
Two residents in the facility did not receive consistent showering and grooming care as per their care plans. One resident, with diabetes and asthma, had not been showered for nearly two weeks, resulting in strong urine odor and flaky skin. Another resident, with diabetes and a history of stroke, had not been showered for over a month, leading to oily hair and dirty fingernails. Staff interviews revealed inconsistencies in staffing and care provision.
A facility failed to assess a resident's use of chewing tobacco, risking potential interactions with medications and health concerns. The resident, admitted after surgery and on psychoactive and IV antibiotic medications, was diagnosed with nicotine dependence but was not assessed for tobacco use. The resident was observed chewing tobacco, and the Assistant DON admitted to being unaware of the resident's continued use, acknowledging the facility's policy was not followed.
A resident with hypoxia and on continuous oxygen was not using their prescribed Bipap device for about two months. The device was stored out of reach, and staff were unaware of the resident's refusal to use it. Physician orders lacked specific settings or mask type, and staff did not discuss the risks and benefits of device use with the resident.
A facility failed to administer Tacrolimus at consistent times for a resident with a heart transplant, risking organ rejection. The MAR lacked specific timing instructions, leading to multiple instances of early or late administration. Staff interviews revealed a lack of awareness about the critical timing requirements for this medication.
The facility failed to ensure residents were free of unnecessary psychotropic medications by not consistently monitoring individualized behaviors, not attempting non-pharmacological interventions, and not conducting AIMS assessments. A resident with dementia received Seroquel without a clear indication, and another with depression and bipolar disorder received Trazodone and Risperidone without proper documentation or consent. The Director of Nursing acknowledged these deficiencies, which were exacerbated by a change in ownership.
The facility failed to provide palatable and warm meals at the proper temperature for several residents. A resident with diabetes and malnutrition reported cold and unappetizing food, while others in the dining hall received meals that were described as disgusting and not appetizing. Staff explained that delays in serving contributed to the issue, and a test tray revealed flavorless and poorly prepared food. The DON expected meals to support nutrition and dignity, but the observations showed otherwise.
The facility did not update its assessment after a change in ownership and the loss of a nursing assistant training program. The assessment, dated September 2023, failed to reflect these changes, placing residents at risk for unmet care needs. The DON confirmed the program's suspension, and the new Administrator noted the previous Administrator's failure to update the assessment.
The facility failed to ensure that two residents with severely impaired cognition understood the implications of signing binding arbitration agreements. Despite their cognitive impairments, both residents signed the agreements without the involvement of their resident representatives. The Admissions Coordinator did not consult medical records or nursing staff about the residents' cognitive status before obtaining their signatures.
The facility failed to educate and obtain consent for influenza vaccination for two residents. One resident, who was alert and oriented, did not receive the vaccine despite expressing a desire for it, with no documentation of consent or declination. Another resident consented but did not receive the vaccine. The Infection Preventionist acknowledged the lack of consents and education, and the Director of Nursing Services admitted the system was broken.
The facility failed to post daily nurse staffing information in a location accessible to residents and visitors, as required. On multiple days, surveyors observed the absence of a staffing roster in the front of the nursing home or by the nursing desk area. Interviews with staff revealed that the necessary information, including the facility name, date, census, and staffing details, was not available. This placed residents and visitors at risk of not being informed about staffing levels.
The facility failed to investigate and resolve grievances for five residents, leaving sections of grievance forms blank and unaddressed. Concerns included bathing frequency, missing items, meal delivery, therapy frequency, and roommate issues. Staff interviews revealed a lack of prioritization and follow-through in the grievance process.
The facility failed to maintain their Respiratory Protection Program for N95 masks during a COVID-19 outbreak. Two staff members were not fit tested, and three staff members wore masks improperly due to facial hair, compromising the effectiveness of infection control measures. The Director of Nursing acknowledged the deficiencies, which were noted as repeat issues.
The facility failed to ensure residents received physician-ordered medication and necessary lab tests, resulting in harm for two residents who required hospitalization due to delayed treatment and worsening conditions. Two other residents were at risk for their conditions to worsen due to similar delays and inaccuracies in treatment.
The facility failed to ensure staff compliance with infection control guidelines during a COVID-19 outbreak. Staff were observed incorrectly donning and doffing PPE, not adhering to fit testing guidelines for N-95 respirators, and performing improper hand hygiene and glove changes. These actions increased the risk of cross-contamination and disease transmission.
A facility failed to notify the physician of a resident's elevated heart rate and low blood pressure, leading to a delay in treatment. The resident, admitted with pneumonia, COPD, and hypertension, experienced significant changes in vital signs that were not communicated to the physician as required. Staff interviews confirmed that the normal process was not followed, and the Interim DON acknowledged the system's failure.
Failure to Consistently Provide Range of Motion and Splinting Care
Penalty
Summary
The facility failed to provide appropriate care and services to maintain or improve range of motion (ROM) for three residents with a history of stroke and left-sided paralysis, all of whom were dependent on staff for activities of daily living. Observations revealed that one resident had a splint positioned incorrectly on their hand, with the foam meant to separate the palm and fingers placed on top of the hand instead of in the palm. Documentation review showed that the daily ROM programs for all three residents were not consistently completed, with 14 days in the month lacking signatures to indicate the programs had been carried out. Additionally, there were no directives or information regarding the use of the splint in the care plan for one resident. Interviews with staff indicated that the restorative nursing programs were often missed due to staffing shortages, with the Restorative Nursing Assistant (RNA) being pulled to work on the floor and no coverage provided during their days off or vacation. One resident's collateral contact reported that the resident's hand splint was frequently dirty and the palm had an odor, suggesting inadequate care. The Director of Nursing acknowledged awareness of the inconsistent completion of ROM programs, attributing it to insufficient staffing.
