Mountain View Rehabilitation And Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Marysville, Washington.
- Location
- 5925 47th Avenue Ne, Marysville, Washington 98270
- CMS Provider Number
- 505407
- Inspections on file
- 37
- Latest survey
- January 12, 2026
- Citations (last 12 mo.)
- 9
Citation history
Health deficiencies cited at Mountain View Rehabilitation And Care Center during CMS and state inspections, most recent first.
A resident with moderate cognitive impairment had their antipsychotic medication dosage increased on two occasions without the responsible party being notified, despite facility policy requiring notification within 24 hours. Both the RN and DON processed the medication changes but did not inform or document communication with the responsible party, who was known to be concerned about medications causing drowsiness.
The facility failed to complete timely and comprehensive Resident Assessment Instruments (RAI) and Care Area Assessments (CAA) for several residents, leading to incomplete evaluations of their needs and preferences. Significant Change in Status Assessments (SCSA) were also delayed for residents electing hospice services. Staff interviews revealed a lack of awareness and training regarding assessment requirements.
The facility failed to ensure accurate PASRR evaluations for residents, leading to potential risks in placement and mental health care. One resident's PASRR did not initially reflect their depression diagnosis, while another had conflicting information regarding their mental illness. Two residents were not referred for necessary level two evaluations, placing them at risk for inappropriate placement and unmet mental health needs.
The facility failed to properly monitor and document bowel movements, weights, and blood glucose levels for residents, leading to potential risks in their medical status. A resident with constipation had no documented bowel movements for several days, while another resident's weight monitoring was inconsistent with physician orders. Additionally, a diabetic resident experienced lapses in blood glucose monitoring and insulin administration, with their care plan lacking necessary diabetes management details.
The facility failed to ensure proper indications and monitoring for antipsychotic medications for several residents, leading to potential adverse effects. A resident was given Seroquel without appropriate indications, and consent was delayed. Another resident lacked individualized monitoring for Seroquel, resulting in unmonitored behaviors and a fall. A third resident was prescribed duloxetine and hydroxyzine without monitoring for adverse effects, despite being at risk for depression and mood issues.
The facility failed to maintain a safe, clean, and homelike environment, with issues such as uncomfortable sound levels, inadequate housekeeping, and insufficient living space. Residents experienced distress due to noise, cramped conditions, and unclean surroundings, with no documented intervention from the facility.
A facility failed to complete a Significant Change in Status Assessment (SCSA) for a resident who elected hospice services. Despite the requirement to perform a SCSA within 14 days of hospice enrollment, the resident's Minimum Data Set (MDS) assessments showed no SCSA was completed. Staff interviews confirmed the oversight without providing an explanation.
A facility failed to develop a baseline care plan for a resident with a hearing impairment, despite documentation of moderate difficulty hearing. The resident, admitted with paranoid schizophrenia and anxiety, had no assistive devices for hearing. Staff interviews revealed reliance on care plans to determine care levels, but the resident's hearing issue was not included, risking unmet needs and complications.
The facility failed to update care plans for two residents, one with multiple falls and another with a discontinued medication for weight loss. Despite recommendations for additional interventions after falls, these were not added to the care plan of a resident with stroke and neurocognitive disorder. Another resident's care plan was not updated after discontinuing Ozempic for weight loss. Staff interviews indicated care plans should be revised by care managers and reviewed quarterly, but this was not consistently done.
The facility failed to provide adequate assistance with ADLs for two residents, leading to deficiencies in care. A resident with stroke and neurocognitive disorder did not receive scheduled showers, while another with Alzheimer's and dysphagia was left without meal assistance for extended periods. Additionally, the latter's call light was repeatedly found out of reach, contrary to care plan directives.
A resident with pulmonary fibrosis and CHF did not receive oxygen therapy as prescribed, with the concentrator settings consistently above the ordered 3 lpm. Despite protocols to check settings every shift, the resident's oxygen levels fell below target, requiring temporary adjustment. Staff interviews confirmed the discrepancy in settings.
The facility failed to accurately complete the daily nurse staffing form with actual hours worked for each shift on multiple days. Observations showed that the posted forms did not reflect the actual hours worked, and interviews revealed that the Staffing Coordinator updated the hours the following day based on time punches, rather than in real-time. This misunderstanding of requirements placed residents and their representatives at risk of not being fully informed of staffing levels.
