North Auburn Care
Inspection history, citations, penalties and survey trends for this long-term care facility in Auburn, Washington.
- Location
- 2830 I Street Northeast, Auburn, Washington 98002
- CMS Provider Number
- 505195
- Inspections on file
- 35
- Latest survey
- December 29, 2025
- Citations (last 12 mo.)
- 1
Citation history
Health deficiencies cited at North Auburn Care during CMS and state inspections, most recent first.
A resident with complex medical needs experienced a delay in receiving a STAT left hip x-ray after reporting pain following transport to dialysis. The x-ray, ordered by a nurse practitioner, was not completed until over a day later, and when results showed an acute hip fracture, nursing staff failed to promptly notify the provider or send the resident to the hospital. The breakdown in communication and delayed response resulted in the resident being sent to dialysis instead of receiving immediate medical intervention.
Surveyors found that staff failed to accurately complete MDS assessments for five residents, resulting in errors related to vision, wounds, cognitive status, language, oral health, and discharge location. Observations and interviews revealed discrepancies between residents' actual conditions and what was documented, including unreported use of eyeglasses, untreated wounds, misidentified communication abilities, and incorrect dental and discharge information.
Multiple residents with diagnoses such as anxiety, depression, and bipolar disorder did not receive timely PASRR Level 2 evaluations after initial screenings indicated the need. Staff failed to promptly coordinate and follow up on these required assessments, resulting in significant delays before contacting the responsible agency.
Several residents with mental health diagnoses were admitted without accurate or timely PASRR assessments, and necessary Level II referrals were delayed or not completed. Staff confirmed that PASRR screenings were not corrected within required timeframes and follow-up was inconsistent, resulting in residents not being properly assessed for serious mental illness.
The facility did not update care plans to reflect changes in residents' conditions or individualized needs, such as weight loss parameters, communication barriers, and mobility status. Additionally, required care plan meetings were not held or documented for several residents, and in one case, a care conference was conducted without the resident or the full interdisciplinary team present.
Nursing staff failed to follow or clarify physician orders, leading to medication errors such as incorrect application and documentation of pain patches, improper administration of as-needed medications, and lack of monitoring after medication changes. Staff also did not follow up on new orders from outside providers, failed to clarify conflicting orders, and documented care that was not provided, affecting several residents with complex medical needs.
Multiple dependent residents did not receive required assistance with ADLs, including bathing, oral care, and nail care. Observations showed several residents with long, dirty fingernails, unwashed feet, and poor oral hygiene. Staff interviews and documentation confirmed that care was not provided as required, and refusals were not documented.
The facility did not provide information on risks and benefits or obtain informed consent before installing bed rails for several residents, including those with cognitive impairment and those who were cognitively intact. Bed rails were often found to be loose, improperly installed, or broken, and staff were unclear about responsibilities for maintenance and repair. These failures affected all residents reviewed for bed rail use and placed them at risk for harm.
Staff failed to follow proper medication administration protocols, including incorrect timing and technique for eye drops, late administration of injectable medication for blood sugar, and giving the wrong stool softener to a resident. These actions resulted in a medication error rate of 20%, exceeding the acceptable threshold.
Staff failed to monitor and maintain proper sanitation in the kitchen's low temperature dishwasher, resulting in dishes being washed without adequate chlorine sanitizer. The dietary manager and dishwasher staff did not ensure or report proper sanitizer levels, and there was no documentation of staff training on replacing sanitizer buckets or responding to inadequate sanitation.
Several residents received vaccinations, psychotropic medication dose changes, and safety devices without documented consent from themselves or their representatives. Staff interviews confirmed that signed consents were not obtained as required, and in some cases, there was no supporting documentation for historical immunizations or evidence of notification to responsible parties. Observations also revealed the use of safety devices without proper consent documentation.
Two residents reported missing personal items, including an Amazon Tablet and an iPhone, but the facility failed to maintain accurate inventories and did not follow up with the residents regarding their grievances. Staff relied on incomplete or missing inventory records and did not ensure residents were informed about the resolution of their concerns.