Failure to Maintain Cleanliness and Proper Storage of Oxygen Equipment
Penalty
Summary
The facility failed to maintain proper cleaning, disinfecting, and storage of oxygen care equipment for three residents who required oxygen therapy. For one resident with obstructive sleep apnea and dementia, the oxygen concentrator filter was found with a thick layer of dust, dirt, and hair, and staff were unable to clean it adequately, despite a protocol requiring weekly cleaning or replacement. Another resident with chronic obstructive pulmonary disease and congestive heart failure had an oxygen concentrator filter with visible dust and dirt, and the nasal cannula and tubing were found under the resident's back on the bed, with no plastic bag available for proper storage when not in use, contrary to facility protocol. A third resident, with a history of pulmonary embolism and respiratory failure, had oxygen tubing connected to a concentrator lying on the floor and the nasal cannula under the bed during multiple observations. There was no plastic bag provided to store the tubing when not in use, as required by the facility's standard protocol. Staff interviews confirmed that the expectation was for nurses to clean or change oxygen concentrator filters weekly and to store tubing securely in a plastic bag to prevent contamination, but these practices were not followed.
Failure to Reassess and Supervise Resident with Exit-Seeking Behaviors Resulting in Elopement and Injury
Penalty
Summary
A deficiency occurred when the facility failed to accurately assess, reassess, and provide adequate supervision and safety monitoring for a resident with moderately impaired cognition and a lack of safety awareness. The resident, who had a history of anxiety, depression, cognitive decline, and required assistance with activities of daily living, exhibited behaviors such as confusion, hallucinations, anxiety, and exit-seeking. Despite these behaviors, the resident's elopement risk assessment was not updated, and their care plan was not revised to reflect the increased risk. The facility's policy required identification and care planning for residents at risk of unsafe wandering or elopement, but this was not followed in this case. The resident was placed on 1:1 supervision and every 15-minute checks at times when they were actively exhibiting exit-seeking behaviors, but this increased supervision was discontinued when the resident appeared calmer, without a documented reassessment of risk. Staff interviews revealed inconsistent awareness and communication regarding the resident's elopement risk, with some staff unaware of the resident's status and the resident not being listed in the facility's elopement risk communication binder. On the night of the incident, the resident was able to exit the facility unsupervised through a window, and staff did not immediately recognize the resident was missing. There was no overhead emergency code called, and the resident was not located until found by staff from a neighboring assisted living facility. As a result of the lack of updated assessment, care planning, and supervision, the resident was found outside the facility, lying on the ground, cold, agitated, and with injuries including a head injury, left elbow fracture, and multiple bruises, requiring hospital evaluation and intervention. The incident report and staff interviews confirmed that the required processes for monitoring, reassessment, and communication of elopement risk were not followed, directly leading to the resident's unsupervised exit and subsequent harm.
Failure to Prevent Chemical Restraint and Unnecessary Psychotropic Medication Use
Penalty
Summary
The facility failed to ensure that a resident was free from chemical restraints and unnecessary psychotropic medication use. A resident with severe cognitive impairment, dementia, diabetes, sleep apnea, and anxiety was admitted and prescribed multiple psychotropic medications, including donepezil, escitalopram, quetiapine, hydroxyzine, and lorazepam. The resident's care plan did not include any specific interventions for behavior management, identified target behaviors, or individualized interventions. Additionally, there were no behavior monitoring records for the resident during the relevant period. On one occasion, the resident became agitated during the night and refused oral lorazepam. The nurse obtained a telephone order for injectable lorazepam and administered it without offering the resident the option to refuse. The resident's representative was not informed of the new injectable medication order prior to its administration and stated they would not have consented. The Director of Nursing confirmed that administering a psychotropic medication without consent constituted a chemical restraint and that licensed nurses were expected to recognize and question such orders.
Failure to Implement Abuse Identification and Reporting Policy
Penalty
Summary
Facility staff failed to implement the required components of their abuse prohibition policy for a resident with severe cognitive impairment and multiple medical conditions, including dementia, diabetes, sleep apnea, and anxiety. The resident required extensive assistance with daily activities. A medication error occurred involving the administration of an injected medication, which was later determined to be a transcription error. The resident's representative raised multiple concerns about care, including medication administration, behavior management, diabetes management, activities, and provider oversight, during a meeting with facility leadership. Despite these concerns and the facility's policy identifying unauthorized chemical restraints as abuse, staff did not identify or report the incident as potential abuse or neglect to the State Agency. Staff interviews revealed that the concerns expressed by the resident's representative were treated as educational opportunities rather than allegations of abuse or neglect. The Assistant Director of Nursing and the Administrator both confirmed that the incident was not reported to the State Agency, as they did not consider it to be abuse or neglect. The Director of Nursing acknowledged that the administration of psychotropic medications as an injectable could constitute a chemical restraint and a form of abuse, as outlined in facility policy. However, the facility did not follow its own procedures for identification and reporting, resulting in a failure to protect residents from potential abuse and neglect.
Failure to Report Medication Error and Alleged Abuse
Penalty
Summary
The facility failed to report an allegation of potential abuse and/or neglect to the State Agency as required, following a medication error involving a resident with severe cognitive impairment and multiple medical conditions, including dementia, diabetes, sleep apnea, and anxiety. The resident required extensive assistance with daily activities. On the day of the incident, a medication error occurred when a psychotropic medication was administered via injection after the resident refused the oral form, due to a transcription error by a registered nurse who failed to enter the new order correctly into the electronic health record. The resident's representative expressed multiple complaints regarding care, including medication management and provider oversight, during a meeting with facility leadership. Despite these complaints and the medication error, facility staff did not generate or report an allegation of abuse or neglect to the State Agency. Interviews with facility staff revealed that the incident was considered a transcription error with no negative effect on the resident and was therefore not reported. However, the Director of Nursing later confirmed that administering a psychotropic medication as an injection constituted a chemical restraint, which is a form of abuse, and acknowledged that the incident should have been reported. The administrator also confirmed awareness of the incident and the complaints but did not report them.
Failure to Obtain Consent and Follow Standards for Psychotropic Medication Administration
Penalty
Summary
A deficiency occurred when a resident with severe cognitive impairment and multiple diagnoses, including dementia and anxiety, was administered lorazepam by injection without proper adherence to professional standards of nursing practice. The resident had an order for lorazepam by mouth as needed for anxiety, but during an episode of agitation, the nurse obtained a telephone order to administer lorazepam subcutaneously. There was no documentation that non-pharmacological interventions were attempted prior to administering the medication, nor was there evidence that the oral form was offered as required by facility policy. Additionally, the resident's representative was not given the opportunity to accept or decline the change in the medication administration route before the injection was given. The nurse involved stated that the resident could not refuse the medication because it was ordered by the physician, and the Director of Nursing confirmed that administering a psychotropic medication in a manner that prevented refusal constituted a chemical restraint. This practice did not meet professional standards and violated the resident's rights regarding informed consent and medication administration.