A resident with stroke, aphasia, and dementia exhibited repetitive yelling and distress, which the facility failed to consistently assess, monitor, or document. Despite having a care plan, there was no evidence of consistent implementation of interventions. Staff responses were inconsistent, and there was no structured system for documenting behavioral symptoms, placing the resident at risk of unmet emotional and psychosocial health needs.
The facility failed to secure and properly label medications, as observed with an LPN leaving an unlabeled insulin pen unattended on a cart. Additionally, two residents had medications accessible at their bedsides without proper authorization or assessment for self-administration. One resident had multiple medications on their nightstand, while another kept an Albuterol inhaler on their overbed table, both without a self-medication program assessment or care plan.
The facility failed to provide prompt dental services for two residents, resulting in a deficiency. One resident experienced pain and needed extractions and dentures, while another had broken teeth and had not seen a dentist since admission. Despite care plans indicating the need for dental coordination, there was no documentation of referrals or evaluations, as confirmed by staff interviews.
A facility failed to follow infection control procedures for a resident on enhanced barrier precautions, as staff did not wear gowns during high-contact care activities. Additionally, mechanical lifts were not sanitized between uses, with staff showing inconsistent understanding of disinfection protocols.
The facility failed to follow proper infection control protocols during wound care for three residents. An LPN and a provider did not change gloves or perform hand hygiene as required, risking contamination. For one resident, the LPN used the same gloves for multiple tasks, including handling soiled items. Another resident's care involved handling a glove box with unwashed hands, and for a third resident, hand hygiene was neglected between glove changes. These actions violated infection control procedures and CDC guidelines.
A resident with multiple wounds did not receive timely and appropriate wound care as per consultant recommendations. The facility delayed implementing treatment changes for the resident's wounds, including the anterior abdomen, right abdominal pannus, and buttocks, leading to a risk of complications. The Director of Nursing confirmed that there was no documentation explaining the delays or lack of implementation.
The facility failed to ensure timely administration of insulin for three residents with diabetes, leading to significant medication errors. Multiple doses were administered outside the required time frame, with some being up to four hours late. The Director of Nursing Services and the Administrator acknowledged the non-compliance but could not provide further information on the delays.
The facility failed to follow physician orders for three residents upon admission, including the use of a bipap machine for one resident and compression stockings and an abdominal binder for two residents with orthostatic hypotension. Staff interviews confirmed that these orders were missed or not documented, placing residents at risk of medical complications.
Failure to Notify Responsible Party of Antipsychotic Medication Change
Penalty
Summary
The facility failed to notify the responsible party when a resident's antipsychotic medication order was changed. Specifically, a resident with moderately impaired cognitive ability was admitted on risperidone, and the dosage was increased on two separate occasions. There was no documentation in the clinical record that the responsible party had been notified of these medication changes, as required by facility policy, which states that notification must occur within 24 hours of a change in treatment. Interviews with the Resident Care Manager/Registered Nurse and the Director of Nursing Services confirmed that both processed the medication order changes but did not notify the responsible party or document any such notification. The responsible party was known to be particularly concerned about medications that could cause drowsiness, yet was not informed of the changes to the resident's antipsychotic regimen.
Deficiency in Timely and Comprehensive Resident Assessments
Penalty
Summary
The facility failed to complete the Resident Assessment Instrument (RAI) and Care Area Assessments (CAA) within the required timeframes and with comprehensive summaries for several residents. This deficiency was observed in the cases of nine residents, where the assessments lacked thorough analysis of the residents' needs, strengths, goals, and preferences. For instance, Resident 70's admission MDS assessment did not include comprehensive summaries for psychosocial well-being, activities, and return to community CAAs. Similarly, Resident 179's annual MDS assessment lacked comprehensive summaries for psychotropic drug use, cognitive loss, and mood CAAs. Additionally, the facility did not complete Significant Change in Status Assessments (SCSA) within the required 14-day period for residents who elected hospice services. Resident 4 and Resident 62 had their SCSA completed 33 and 31 days after starting hospice services, respectively. Furthermore, Resident 66's admission MDS assessment and Medicare discharge assessment were completed late, as were Resident 61's comprehensive admission assessment and Resident 55's quarterly MDS assessment. Interviews with facility staff revealed a lack of awareness and training regarding the completion of CAAs and MDS assessments. Staff H, an LPN/MDS Coordinator, was unaware of the requirement to fill out CAAs, while Staff G, responsible for cognition, psychotropic meds, and psychosocial well-being CAAs, identified issues with the CAA process and acknowledged incomplete assessments for several residents. The Director of Nursing and Staff H confirmed the late completion of assessments for multiple residents.