The facility did not ensure residents received timely follow-up appointments, proper skin assessments and treatments, or necessary laboratory monitoring. A resident with a diabetic foot ulcer missed a critical infectious disease consult, two residents did not have their skin conditions properly assessed or treated, and another resident was started on high-dose vitamin D without prior lab testing. These lapses were confirmed by staff and documented in resident records.
A resident who reported difficulty reading and outdated eyeglasses did not receive timely vision services after missing a scheduled eye exam. Staff failed to reschedule the appointment or follow up on the resident's request for an eye exam, resulting in the resident not receiving needed vision care or updated corrective lenses.
Two residents at risk for pressure ulcers did not receive consistent pressure-reducing interventions or repositioning as required by their care plans and physician orders. One resident's air mattress was set incorrectly and repositioning was not performed as directed, while another resident's air mattress was also set at the wrong weight and not monitored per protocol. Staff interviews and observations confirmed these lapses in care.
Three residents with diabetes and complex medical needs did not receive timely podiatry services or necessary foot care, including nail care and follow-up for foot wounds, despite staff awareness of the need for regular podiatry referrals and multiple recommendations from consulting providers. Staff interviews and record reviews confirmed lapses in arranging and documenting podiatry care.
A resident who was identified as a smoker was not assessed for smoking safety, and their care plan did not address smoking, despite facility policy requiring such measures. The resident kept cigarettes and a lighter in a lock box in their room, and staff were unaware of the resident's current smoking activity or the presence of smoking materials.
A resident was maintained on an indwelling urinary catheter without documented valid medical justification or a plan for discontinuation, contrary to facility policy. Staff did not complete required assessments such as post-void residuals or consider a urology consult, and failed to document key information during a voiding trial. These omissions resulted in the continued use of the catheter without proper evaluation.
The facility did not consistently monitor or respond to significant weight changes for a resident with complex medical needs, resulting in unaddressed weight fluctuations and lack of timely assessments. Additionally, two residents were not routinely offered or provided hydration services, with one reporting frequent thirst and the other observed without fluids in their room. Staff expectations for hydration were not met, and care plans lacked clear guidance for weight monitoring and intervention.
Surveyors found that drugs and biologicals were not properly stored, labeled, or removed in two medication carts and a medication room. Discontinued and unlabeled medications, as well as medications for discharged residents, were left in storage areas. An LPN and other staff confirmed that these medications should have been removed but were not. Additionally, a resident was found with unsecured supplements and multivitamins at their bedside, which staff acknowledged should have been secured.
The facility did not maintain complete and accurate medical records for multiple residents, including missing or delayed documentation of podiatry consults and services, unclear physician orders, and incomplete assessment documents and inventories. Staff confirmed that required medical consults were not consistently entered into resident records, resulting in a lack of documentation to support that necessary services were provided.
Surveyors observed multiple failures in infection prevention and control, including staff not performing hand hygiene before and after resident care, improper storage and labeling of personal care items in resident rooms, medication administration without barriers to prevent cross-contamination, and staff not wearing required surgical masks correctly. These lapses were confirmed by staff interviews and occurred during various care activities, such as catheter care, enteral feeding, and medication passes.
The facility failed to ensure that the personal funds of 21 out of 24 residents with trust accounts were adequately covered by a surety bond. The bond amount was $21,000, while the total balance of the trust accounts was $33,771.68, placing residents at risk of being unable to recover their money in the event of loss.
The facility failed to ensure residents were informed and provided written information concerning their rights to accept, refuse, or formulate an Advance Directive (AD) for six residents. Interviews and record reviews revealed that the facility did not follow its policy of determining whether a resident had an AD upon admission and offering information if they did not. Staff did not consistently follow up or offer assistance to residents to formulate ADs, as required by their policy.
The facility failed to ensure a clean, comfortable, and homelike environment, with issues including damaged walls, institutional-style overhead paging, broken window blinds, and cold water in resident bathrooms. Staff interviews confirmed awareness of these problems.