Inconsistent Showering Care for Dependent Residents
Penalty
Summary
The facility failed to provide consistent showering and grooming care for three residents who were dependent on staff for activities of daily living (ADL). Resident 1, who had moderate cognitive impairment and required substantial assistance with showering, missed six out of eight scheduled showers in February and four out of eight in March. During an observation, Resident 1 was found with unkempt hair and dirty nails, indicating a lack of proper hygiene care. Staff M, a Nursing Assistant, admitted to not having given any showers during their shift, despite being responsible for resident showers. Resident 3, with intact cognition but dependent on staff for personal care, missed seven out of eight scheduled showers in both January and February, and four out of eight in March. The resident reported receiving a shower only once every three weeks, usually a bed bath, due to staff shortages. Similarly, Resident 4, who also required assistance with showering, missed seven out of eight scheduled showers in January and six out of eight in March. The resident expressed discomfort and a sense of neglect due to the lack of regular showers. Staff C, the Assistant Director of Nursing, acknowledged a breakdown in the showering process, confirming the lack of regular showers for Resident 4.
Neglect in Resident Care Leading to Amputation
Penalty
Summary
The facility failed to ensure a resident was free from neglect, resulting in harm to the resident. Resident 1, who had a history of a fractured right hip and right side hemiplegia/hemiparesis, was admitted with severely impaired cognition and required assistance with personal care. The facility's policy required weekly skin assessments, but these were not consistently performed for Resident 1. The resident developed a necrotic area on the right foot and little toe, which was not promptly addressed, leading to hospitalization and partial amputation. The deficiency arose from multiple lapses in care. Staff D, the Resident Care Manager, admitted to not assessing Resident 1's right foot for 14 days, despite the policy requiring weekly checks. Staff O, an LPN, noted a small open area on the resident's foot but failed to notify anyone or document the change. Staff E, another LPN, reported that the resident refused a dressing change due to pain, yet no further action was taken. Staff F observed changes in the wound but did not document or notify the physician, and Staff H, who worked double shifts, did not perform treatments or dressing changes on weekends. Interviews with various staff members revealed a lack of communication and documentation regarding the resident's condition. Staff J, a Restorative Assistant, discovered the wound without a dressing and reported it to Staff E. The Assistant Director of Nursing confirmed that Staff F did not document the wound's condition or notify the physician. The resident was eventually transferred to a hospital, where a partial amputation was performed due to the severity of the necrotic tissue.
Deficiencies in Resident Hygiene and Dining Experience
Penalty
Summary
The facility failed to ensure that residents were bathed, free from odors, and provided a dignified dining experience, affecting five residents. Resident 13, who was alert and oriented, had long fingernails with a brown substance underneath and had not received a bed bath since 12/31/2024, despite being scheduled for showers twice a week. The resident's room had a musty urine smell, and the resident expressed embarrassment about their hygiene, especially during family visits. Staff failed to document refusals of baths and did not reapproach the resident for bathing. Resident 14, who was dependent on staff for bathing, had not had a shower for over a week, resulting in long, split fingernails with a brown substance underneath and greasy, unkempt hair. The resident expressed feeling unclean and embarrassed. Similarly, Resident 25, who was recovering from pneumonia, had not had a bath since 12/13/2024 and expressed a desire for at least a basin of water and a washcloth to feel better. The resident felt unmotivated to leave bed due to feeling unclean. Resident 27, who shared a room with Resident 13, also experienced a lack of bathing, with their last shower documented on 12/10/2024. The resident's room had a strong urine odor, and the resident expressed embarrassment about their hygiene. Additionally, Resident 7, who was severely cognitively impaired, was observed eating with their hands instead of using an adaptive spoon, which staff failed to assist with until a LPN intervened. The dining experience was further compromised by staff removing tablecloths and cleaning while residents were still eating, which was acknowledged as undignified by the Assistant Director of Nursing.
Failure to Resolve Resident Grievances Promptly
Penalty
Summary
The facility failed to ensure a prompt effort to resolve grievances as required by their policy, which placed residents at risk for unmet care needs. During a Resident Council meeting, residents expressed concerns about call lights not being answered timely and nursing assistants only addressing the resident closest to the door, regardless of who activated the call light. Additionally, residents reported that food was not consistently delivered hot, despite previous complaints. These grievances were not followed up on, and residents were unaware of the grievance process or their right to file grievances anonymously. The facility's grievance policy required the Activities Director to complete a grievance form for concerns raised during Resident Council meetings and forward it to the Social Services Director, who would then log and distribute the grievances to the appropriate department heads for resolution. However, the Social Services Director did not receive or log the grievances from the December 2024 meeting, and the Activities Director did not retain copies of the grievances. This lack of follow-through and communication resulted in residents not receiving feedback or resolution for their concerns.
Failure to Validate PASARR Assessments
Penalty
Summary
The facility failed to properly review and validate the Preadmission Screening and Resident Reviews (PASARR) for four residents, which is essential to ensure that individuals with serious mental illness (SMI) or intellectual/developmental disabilities (ID/DD) are not inappropriately placed in nursing homes. For Resident 9, the PASARR forms completed did not accurately reflect the resident's diagnoses of bipolar disorder and anxiety, and a level 2 evaluation was not referred as required. Staff E, the Social Service Director, acknowledged the oversight during an interview. Resident 263's medical record lacked a level 1 PASARR, although a level 2 Invalidation Assessment was completed, indicating no need for further psychiatric evaluation. However, the absence of a level 1 PASARR meant that the initial screening process was incomplete. Similarly, Resident 56's PASARR level 1 assessment was conducted after admission, contrary to the requirement for it to be completed prior to admission. The facility staff mistakenly believed that a level 2 Invalidation Assessment sufficed without a level 1 PASARR. Resident 4's record showed a level 1 PASARR indicating a mood disorder that required a level 2 evaluation, but no such evaluation was requested or completed. The facility's failure to ensure the completion and accuracy of PASARR assessments before admission placed these residents at risk of not receiving appropriate care and services tailored to their needs, as mandated by the Department of Social and Health Services guidelines.