PASRR Deficiencies in Resident Evaluations
Penalty
Summary
The facility failed to ensure the Pre-Admission Screening and Resident Review (PASRR) accurately reflected the current status for two residents and failed to refer two residents for level two evaluations. Resident 50 was admitted with diagnoses including depression and a genetic condition, but their PASRR did not initially reflect these conditions. The PASRR was reviewed by the Social Services Supervisor and Administrator, who noted that the diagnosis of depression was added after admission, and a new PASRR was completed to address this. Resident 45's records showed no completed level one PASRR initially, and conflicting information was found regarding their diagnoses and indicators of serious mental illness. The PASRR was eventually uploaded, showing the resident was discharged to a different facility. Resident 56 was admitted with a diagnosis of depression and was taking an antidepressant, but their PASRR indicated a need for a level two evaluation, which was not completed prior to admission. Staff A confirmed that no level two evaluation was done. Resident 5 was referred for a PASRR level two evaluation 19 days after initial admission, and Staff A mentioned an invalidation for the level two PASRR. These failures placed the residents at risk for inappropriate placement and not receiving timely and necessary services to meet their mental health care needs.
Deficiencies in Monitoring and Documentation of Resident Care
Penalty
Summary
The facility failed to ensure proper monitoring and documentation of bowel movements, weights, and blood glucose levels for several residents, leading to potential risks in their medical status and quality of life. Resident 20, who was admitted to the facility, had physician orders for laxatives and stool softeners due to constipation. However, there was no documentation of bowel movements for several days, and no abdominal assessments or new orders were documented until a week later. Staff interviews revealed that the electronic health record system was supposed to alert nurses when a resident had not had a bowel movement for three days, but this was not effectively followed. Additionally, Resident 20 had orders for weekly weight monitoring, but there were multiple instances where weights were not documented as required. Staff interviews indicated a lack of consistent communication and adherence to weight monitoring protocols. Similarly, Resident 5's weight monitoring was not conducted according to the physician's orders, with weights not being taken on consecutive days as required upon admission. Resident 50, diagnosed with Type II Diabetes Mellitus, had issues with blood glucose monitoring and insulin administration. There were numerous days without documented blood glucose levels, and insulin was not administered as ordered. The care plan for Resident 50 did not address their diabetes management, and staff interviews highlighted a lack of clarity and adherence to protocols for insulin management and blood glucose checks. The facility's failure to follow these protocols and document necessary information placed residents at risk of unmanaged medical conditions.
Inadequate Monitoring and Indications for Antipsychotic Use
Penalty
Summary
The facility failed to ensure adequate indications for the use of antipsychotic medications for several residents, leading to potential adverse side effects. Resident 179 was administered Seroquel for agitation without appropriate indications, as the consent form listed confusion, anxiety, and depression, which are not suitable reasons for antipsychotic use. Additionally, the consent for Seroquel was obtained 23 days after administration, and the consent for Hydroxyzine lacked a diagnosis or indication for use. Observations showed Resident 179 frequently asleep or restless in their wheelchair, indicating possible adverse effects from the medication. Resident 380, diagnosed with paranoid schizophrenia and anxiety, was prescribed Seroquel without individualized monitoring for target behaviors. The care plan did not direct staff to monitor the efficacy of the antipsychotic medication, and behaviors such as crying and paranoia were not documented for monitoring purposes. A fall incident occurred when the resident became agitated and was not effectively de-escalated, highlighting the lack of proper behavior monitoring and documentation. Resident 45, with diagnoses including PTSD and major depressive disorder, was prescribed duloxetine and hydroxyzine without monitoring for adverse consequences or behaviors. The care plan indicated a risk for depression and mood problems, but there was no documentation of monitoring for side effects or effectiveness of the medications. The facility's failure to implement proper monitoring and documentation for these residents' psychotropic medication use put them at risk for adverse side effects and ineffective treatment.