The facility failed to notify the Office of the State Long-Term Care Ombudsman (LTCO) of resident hospital transfers for three residents, preventing the Ombudsman from advocating for them. Staff interviews confirmed that the required notification process was not being followed.
The facility failed to provide written notice of the bed hold policy to residents and/or their representatives at the time of transfer or within 24 hours for three residents. The bed hold portion of the transfer/discharge notices did not indicate whether the residents accepted or declined a bed hold. The current electronic form lacked an option to select a choice, and the facility's bed hold process was not conducted as required.
The facility failed to ensure accurate MDS completion for eight residents, leading to discrepancies in nutritional and vision assessments. Errors included incorrect reporting of tube feeding and vision status, confirmed through staff interviews and record reviews.
The facility failed to update CPs for three residents and did not conduct CP meetings for three others, leading to inaccuracies in care documentation and unmet care needs. Staff acknowledged the importance of accurate CPs and the necessity of CP meetings for resident involvement.
The facility failed to provide adequate ADL assistance for several residents, including those with memory impairment and depression. Observations revealed long, dirty fingernails, unclean teeth, and unchanged clothes, despite care plans indicating the need for assistance. Staff interviews confirmed the lack of required care.
The facility failed to provide restorative nursing services for three residents, leading to a risk of diminished ROM and loss of function. Residents were observed without the required splints, despite physician's orders and care plans indicating the need for daily splinting. Staff interviews confirmed the lack of adherence to the care plans.
The facility failed to ensure ongoing communication and collaboration with the kidney center for two residents requiring dialysis, leading to unmet care needs and potential health risks. Incomplete and missing communication forms and lack of follow-up by nursing staff were identified as key issues.
The facility failed to ensure that residents received their prescribed diets, as evidenced by a resident with heart failure and diabetes receiving inappropriate food items and multiple residents with CCHO diet orders being served incorrect desserts. Staff interviews confirmed that dietary orders were not followed as expected.
The facility failed to store and prepare food under sanitary conditions, including improper labeling and storage of food items, lack of handwashing supplies, and inadequate handling of food brought by visitors. These lapses placed residents at risk for consuming expired or spoiled foods and potential exposure to food-borne illness.
The facility failed to provide sufficient nursing staff to ensure timely assistance with toileting and call light response, leading to residents waiting for extended periods, lying in soiled undergarments, and not receiving prescribed restorative care. Call light reports and staff interviews confirmed significant delays, particularly during night shifts.
The facility failed to implement and document comprehensive Care Plans for three residents, leading to unmet care needs and increased anxiety. A male CNA was assigned to a resident despite a CP intervention requiring only female staff, and two residents did not have documented discharge plans, leaving them uninformed about their care status.
The facility failed to ensure privacy and maintain resident dignity for two residents. One resident was left exposed in bed without proper documentation of their preferences, while another was incorrectly assessed as incontinent and not provided with appropriate toileting assistance, leading to a lack of dignity and proper care.
The facility failed to provide a resident with the required Skilled Nursing Facility Notice of Medicare Non-coverage (SNF-NOMNC) at least two days before the end of their Medicare-covered Part A stay. The resident was discharged without receiving the notice, which is essential for informing them about their right to an expedited appeals process.
The facility failed to investigate and resolve grievances for two residents. One resident reported a missing blouse, and another complained about environmental noise affecting their sleep. Both grievances were not logged or resolved, despite staff being aware of the issues.
The facility failed to complete a Significant Change in Status Assessment (SCSA) MDS for a resident who experienced a significant decline in condition, including acute mental status changes and hallucinations. Despite recognizing the need for a SCSA MDS, the MDS Coordinator did not initiate the assessment, leaving the resident at risk for unmet care needs.
The facility failed to revise PASRR assessments for two residents to reflect mental health changes. One resident required a Level 2 evaluation due to diagnoses including traumatic brain dysfunction and psychotic disorder, but no follow-up was documented. Another resident's Level 1 PASRR was inaccurate despite worsening behaviors and daily antipsychotic medication, necessitating a Level 2 evaluation.