Failure to Develop Timely Baseline Care Plans
Penalty
Summary
The facility failed to develop and implement baseline care plans (BCPs) within 48 hours of admission for five newly admitted residents, which included specific initial goals and treatment plans. This deficiency was identified for residents with various medical conditions such as stroke, dementia, heart complications, Parkinson's, and mental health disorders. The absence of BCPs or incomplete BCPs meant that residents and their representatives were not informed about the initial care plans, medications, dietary instructions, or services to be provided by the facility. For instance, Resident 49, who had severe cognitive impairment and non-verbal pain indicators, did not have a BCP formulated. Similarly, Resident 62's BCP lacked initial nursing or therapy goals, and neither the resident nor their representative received a summary of the BCP. The report also highlights that some BCPs were initiated late, such as Resident 263's BCP, which was started on the third day of admission instead of within the required 48 hours. Additionally, the BCPs for Residents 263 and 48 were incomplete, lacking initial goals and failing to provide summaries to the residents or their representatives. Interviews with facility staff revealed that the transition to a new system for managing BCPs was incomplete, leading to inconsistencies and omissions in the care planning process. This situation placed residents at risk of unmet care needs and a lack of knowledge regarding their initial care plans.
Deficiencies in Care Plan Revisions and Care Conferences
Penalty
Summary
The facility failed to ensure that care plans were consistently reviewed and revised to meet the current needs of five residents. For Resident 25, the care plan lacked specific parameters for the use of a Bipap machine, including settings for oxygen use, pressure delivery, and instructions for the humidifier. Resident 30's care plan did not identify the type of IV catheter used, its size, or the treatment for its maintenance, and it lacked a complete focus on the resident's pain management. Resident 13's care plan did not reflect the administration of an antidepressant medication that was ordered, indicating a failure to update the care plan with current medication interventions. Resident 4's care plan did not address the high-risk immunosuppressive medication they were taking or the presence of untreated melanoma, which required monitoring. Additionally, Resident 17's care plan did not include the use of a seat belt restraint or enabling device for their electric wheelchair, which was necessary for their mobility and safety. These omissions in the care plans indicate a lack of comprehensive and up-to-date documentation to address the residents' medical needs and conditions. Furthermore, the facility failed to conduct care conferences with the participation of residents or their representatives. Resident 4 reported attending only one care conference since their admission, despite multiple conferences being documented. The facility did not consistently include input from nursing assistants in care conferences, and there was a lack of evidence that all required interdisciplinary team members attended these meetings. This lack of resident involvement and comprehensive team input in care planning further contributed to the deficiencies identified in the facility's care planning process.
Deficiencies in Resident Care and Monitoring
Penalty
Summary
The facility failed to provide appropriate care and obtain necessary physician assistance for a resident with a history of mental health and substance use disorder. Resident 263, who was admitted with a right foot ulcer, bipolar disorder, and depression, exhibited significant behavioral issues, including hallucinations, delusions, and suicidal tendencies. Despite these behaviors and the resident's lack of sleep, the facility staff did not notify the medical provider or seek further interventions. The resident's wound vac was turned off due to their behavior, and the facility did not have specific training on substance use disorder, which contributed to the inadequate care provided. Another deficiency involved Resident 28, who was admitted with cellulitis and required IV antibiotic treatment. The facility failed to properly maintain and monitor the resident's peripheral IV line. The IV dressing was not changed for over a week, and the line was not flushed or maintained as per standard protocol. The orders for flushing and monitoring the IV site were not included in the Medication Administration Record, leading to the peripheral IV line becoming clogged and dirty. Resident 13, who was admitted with a stroke and left-sided paralysis, experienced skin breakdown due to inadequate repositioning and monitoring. The resident reported soreness and skin issues, but the facility staff failed to conduct regular skin assessments. The last documented skin check was on 12/28/2024, and no assessments were conducted in the first week of January 2025. The resident was later found to have Moisture Associated Skin Dermatitis due to prolonged exposure to moisture from wearing a brief and bowel incontinence.
Deficiency in Restorative Nursing Services for ROM
Penalty
Summary
The facility failed to provide adequate treatment and services to maintain or improve the range of motion (ROM) for four residents, leading to a deficiency in restorative nursing services. Resident 13, who had a history of stroke and paralysis, was supposed to receive ROM exercises for their left shoulder, elbow, and wrist six times a week. However, the resident reported that the exercises were infrequent and not part of a structured therapy program. Similarly, Resident 14, who was dependent on staff for transfers and had a prescribed RA program involving TheraBand exercises, reported that the program was inconsistent and had not been conducted for at least ten days. Resident 30, who was recovering from a partial foot amputation and sepsis, was supposed to engage in an exercise program involving TheraBand and weights. However, the resident stated that the program never commenced after their discharge from physical therapy. The care plan indicated a six-day-a-week exercise regimen, but there was no documentation to confirm that these exercises were being performed. Staff D, responsible for the restorative nursing program, admitted to not reviewing the residents' programs for maintenance and acknowledged the lack of quarterly reviews. Resident 42, who had undergone a left hip replacement and had a contracture, was supposed to perform active ROM exercises for bed mobility. However, the resident reported a decline in their ability to move their right leg and had not participated in exercises for some time. Staff O, who had been working in restorative care, confirmed that no exercises had been conducted for Resident 42 and could not provide documentation of any refusals by the resident. The Director of Nursing Services acknowledged that the restorative nursing programs for the 37 residents were broken and needed review.