Facility Fails to Maintain Safe and Homelike Environment
Penalty
Summary
The facility failed to maintain a safe, clean, and homelike environment for its residents, as evidenced by multiple observations and interviews. Residents were subjected to uncomfortable sound levels, particularly in a three-bed room where one resident, who was cognitively impaired, frequently yelled and disrupted the other two residents. Despite the distress caused, there was no documentation of resident preferences related to personal space or privacy curtains, and no grievances were logged regarding these issues. The facility also failed to provide adequate housekeeping and maintenance. Observations revealed sticky floors, dusty light fixtures, and walls with exposed drywall and nail holes. The hallways and utility room doors were dusty and discolored, and there were reports of gnats in the nurse's station and resident rooms. Bathrooms were found to be unclean, with rust stains, clogged drains, and unlabeled personal items scattered around. Privacy curtains were visibly soiled with brown stains and particulate matter, and there was no clear protocol for their regular cleaning or replacement. Additionally, the facility did not ensure residents had adequate living space, as some rooms did not meet the required square footage for a homelike environment. Residents in three-person rooms were cramped, with privacy curtains reducing their personal space. Interviews with staff and residents highlighted a lack of intervention from the facility to address these issues, leading to a diminished quality of life for the residents.
Failure to Complete Significant Change in Status Assessment for Hospice Resident
Penalty
Summary
The facility failed to identify a Significant Change in Status Assessment (SCSA) for Resident 229, who was reviewed for hospice services. According to the Long-Term Care Facility Resident Assessment Instrument, a SCSA is required within 14 days when a resident enrolls in a hospice program. The facility's policy also mandates that significant change in status assessments be completed within 14 days of identification. Resident 229 elected their hospice benefit on December 20, 2024, but a review of their Minimum Data Set (MDS) assessments since admission showed no SCSA had been completed. During interviews, both the Licensed Practical Nurse/MDS Coordinator and the Director of Nursing confirmed that Resident 229 was on hospice and acknowledged that a SCSA had not been performed, with no explanation provided for the oversight.
Failure to Address Hearing Impairment in Resident's Care Plan
Penalty
Summary
The facility failed to develop and implement a baseline care plan for a resident with a hearing impairment, which is necessary to provide effective and person-centered care. Resident 380, who was admitted with diagnoses including paranoid schizophrenia and anxiety, was documented to have mild cognitive impairment and moderate difficulty hearing without any assistive devices. Despite this, the resident's care plan did not address their hearing impairment, as confirmed by the nursing staff and the Resident Care Manager. The lack of a focus area for the resident's hearing impairment in the care plan was evident from the nursing admission assessment and progress notes, which consistently noted the resident's difficulty hearing. Interviews with staff revealed that the baseline care plan was supposed to be individualized based on the nursing admission assessment and other relevant information. However, the nursing manager responsible for starting the baseline care plan did not include the resident's hearing impairment. Staff members, including Nursing Assistants and the Resident Care Manager, indicated that they rely on the care plan to determine the level of care needed for each resident. The failure to include the hearing impairment in the care plan placed the resident at risk of not being informed of their initial plan for care and services, leading to potential unmet needs and complications.
Failure to Revise Care Plans for Falls and Nutrition
Penalty
Summary
The facility failed to review and revise care plans for two residents, leading to potential risks for unmet care needs. Resident 179, who was admitted with conditions including stroke with hemiparesis and neurocognitive disorder, experienced 15 falls since admission. Despite fall investigations recommending additional interventions such as checking the resident's position and incontinence status at specified intervals, these interventions were not incorporated into the resident's care plan. This oversight occurred on multiple occasions, including after falls on 07/01/2024, 08/31/2024, and 10/12/2024. Resident 20, admitted with a diagnosis of diabetes, was receiving Ozempic for weight loss from 10/24/2024 until it was discontinued on 12/12/2024. However, the care plan for expected weight loss was not updated to reflect the discontinuation of the medication. Interviews with staff revealed that care plans were supposed to be revised by resident care managers and reviewed as needed and quarterly, but this process was not adequately followed, resulting in deficiencies in care plan management.