The facility failed to clarify and follow physician's orders for several residents, including incorrect administration of pain medications, improper placement of a wander guard alarm, inaccurate orthostatic blood pressure measurements, and non-compliance with feeding and medication schedules. These lapses in care and documentation put residents at risk for adverse health outcomes.
The facility failed to provide timely care for a resident with a neck lump, did not follow prescribed treatment for another resident's dermatitis, and allowed a resident to self-administer insulin without proper assessment, leading to potential risks.
The facility failed to ensure that a resident with vision deficits was assessed and provided with assistive devices. Despite the resident's diagnosis of diabetic eye disease and complaints of seeing double, the facility did not provide an eye consultation for new prescription eyeglasses. The Social Services Director was unaware of the resident's need for vision care, and the resident was not listed for routine vision services.
A facility failed to ensure a resident with multiple Stage 4 pressure ulcers received the ordered air mattress setting of 270 pounds. Observations showed the mattress was set at 360 pounds, and staff were unaware of the need to check the pressure setting, leading to potential risks for the resident.
The facility failed to identify, assess, and implement interventions to prevent accidents for three residents. One resident was not assessed for smoking safety, another used an unassessed bolster air mattress, and a third was without a wander guard alarm for several days, compromising their safety.
The facility failed to provide appropriate respiratory care to two residents. One resident received supplemental oxygen without a physician's order, while another received a higher oxygen flow rate than prescribed and had an empty humidifier bottle. Additionally, there was a lack of documentation and communication with the physician regarding the PRN oxygen administration.
The facility failed to provide necessary social service interventions for two residents, leading to early termination of skilled care benefits for one resident and inadequate pain management for another. The staff did not follow up on therapy and medication refusals, resulting in unmet care needs and decreased quality of life.
The facility failed to dispose of expired medications and properly secure controlled pain medications. Expired Covid-19 injectable medications and swab collection tubes were found, along with various expired medications, including narcotic pain medications, in an unlocked drawer. Staff acknowledged the need for proper disposal and security of medications.
The facility failed to provide prompt dental care for two residents, leading to unmet dental needs and diminished quality of life. One resident had broken teeth and required extractions and cleanings, while another had very loose teeth needing urgent follow-up. Both cases lacked proper follow-up and documentation.
Delayed Response to STAT X-ray Order and Failure to Notify Provider of Acute Hip Fracture
Penalty
Summary
The facility failed to ensure that a resident received timely care and treatment as prescribed by the medical provider following a change in condition related to an injury sustained during transport to a dialysis clinic. The resident, who had diagnoses including kidney failure requiring dialysis and a chronic neurological-muscle disease, was dependent on staff for care and required a mechanical lift for transfers. After reporting pain in the left leg following transport, the nurse practitioner assessed the resident and ordered a STAT left hip x-ray and pain medication. However, there was a significant delay in confirming and initiating the x-ray order, with the order being confirmed over four hours after it was entered and the x-ray not completed until 33 hours later. Upon receipt of the x-ray results, which showed an acute hip fracture, nursing staff failed to immediately notify the medical provider as required. The x-ray company reported the fracture to the facility during a shift change, but the nurse on duty did not report the findings to the provider or ensure the information was communicated to the incoming shift. As a result, the resident was not sent to the hospital promptly and was instead transported to dialysis the following day despite having a hip fracture. Interviews with facility staff confirmed that the expected protocol was not followed, including immediate notification of the provider upon receipt of critical results and timely processing of STAT orders. The facility's investigation did not initially identify these delays or failures in communication and order processing. Staff acknowledged that the resident should have been sent to the hospital immediately upon confirmation of the fracture and that the breakdown in communication and delayed response led to a lack of timely medical intervention.