Staffing Shortages Lead to Multiple Deficiencies in Resident Care
Penalty
Summary
The facility failed to provide sufficient nursing staff to meet the needs of its residents, resulting in multiple deficiencies across various aspects of care. Observations and interviews revealed that residents were not receiving adequate assistance with activities of daily living (ADLs), such as bathing and grooming, leading to poor hygiene and dignity issues. For instance, several residents reported not having received showers for extended periods, and their physical appearance, such as long, dirty fingernails and unkempt hair, reflected this neglect. Additionally, the facility's grievance process was not effectively implemented, as residents' complaints about issues like cold food and delayed call light responses were not adequately addressed. The facility also failed to provide necessary medical care and monitoring, as evidenced by the lack of ongoing assessment and treatment of skin conditions and peripheral intravenous (IV) line care. One resident had a purple discoloration on their skin that had not been assessed since late December, and another resident's IV line had not been flushed or had its dressing changed for over a week. Furthermore, the facility did not ensure that residents received appropriate restorative nursing services to maintain their range of motion and mobility. Residents expressed dissatisfaction with the lack of physical therapy and exercise programs, which were either not provided or inadequately implemented. Staffing issues were a significant contributing factor to these deficiencies. The facility relied heavily on agency staff who received minimal orientation, leading to inconsistent care. Interviews with staff members revealed that they were often overworked, with nursing assistants being pulled from their assigned duties to cover shortages in other areas. This resulted in incomplete care tasks, such as showers and restorative exercises, and increased workloads for the remaining staff. The facility's assessment of its staffing needs was outdated and did not reflect the current situation, further exacerbating the problem.
Inadequate Maintenance of Oxygen Equipment
Penalty
Summary
The facility failed to maintain proper cleaning, disinfecting, and storage of oxygen care equipment, which led to potential risks of infectious disease transmission among residents. Resident 1, who was admitted with obstructive sleep apnea and dementia, had an oxygen concentrator with a filter covered in dust, dirt, and hair, despite physician orders for weekly changes. Observations on two separate dates confirmed the filter remained uncleaned. Similarly, Resident 36, with a history of bronchitis and severe cognitive impairment, also had a dirty oxygen concentrator filter, with no records indicating the filter had been changed as required. Resident 35, who had bronchitis and heart failure, was observed with an oxygen concentrator filter similarly covered in dust, dirt, and hair. Unlike the other residents, there were no physician orders for changing the filter, indicating a lack of protocol for maintaining the equipment. Staff interviews revealed a lack of adherence to scheduled maintenance, with a Licensed Practical Nurse acknowledging the weekly schedule but not performing the task. Resident 25, who required continuous oxygen due to heart failure and respiratory issues, had their oxygen humidifier bottle placed on the floor due to tubing length issues, contrary to infection control practices. The oxygen tubing was also observed on the floor, and staff interviews confirmed these practices were not compliant with infection control standards. The Director of Nursing Services expected staff to follow physician orders and maintain infection control, but observations and interviews indicated these expectations were not met.
Facility Fails to Maintain Safe and Sanitary Environment
Penalty
Summary
The facility failed to maintain a safe, comfortable, and sanitary environment across multiple areas, including the East and West halls, East dining room, shower room, specific resident rooms, laundry room, utility rooms, and the conference/activities room. Observations revealed that the floors in the East and West halls had embedded dirt and grime that could not be cleaned by regular sweeping and mopping. The East dining room had split tiles with black substances and a damaged base heater, posing potential risks to residents. The shower room had a black tar-like substance on the walls and tiles, stained toilets, and dusty vents, indicating poor maintenance. In specific resident rooms, issues such as deep gouges in walls, stale urine smells, and temperature control problems were noted. Residents expressed discomfort due to excessive heat in their rooms, which was difficult to regulate. The laundry room and utility rooms had black and brown grime that could not be cleaned, and damaged countertops and cabinets were observed. The conference/activities room had chipped tiles, a large hole in the floor, and a damaged door, all of which were potential safety hazards. Interviews with staff revealed that the facility was old and in need of repairs, with no current repair plans in place. The floors were overdue for waxing and stripping, contributing to the uncleanable conditions. The administrator acknowledged the expectation to maintain a clean and comfortable environment, but the facility's current state did not meet these standards, placing residents at risk for potential accidents and exposure to contaminants.
Failure to Assess Wheelchair Seat Belt as a Restraint
Penalty
Summary
The facility failed to comprehensively assess and monitor the need for a physical restraint for a resident using a seat belt in their electric wheelchair. The resident, who had moderately impaired cognition and mobility impairments, was unable to unbuckle the seat belt independently, which was confirmed by staff interviews. Despite the facility's policy requiring an evaluation to determine if a device acts as a restraint or enabler, no such evaluation was conducted for the wheelchair seat belt. Observations showed the resident leaning to one side in the wheelchair, indicating a potential risk of injury. Interviews with various staff members, including nursing assistants and the Assistant Director of Nursing Services, revealed a lack of awareness and adherence to the required assessment process for determining the use of the seat belt as a restraint. The staff acknowledged that the resident could not unbuckle the seat belt independently, and the necessary evaluation to classify the seat belt as a non-restraint was not performed. The facility's administrator and Director of Nursing Services admitted that the correct process for assessing the need for a physical restraint was not followed for the resident.
Failure to Implement Abuse Prevention Policies
Penalty
Summary
The facility failed to implement its abuse prohibition policy and procedures, which include components of resident protection, identification, reporting, and investigation. This deficiency was evident in the cases of four residents who were reviewed for abuse and neglect. For Resident 41, the facility did not conduct an investigation into allegations of verbal abuse by a Licensed Practical Nurse (LPN), despite the resident's grievance being submitted. The resident reported being yelled at and having their smoking supplies demanded by the LPN, yet the staff member continued to work with the resident after the allegations were made. Resident 28 experienced rough handling by a Registered Nurse (RN) during care, which resulted in pain and the need for a diagnostic image. Although the incident was reported to the Assistant Director of Nursing Services, it was not logged or investigated. Similarly, Resident 42's refusal of care by a new Nursing Assistant (NA) was not properly addressed, as the NA continued to work additional shifts without an investigation being conducted. Resident 27 reported being teased and called gay by an NA, which was documented in a grievance. However, the incident was not reported to the state agency, and the NA was not removed from resident care pending an investigation. The facility's failure to follow its own policies and procedures for abuse prevention and response placed residents at risk for continued exposure to abuse and neglect.