Deficiencies in ADL Assistance and Call Light Accessibility
Penalty
Summary
The facility failed to provide adequate assistance with activities of daily living (ADLs) for two residents, leading to deficiencies in care. Resident 179, who was admitted with conditions including stroke with hemiparesis and neurocognitive disorder, required maximum assistance for bathing twice a week. However, records showed that Resident 179 did not receive showers as scheduled between 12/30/2024 and 01/07/2025, receiving only one shower during this period. The facility's administrator stated that showers should be provided at least once a week, indicating a discrepancy between the care plan and actual care provided. Resident 4, diagnosed with Alzheimer's Disease and dysphagia, required assistance with eating. Observations revealed that Resident 4 was left without assistance for extended periods during meals, with their breakfast tray left unattended from approximately 7:30 AM until 8:55 AM on one occasion. Staff interviews confirmed that Resident 4 needed one-on-one feeding assistance due to shaky hands, yet the care plan only indicated set-up assistance. Documentation showed that Resident 4 was dependent on staff for eating in 14 out of 24 opportunities, highlighting inconsistencies in the care plan and actual needs. Additionally, Resident 4's call light was repeatedly found out of reach, clipped to the pillowcase or on the floor, contrary to the care plan directive that it should always be within reach. This oversight was observed on multiple occasions, indicating a failure to ensure the resident's ability to call for assistance. Staff interviews confirmed that the call light should be accessible, yet it was not consistently positioned as required, further contributing to the deficiency in care provided to Resident 4.
Failure to Adhere to Prescribed Oxygen Therapy
Penalty
Summary
The facility failed to provide respiratory care consistent with professional standards of practice for a resident with pulmonary fibrosis and congestive heart failure. The resident was admitted with a physician's order for oxygen therapy at 3 liters per minute (lpm) via nasal cannula. However, observations revealed that the oxygen concentrator settings were consistently set higher than the prescribed 3 lpm, with settings observed at 3.5 lpm and 3.25 lpm during different checks. The resident reported not adjusting the settings themselves, and the concentrator was placed in the bathroom to reduce noise. Staff interviews indicated that the oxygen settings should be checked every shift to ensure compliance with the physician's order. Despite this protocol, the settings were not maintained as ordered, and the resident's oxygen saturation levels were recorded below the target, at 85%, necessitating an increase to 4 lpm temporarily. The facility's failure to adhere to the prescribed oxygen therapy placed the resident at risk for unmet needs and potential negative outcomes.
Failure to Accurately Post Daily Nurse Staffing Information
Penalty
Summary
The facility failed to ensure the daily nurse staffing form was accurately completed with actual hours worked for each shift on five out of six days reviewed. Observations on multiple days revealed that the posted daily nursing staffing forms did not reflect the actual hours worked by the nursing staff. Interviews with Staff C, the Staffing Coordinator, indicated that the actual hours worked were updated the following day based on time punches, rather than at the beginning of each shift as required. Staff C was unaware of the requirement to update the actual hours worked section in real-time after each shift. Further interviews with Staff A revealed a misunderstanding of the requirement, as they believed the staffing posting was updated every 12 hours due to some staff working 12-hour shifts. However, during the survey period, no updates to the daily staffing sheet were observed, and the staffing coordinator did not understand the requirement to update in real-time after each shift. This failure placed residents and their representatives at risk of not being fully informed of the current staffing levels.