Inaccurate MDS Assessments Across Multiple Domains
Penalty
Summary
The facility failed to ensure accurate completion of the Minimum Data Set (MDS) assessments for five residents, resulting in multiple inaccuracies across various assessment domains. For one resident, staff documented adequate vision and no use of corrective lenses on several MDS assessments, despite observations of the resident using eyeglasses and stating a need for them. Additionally, a chronic ulcer treated by a contracted wound company was not reflected in the MDS, even though the resident was being treated for it at the time. Another resident was incorrectly coded as not interviewable for cognitive patterns and as demonstrating delusions, despite multiple observations and staff interviews confirming the resident was able to communicate and did not exhibit delusional behavior. For a third resident, the MDS inaccurately indicated staff were unable to examine dental status, and inconsistencies were found regarding the resident's ability to communicate and primary language. Staff failed to document the need for an interpreter, even though the resident's family confirmed Samoan as the primary language and that the resident would benefit from interpretation services. Further, one resident's MDS inaccurately reported no natural teeth, while both care plans and direct observation confirmed the presence of two natural teeth, which were loose and causing chewing difficulties. Another resident's discharge MDS incorrectly documented the discharge location as a hospital, while the discharge summary indicated the resident was sent home. In each case, staff interviews confirmed the MDS assessments were completed inaccurately, leading to discrepancies between the residents' actual conditions and their documented assessments.
Delayed Coordination of Required PASRR Level 2 Evaluations
Penalty
Summary
The facility failed to ensure timely completion and coordination of required Pre-Admission Screening and Resident Review (PASRR) Level 2 evaluations for multiple residents identified as having or suspected of having Serious Mental Illness (SMI), intellectual disability, developmental disability, or related conditions. For five residents, documentation showed that although Level I PASRR screenings indicated the need for a Level 2 evaluation, there were significant delays in initiating and following up on these referrals. In several cases, no action was taken to coordinate the Level 2 evaluation until several months after the need was identified, and there was a lack of timely follow-up with the agency responsible for conducting the evaluations. Residents involved had diagnoses including anxiety disorder, depression, and bipolar disorder, and some were receiving related medications. Staff interviews confirmed that delays occurred due to workload issues and lack of assistance, and that follow-up with the PASRR agency did not occur within the expected timeframe. The records did not show evidence of prompt or consistent efforts to ensure that residents received the required person-centered evaluations prior to or shortly after admission, as mandated.
Failure to Complete Accurate and Timely PASRR Assessments
Penalty
Summary
The facility failed to ensure that Pre-Admission Screening and Resident Review (PASRR) assessments were accurately completed prior to or upon admission for several residents with mental health diagnoses. For multiple residents, initial Level I PASRR screenings either failed to identify serious mental illness (SMI) or did not result in timely Level II referrals when indicated. In some cases, updated PASRR screenings were completed months after admission, revealing previously unrecognized SMIs and the need for Level II evaluations. Documentation showed that PASRRs were not corrected within the required timeframe, and follow-up on PASRR II referrals was not consistently performed. Specifically, residents with diagnoses such as anxiety disorder, depression, and schizophrenia were admitted without accurate or timely PASRR assessments. Staff interviews confirmed that changes in PASRR rules were not implemented promptly, and that audits and corrections were delayed due to staffing issues and lack of follow-up. As a result, residents with mental health needs were at risk of not receiving appropriate assessments and services as required by regulation.
Failure to Update Care Plans and Conduct Required Care Plan Meetings
Penalty
Summary
The facility failed to ensure that care plans (CPs) were updated and revised as needed to reflect person-centered care for several residents, and did not provide required care plan meetings for others. For four residents, care plans were not revised to reflect changes in condition, interventions, or individualized needs. For example, one resident with a brain injury and significant weight loss had a care plan that lacked clear parameters for safe weight loss and did not specify when weights should be taken, despite a documented 14.2-pound loss in one month. Another resident who was dependent on tube feeding had conflicting care plans regarding oral intake and tube feeding details, and the care plan did not address the resident's language barrier or specify the correct type and rate of tube feeding as reflected in the medication administration records. A third resident receiving antipsychotic medication for bipolar disorder with psychotic features had a care plan that did not include monitoring for hallucinations, which was a directive from the psychiatric practitioner, and incorrectly listed neurogenic bladder instead of obstructive uropathy as a diagnosis. Another resident who was independently mobile with a walker continued to have a care plan requiring two-person mechanical lift transfers, which was not updated to reflect the resident's current abilities, as confirmed by staff interviews and direct observation. Additionally, the facility failed to provide or document care plan meetings for four residents as required by policy. One resident reported never having a care plan meeting since admission, and staff confirmed there was no documentation of such a meeting. Another resident did not have a care conference until more than six months after admission, despite policy requiring one within 72 hours and quarterly thereafter. For another resident, there was no documentation of a care conference being offered or provided, and for one resident, only the family member attended the care conference without the resident or the full interdisciplinary team, with no documentation explaining the absence.