Failure to Notify Ombudsman of Resident Transfer
Penalty
Summary
The facility failed to provide a written notice of transfer or discharge to the representative of the Office of the State Long Term Care Ombudsman for a resident reviewed for transfer/discharge notice requirements. This deficiency was identified for a resident who was admitted with heart complications and Parkinson's disease and was transferred to the hospital due to a change in their baseline status. The resident's medical records indicated a moderately impaired cognition, and the transfer occurred without the required notification to the Ombudsman. Interviews with facility staff revealed a lack of awareness and process for notifying the Ombudsman of resident transfers or discharges. The Social Service Director, who started working at the facility after the incident, was unaware of the requirement to provide such notifications. The Administrator and Director of Nursing Services acknowledged that the correct process was not being followed, and a written notice should have been provided to the Ombudsman regarding the resident's transfer to the hospital.
Failure to Provide Written Bed Hold Notice During Hospital Transfer
Penalty
Summary
The facility failed to provide a written notice of bed hold to a resident or their representative at the time of the resident's transfer to a hospital. This deficiency was identified during a review of the medical records for a resident who was admitted with heart complications and Parkinson's disease and was transferred to the hospital due to a change in their status. The comprehensive assessment indicated that the resident had moderately impaired cognition, which underscores the importance of ensuring that the resident or their representative is informed about the bed hold policy. Interviews with facility staff revealed that the standard procedure was to inform the resident or their representative about the bed hold policy during a phone conversation, which should then be documented in the resident's medical records. However, in this case, the staff member responsible for the resident's case management acknowledged that the notice of bed hold was not completed with the resident's representative at the time of the hospital transfer. The Director of Nursing Services confirmed that if the notification was not documented in the medical record, it was not completed, indicating a lapse in the facility's adherence to the required notification process.
Failure to Develop Comprehensive Care Plans for Residents
Penalty
Summary
The facility failed to develop and implement comprehensive, resident-centered care plans for two residents, leading to unmet care and safety needs. Resident 21, who was admitted with a urinary tract infection and urine retention, had a severely impaired cognition and required a retention catheter. Observations revealed improper management of the catheter, with tubing touching the floor and the leg bag positioned at the same level as the bladder. The comprehensive care plan for Resident 21 lacked measurable goals, interventions, and specific information related to their urinary system, urinary tract infections, and activities of daily living. Staff interviews confirmed the absence of a comprehensive care plan for Resident 21's catheter use and urinary tract infections. Resident 56, admitted with a history of substance abuse, had a moderately impaired cognition. Observations showed Resident 56 appeared confused and expressed a desire to smoke, indicating a lack of a structured care plan addressing their substance use disorder (SUD). The care plan for Resident 56 did not include specific goals or interventions for assessing risks associated with SUD, monitoring for overdose, or preventing relapse. The Social Services Director acknowledged the absence of a care plan for SUD and admitted to lacking training in this area, which contributed to the deficiency.
Inconsistent Showering and Grooming Care for Residents
Penalty
Summary
The facility failed to provide consistent showering and grooming care for two residents, leading to unmet care needs. Resident 37, who has diabetes and asthma, was supposed to receive assistance with showering twice a week, as per their care plan. However, interviews and observations revealed that Resident 37 had not received a shower for nearly two weeks, resulting in strong urine odor, disheveled hair, and flaky skin. The shower book indicated that the last recorded shower was on 12/30/2024, and no showers were documented in the shower tasks from 12/08/2024 to 01/08/2025. Similarly, Resident 22, who has diabetes and a history of a cerebral vascular accident with right hemiparesis, was dependent on staff for showering and grooming. Despite being scheduled for weekly showers, Resident 22 had not received a shower since 12/10/2024, over a month ago. This lack of care resulted in flat, oily hair, long and dirty fingernails, and untrimmed facial hair. Staff interviews confirmed that the assigned nursing assistants were responsible for completing the residents' showers and nail care, but staffing inconsistencies were noted.
Failure to Assess Resident's Chewing Tobacco Use
Penalty
Summary
The facility failed to assess a resident who used chewing tobacco, which was necessary to prevent potential interactions with medications and health concerns. The resident, who was admitted after surgery for an infection and partial foot amputation, was on psychoactive and intravenous antibiotic medications. Despite being diagnosed with nicotine dependence to chewing tobacco, the resident was not assessed for tobacco use upon admission. During an observation and interview, the resident was found chewing tobacco at their bedside and stated that no one had inquired about their tobacco use since admission. The Assistant Director of Nursing Services admitted to being unaware of the resident's continued use of chewing tobacco and confirmed that the facility's policy to assess all residents for tobacco use was not followed in this case.
Failure to Ensure Proper Use of Bipap Device for Resident
Penalty
Summary
The facility failed to ensure proper respiratory care for a resident who required a Bipap device. The resident, who was on continuous oxygen and diagnosed with hypoxia, was supposed to use the Bipap device nightly. However, the resident had not used the device for about two months and it was found stored in a location they could not reach. The resident mentioned the need to return the device to the medical supply store. The physician orders from September did not specify the settings or type of mask for the device. Staff responsible for the resident's care were unaware of the resident's refusal to use the device and had not discussed the risks and benefits of using or not using the device with the resident.
Failure to Administer Tacrolimus Timely for Transplant Resident
Penalty
Summary
The facility failed to ensure the timely administration of the immuno-suppressive medication Tacrolimus for a resident who had undergone a heart transplant. The medication administration record (MAR) lacked specific instructions indicating the importance of administering Tacrolimus at the same time every day to maintain steady blood levels and reduce the risk of organ rejection. This oversight resulted in the medication being administered either too early or too late on multiple occasions, with deviations ranging from 40 minutes to over four hours outside the prescribed 12-hour interval. Interviews with facility staff revealed a lack of awareness regarding the critical timing requirements for Tacrolimus administration. The Resident Care Manager and a Licensed Practical Nurse were unaware of the necessity for strict adherence to administration times, and the Director of Nursing Services expected nurses to be knowledgeable about the medications they administer. The transplant pharmacist emphasized the importance of administering Tacrolimus precisely 12 hours apart to prevent organ transplant rejection, highlighting the risk posed by the facility's failure to adhere to these guidelines.