Failure to Address Behavioral Health Needs
Penalty
Summary
The facility failed to adequately address the emotional and psychosocial well-being of a resident, identified as Resident 53, who was admitted with diagnoses including stroke, aphasia, and dementia without behavioral disturbance. The resident exhibited repetitive yelling and distress, which was not consistently assessed, monitored, or documented by the facility staff. Despite having a care plan that included monitoring for signs of depression and obtaining mental health consultations as needed, there was no evidence of consistent implementation of these interventions. Observations and interviews revealed that Resident 53 frequently yelled out in a distressed manner, causing disruption to themselves and their roommate. Staff responses were inconsistent, and there was no documentation of specific interventions attempted to address the resident's behaviors. The facility's records showed instances of target behaviors related to the resident's antidepressant medication, but these were not specified or accompanied by corresponding progress notes detailing the behaviors or interventions. The lack of a structured system for nursing assistants to document behavioral symptoms further contributed to the deficiency. Interviews with staff indicated that while they were aware of the resident's behaviors, there was no clear protocol for documenting or addressing these issues. The facility's failure to implement a consistent approach to managing Resident 53's behavioral health needs placed the resident at risk of unmet emotional and psychosocial health needs, as well as a decreased quality of life.
Medication Security and Labeling Deficiencies
Penalty
Summary
The facility failed to ensure the security and proper labeling of medications, as observed with one of four medication carts. During an observation, an LPN left an insulin pen unattended on the cart under the computer screen. The pen contained medication but was not labeled with a resident's name. Upon returning, the LPN attempted to identify the pen by checking the insulin lids in the drawer to find the missing lid and subsequently placed the pen in the drawer with a resident label. Additionally, the facility did not secure medications for two residents, which were accessible at their bedsides without proper authorization or assessment for self-administration. One resident had multiple medications, including artificial eye drops, nasal spray, oral throat spray, antifungal powder, and Diclofenac Sodium External Gel, on their nightstand. These medications were not prescribed or assessed for self-administration, and there was no care plan in place. The resident stated that they used the Diclofenac gel for knee pain relief. Another resident kept an Albuterol inhaler on their overbed table, stating they needed it frequently and did not want to wait for staff assistance. Despite staff advising the resident to store the inhaler away, the resident insisted on keeping it nearby. There was no self-medication program assessment, physician order, or care plan for this resident either. Interviews with staff confirmed that no residents were on a self-medication program, and the expectation was for medications to be safely stored and residents assessed for self-administration programs.
Failure to Provide Prompt Dental Services
Penalty
Summary
The facility failed to ensure prompt dental services for two residents, leading to a deficiency in care. Resident 33, who was admitted with obvious dental issues, expressed pain and the need for dental care. Despite a care plan indicating the need for dental coordination, there was no documentation of a referral for teeth extractions or dentures, as recommended by a consulting dentist. Interviews with staff revealed a lack of documentation and follow-up on the resident's dental needs. Similarly, Resident 56, admitted with broken teeth, had not seen a dentist since admission. The resident reported dental issues to several staff members, yet there was no documentation of a dental evaluation or appointment. The care plan for Resident 56 also included coordination for dental care, but staff interviews confirmed the absence of any documented assistance or follow-up regarding the resident's dental condition.
Infection Control Deficiencies in Resident Care and Equipment Sanitation
Penalty
Summary
The facility failed to ensure staff adhered to infection control procedures for a resident on enhanced barrier precautions (EBP). During an observation, staff members providing incontinent care to a resident in a shared room did not wear gowns as required by the EBP sign posted outside the room. The sign indicated that gloves and gowns were necessary for high-contact activities, but staff only wore gloves. Interviews with the staff confirmed their awareness of the requirement, yet they did not comply during the care of the resident. Additionally, the facility did not properly disinfect resident care equipment between uses. Observations revealed that mechanical lifts used for resident care were not sanitized after use, as required. Staff members were observed moving the lifts from one room to another without cleaning them, and some staff were unsure of the proper sanitation procedures. Interviews with various staff members, including nursing assistants and licensed practical nurses, highlighted inconsistencies in understanding and implementing the required disinfection protocols for equipment.
Inadequate Infection Control During Wound Care
Penalty
Summary
The facility failed to implement proper infection prevention and control measures during wound care for three residents. Observations revealed that a Licensed Practical Nurse (LPN) and a provider from a consulting wound clinic did not adhere to hand hygiene protocols. For Resident 1, the LPN and the provider did not change gloves or perform hand hygiene after removing a soiled dressing and before applying a new one. The LPN also used the same contaminated gloves to handle various items and perform incontinent care, further risking contamination. For Resident 2, the LPN did not change gloves or perform hand hygiene after cleansing a wound and before applying a clean dressing. Additionally, the LPN contaminated a box of gloves by handling it with unwashed hands. In the case of Resident 3, the provider and the LPN failed to perform hand hygiene after removing gloves and before applying new ones during wound care. These actions were contrary to the facility's infection control procedures and the CDC's hand hygiene guidelines, placing residents at risk for germ transmission and potential wound infections.