Failure to Monitor and Implement Non-Pharmacological Interventions for Psychotropic Medications
Penalty
Summary
The facility failed to ensure residents were free of unnecessary psychotropic medications, as evidenced by the lack of consistent monitoring of individualized targeted behaviors, failure to attempt non-pharmacological interventions prior to administering psychotropic medications, and the absence of assessments for abnormal involuntary movements (AIMS). For Resident 21, who was admitted with dementia without behavioral disturbance, the facility administered Seroquel without a clear indication for its use. The resident's care plan lacked specific goals and documentation of behaviors, and no non-pharmacological interventions were implemented. Additionally, a pharmacy review indicated that Seroquel was inappropriately prescribed for insomnia, and no AIMS assessment was conducted. Resident 263, admitted with depression and bipolar disorder, also received psychotropic medications without proper monitoring or non-pharmacological interventions. The resident's medication administration record showed orders for Trazodone and Risperidone, but there was no documentation of targeted behaviors or non-pharmacological interventions. Informed consent forms were incomplete, lacking signatures and specific non-pharmacological approaches. The care plan for Resident 263 was generic, with no resident-specific goals or monitoring of sleep patterns, and no AIMS assessment was completed. During an interview, the Director of Nursing Services acknowledged that informed consent and AIMS assessments should have been completed before administering the first dose of medication. The director also noted that the monitoring of targeted behaviors and non-pharmacological interventions was disrupted during a change of ownership and had not been properly documented. These deficiencies placed residents at an increased risk for medication-related adverse side effects and unmet care needs.
Failure to Provide Palatable and Warm Meals
Penalty
Summary
The facility failed to provide palatable and warm meals at the proper temperature for several residents, which was observed during a survey. Resident 4, who has diagnoses including diabetes and malnutrition, reported that the food was often served cold and unappetizing, making it difficult to eat. During an observation, Resident 4's breakfast consisted of cold, hard eggs and a grayish potato patty, which the resident found unappetizing. In the East Dining Hall, Resident 23 received a pureed diet that was described as disgusting and not appetizing, with no alternative offered by the nursing assistant staff. Resident 41 was served cold chicken strips and French fries and requested a warm plate, but the replacement was still not hot, and ranch dressing was unavailable. Resident 48 loudly expressed dissatisfaction with the food, describing it as garbage. Staff T, a nursing assistant, explained that residents who complained of cold food were served last from the hall cart, which took at least 15 minutes to reach the East Dining Room. A test tray observation in the West Dining Room revealed that the mechanical soft diet lacked flavor, with teriyaki beef not tasting like teriyaki, flavorless rice pilaf with a gummy consistency, and overcooked, brownish broccoli. The Director of Nursing Services stated that they expected meals to support residents' nutrition and dignity, but the observations indicated that the food served was not palatable or appetizing.
Failure to Update Facility Assessment After Ownership Change and Program Loss
Penalty
Summary
The facility failed to update its facility-wide assessment following a substantial change in ownership and the loss of access to a nursing assistant training program. The assessment, dated September 2023, did not reflect the change in ownership that occurred on August 1, 2024. Additionally, the facility did not update the assessment to account for the loss of the nursing assistant training program, which previously helped fill nursing assistant vacancies. During interviews, the Director of Nursing Services confirmed the suspension of the nursing assistant program, and the new Administrator acknowledged that the previous Administrator did not update the Facility Assessment after the change in ownership. These oversights placed residents at risk for unmet care needs.
Failure to Ensure Residents' Cognitive Capacity for Arbitration Agreements
Penalty
Summary
The facility failed to ensure that residents had the cognitive capacity to understand the nature and implications of entering into a binding arbitration agreement. This deficiency was identified for two residents, both of whom had severely impaired cognition due to conditions such as dementia. Resident 52 was admitted with diagnoses including a fracture, stroke, and dementia, and their comprehensive assessment indicated severely impaired cognition. Despite this, Resident 52 signed an arbitration agreement without the involvement of their resident representative (RR). Similarly, Resident 21, who was readmitted with heart and kidney complications and dementia, also signed an arbitration agreement despite having severely impaired cognition. The facility's Admissions Coordinator, Staff L, was responsible for having the residents sign the arbitration agreements. Staff L admitted to not referencing the residents' medical records or consulting with nursing staff about their cognitive status before having them sign the agreements. Both residents were unable to understand the agreements they signed, as confirmed by interviews with facility staff. The facility's Administrator acknowledged that the correct process was not followed, and the cognitive status of the residents should have been identified before they were asked to sign a binding legal contract.
Failure to Educate and Obtain Consent for Influenza Vaccination
Penalty
Summary
The facility failed to ensure that residents and/or their representatives were properly educated on the risks and benefits of the influenza vaccine, and that consent or declination was obtained for the vaccine for two of the five sampled residents. Resident 14, who was alert and oriented, reported not receiving the flu vaccine for the 2024/2025 season despite expressing a desire to receive it. The medical record showed no documentation of education, consent, or declination for the influenza vaccine, and the resident stated they had not been approached for consent. Additionally, the comprehensive assessment inaccurately noted that Resident 14 declined the vaccine and was not in the facility at the time, which the resident contradicted by stating they had not left the building. Resident 27, who had a representative assisting in decision-making, had a documented consent for the influenza vaccine dated 11/22/2024. However, the resident reported not receiving the vaccine despite consenting to it. The Infection Preventionist (IP), Staff U, acknowledged that there were no consents or education offered to residents for the flu season start and that they had recently assumed the position. The IP's list did not include Resident 14, and although Resident 27 was listed as having consented, they had not received the vaccine. The Director of Nursing Services admitted that the infection control and vaccine system was broken and needed assessment and updating. The local health department confirmed an influenza outbreak, emphasizing the need for up-to-date vaccinations.
Failure to Post Daily Nurse Staffing Information
Penalty
Summary
The facility failed to ensure that the daily nurse staffing information was posted in a location readily accessible to residents and visitors, as required by regulations. This deficiency was observed on three separate days during the recertification survey. On January 8th, 9th, and 13th, 2025, surveyors noted the absence of a daily staffing roster in the front of the nursing home or by the nursing desk area. The required information, including the facility name, date, census, and the total number and actual hours worked per shift for RNs, LPNs, and Nursing Assistants, was not available for residents or visitors to view. During interviews, staff members acknowledged the lack of posted staffing information. Staff C, the Assistant Director of Nursing Services, showed the surveyor a staffing schedule binder at the nursing station, which did not contain the necessary information. Staff B, the Director of Nursing Services, admitted that the facility did not have a daily nurse staffing information document posted in an accessible location. Staff B mentioned that the night shift staff used to complete this task, but it had been discontinued for unknown reasons. This failure to post staffing information placed residents, family members, and visitors at risk of not being fully informed about current staffing levels and resident census information.