Failure to Implement Wound Care Recommendations
Penalty
Summary
The facility failed to follow consultant recommendations for a resident reviewed for wound clinic visits, which placed the resident at risk of complications. The resident, who was admitted to the facility on 05/30/2024, had wounds on the anterior abdomen, right abdominal pannus, left buttock, and right buttock. A wound clinic consult note dated 10/09/2024 recommended specific treatment changes for these wounds. However, the Treatment Administration Record (TAR) for October 2024 showed that the treatment changes for the anterior abdomen and right abdominal pannus wounds were not implemented until 10/12/2024 and were ordered three times a week instead of every other day. Additionally, there were no treatment order changes for the right and left buttock wounds. Further review revealed that a subsequent wound clinic note dated 10/16/2024 indicated an infection in the buttock wounds and recommended a change in treatment. Despite this, the TAR showed that the treatments for the buttock wounds were not initiated until 10/21/2024. Interviews with the Director of Nursing confirmed that consultant notes should be followed up within 24-48 hours, and there was no documentation explaining the delays or lack of implementation of the recommended treatments.
Significant Medication Errors in Insulin Administration
Penalty
Summary
The facility failed to ensure that three residents with diabetes (Residents 4, 2, and 5) were free from significant medication errors related to the administration of insulin. The facility's policy required insulin to be administered within one hour before or after the scheduled time. However, multiple doses of insulin were administered outside this time frame, placing the residents at risk of abnormal blood sugar levels. For instance, Resident 4 received several doses of lispro, glargine, and detemir insulin more than one hour late, with some doses being administered up to four hours late. Similarly, Resident 2 had instances where insulin was either not given or administered significantly earlier or later than scheduled. Resident 5 also experienced delays in receiving both aspart and NPH insulin doses. During interviews, it was revealed that the facility staff, including the Director of Nursing Services and the Administrator, were aware of the policy but failed to adhere to it. Staff B, the Director of Nursing Services, acknowledged the multiple instances of non-compliance but could not provide further information on why the insulin was administered late. Staff A, the Administrator, admitted to not having reviewed the administration times of insulin before. This lack of oversight and adherence to the facility's medication administration policy contributed to the significant medication errors observed. The report highlights that the facility's failure to administer insulin within the required time frame compromised the residents' diabetes management. The documented instances of late insulin administration for Residents 4, 2, and 5 indicate a systemic issue in the facility's medication administration process. The facility's inability to ensure timely insulin administration as per their policy resulted in significant medication errors, as confirmed by the surveyors' findings.
Failure to Follow Physician Orders on Admission
Penalty
Summary
The facility failed to provide treatment and care in accordance with professional standards of practice for three residents upon their admission. Resident 1, who was admitted with acute and chronic respiratory failure, sleep apnea, and lung disease, did not have an order for a bipap machine in their admission orders despite it being prescribed in the SNF transfer orders. The resident reported that the bipap mask was missing and that staff did not obtain a replacement for the first 10 days of their stay. Staff interviews confirmed that the bipap orders were missed during the admission process, and the second nurse reviewing the orders only checked medications, not treatment orders. Resident 2, admitted with orthostatic hypotension, had physician orders for compression stockings and an abdominal binder to be worn when out of bed or during therapy sessions. These orders were not included in the resident's admission orders, care plan, or Kardex. The resident's family member reported that the resident was not wearing the prescribed items, and therapy notes showed no documentation of their use. Staff interviews revealed that the orders were not entered correctly, and there was no documentation to confirm the application of the compression stockings or abdominal binder. Resident 3, also admitted with orthostatic hypotension, had similar physician orders for compression stockings and an abdominal binder. These orders were also missing from the resident's current physician orders and Kardex. Staff were unable to provide documentation that the prescribed items were being used. The deficiency in following physician orders for these residents placed them at risk of medical complications and a decline in health status.
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.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release May 27, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