Failure to Address Resident Grievances
Penalty
Summary
The facility failed to timely complete, thoroughly investigate, and provide prompt resolutions for grievances filed by five residents. The facility's grievance policy required investigations to be completed within five working days, with resolutions communicated to the resident or their representative. However, the grievance forms for these residents were found to be incomplete, with sections for investigation steps, administrator review, and follow-up left blank and unaddressed. Resident 1 had grievances regarding bathing frequency, use of personal hygiene items, and missing personal items, which were not investigated or resolved. Resident 2's grievances about increased leg swelling, a bed sore, and meal delivery issues were similarly unaddressed, and the resident was discharged without resolution. Resident 3's concerns about food quality and room cleanliness were forwarded to respective departments, but no further action was documented. Resident 4's grievances about therapy frequency, medication, and food quality, and Resident 5's request for a room change due to roommate issues, were also left unresolved. Interviews with staff revealed a lack of prioritization and follow-through in the grievance process, with responsibilities not being met and grievances not being communicated or addressed as required by the facility's policy.
Deficient Respiratory Protection Program During COVID-19 Outbreak
Penalty
Summary
The facility failed to maintain their Respiratory Protection Program (RPP) for N95 respirator masks, specifically related to fit testing and appropriate wear during a COVID-19 outbreak. Two staff members, Staff F and G, were not fit tested for N95 respirators despite being hired during the outbreak and working with residents. This was due to miscommunication between hiring and nursing managers. Additionally, three staff members, Staff E, H, and I, were observed wearing N95 masks with full facial beards, which interfered with the proper seal of the respirators. Despite being aware of the issue, none of the licensed nurses or nurse managers addressed the facial hair with the staff. The facility's COVID-19 outbreak began 51 days prior to the report, affecting 31 residents and 12 staff members. The facility had implemented source control interventions requiring all staff and visitors to wear N95 masks. However, the lack of fit testing and improper mask wear due to facial hair compromised the effectiveness of these interventions. The Director of Nursing acknowledged the deficiencies in the infection control program and stated that they were addressing issues as they arose. This deficiency was noted as a repeat issue from a previous statement of deficiencies.
Failure to Administer Medications and Conduct Lab Tests as Ordered
Penalty
Summary
The facility failed to ensure residents received physician-ordered medication, necessary laboratory values were drawn as ordered, and timely treatment for abnormal labs was provided. This resulted in harm for two residents who required hospitalization due to delayed treatment and worsening conditions. Two other residents were at risk for their conditions to worsen due to similar delays and inaccuracies in treatment. Resident 1, who had a history of kidney failure and a recent leg amputation, was admitted to the hospital for hyponatremia and an infected abscess. Despite orders for weekly blood draws to monitor these conditions, the facility failed to obtain the necessary labs on multiple occasions and did not notify the provider of abnormal lab results in a timely manner. This led to a critical drop in sodium levels, causing the resident to become lethargic and pale, ultimately requiring hospitalization. Resident 2, admitted with asthma and low blood pressure, was sent to the hospital shortly after admission due to a fever and productive cough. The resident was diagnosed with bacteremia and pneumonia and was prescribed Fluconazole and Vancomycin. However, the facility failed to administer Fluconazole for three consecutive days and did not notify the provider. This resulted in the resident's condition worsening, leading to hospitalization for pleural effusions and worsening fungal pneumonia. Similar issues were observed with Residents 3 and 5, where critical lab values were not communicated to the provider, and medication orders were not processed correctly, putting them at risk for delayed or inaccurate treatment.
Infection Control Deficiencies During COVID-19 Outbreak
Penalty
Summary
The facility failed to ensure staff compliance with current infection control guidelines and standards of practice. Specifically, staff were observed incorrectly donning and doffing personal protective equipment (PPE), not adhering to fit testing guidelines for N-95 respirators, and performing improper hand hygiene and glove changes between dirty and clean tasks. These actions were observed during a COVID-19 outbreak, placing residents at an increased risk for exposure to cross-contamination and transmission of diseases. During observations, staff were seen reusing disposable face shields throughout their shifts, contrary to the facility's policy that required face shields to be discarded after each use. Staff were also observed not performing hand hygiene after removing contaminated PPE and before donning new PPE. Additionally, some staff were seen handling clean linens and other items without proper hand hygiene, further increasing the risk of contamination. The facility also failed to ensure that staff were properly fit-tested for N-95 respirators. Several staff members had no documented fit testing in their personnel files, and some were observed wearing N-95 respirators with full facial beards, which is against the guidelines. The facility's infection preventionist and interim director of nursing services acknowledged these deficiencies and stated that the facility was behind on fit testing and that staff were not following CDC guidelines for PPE and hand hygiene.
Failure to Notify Physician of Change in Condition
Penalty
Summary
The facility failed to notify the provider of an elevated heart rate and a low blood pressure for one resident reviewed for a change in condition. This failure placed the resident at risk of inappropriate medication dosages, health complications, and timely care of services from the physician, resulting in a delay of treatment. The resident was admitted with diagnoses including pneumonia, chronic obstructive pulmonary disease, and hypertension. On one occasion, the resident's heart rate was significantly elevated, and on another, the resident's blood pressure was below the physician's specified threshold, but the physician was not notified in either instance. Staff interviews revealed that the normal process was to notify the physician of changes in condition, but this process was not followed. The resident's heart rate was recorded as elevated on multiple occasions, and the resident was eventually sent to the emergency department, where they were diagnosed with atrial fibrillation and prescribed new medications. Additionally, the resident's blood pressure readings were below the specified threshold on two occasions, but there was no documentation of the physician being notified. Staff members acknowledged that they did not follow the correct process, and the Interim Director of Nursing Services confirmed that the expectation was for nurses to follow physician orders and notify the provider of any changes in condition.
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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