Failure to Follow Physician Orders and Professional Standards in Medication Management
Penalty
Summary
Nursing staff failed to follow or clarify physician orders for multiple residents, resulting in medication administration errors and improper documentation. For one resident, pain patches were applied for longer than the prescribed duration, patches were not dated or initialed upon application, and a patch was applied to an area without a physician order. Staff also documented the removal and reapplication of patches that did not occur, and failed to properly document or reattempt obtaining a resident's weight as ordered. Additionally, as-needed medications were administered together without clarification, contrary to best practice. Another resident experienced a significant increase in antianxiety medication dosage without any alert charting or monitoring for side effects. Orders for medications requiring administration on an empty stomach were not clarified, resulting in the medication being given with other oral medications. In a separate case, a vitamin D supplement was administered daily instead of weekly due to a transcription error, which was only identified after nine days by pharmacy review. Blood sugar checks and insulin administration were performed after a resident began eating, rather than before meals as ordered, potentially affecting blood glucose management. Staff also failed to follow up on recommendations and new orders from outside providers. One resident returned from frequent oncology appointments with an IV catheter and medication pump, but there were no corresponding physician orders or monitoring instructions in the facility record. Staff were unaware of the IV and pump, and did not check for new orders or document recommendations from the oncologist. In another instance, a resident with a 'nothing by mouth' order was documented as having consumed snacks, despite the resident stating they were unable to swallow and did not receive snacks. Finally, an as-needed pain medication order lacked necessary parameters, such as maximum dose in 24 hours, and staff did not clarify or update the order.
Failure to Provide Required ADL Assistance Including Hygiene and Nail Care
Penalty
Summary
The facility failed to provide necessary assistance with Activities of Daily Living (ADLs) for five residents who were assessed as dependent on staff for personal care. Observations and interviews revealed that residents did not receive required support with bathing, oral care, and nail care. For example, one resident with a brain injury and total dependence on staff was observed multiple times with long fingernails, dried debris around the mouth, and yellow film on the teeth, indicating a lack of oral hygiene. The Director of Nursing confirmed that oral care did not appear to have been provided. Another resident, who was dependent on staff for showers and personal hygiene, reported only receiving bed baths instead of preferred showers, and stated that their feet had not been washed for several weeks. Documentation showed this resident received only four bed baths in thirty days, with no showers or nail care provided, and no refusals documented. Staff interviews confirmed that showers and nail care should have been provided but were not. Additional residents were observed with long, dirty fingernails and toenails, and some had black debris under their nails. These residents stated they needed staff assistance for nail care, which was not documented as provided. Staff interviews indicated that nail care was expected to be performed weekly and as needed, with refusals to be documented, but this was not consistently done. In one case, documentation of nail care was unclear as to whether it referred to finger or toenails, and care plans lacked specific instructions for nail care assistance.
Failure to Assess, Obtain Consent, and Maintain Bed Rails
Penalty
Summary
The facility failed to follow its own policy and regulatory requirements regarding the use of bed rails for multiple residents. Specifically, the facility did not provide residents or their representatives with information about the risks and benefits of bed rail use prior to installation, nor did it obtain informed consent in several cases. For example, residents who were cognitively intact reported that staff had not discussed bed rail use with them, and in cases where residents had cognitive impairment and a designated Power of Attorney (POA), the POA was not notified or asked for consent. Documentation of consent or notification was missing for several residents. Observations revealed that bed rails were not properly installed or maintained for several residents. Multiple residents were found with loose or improperly positioned bed rails, and in some cases, the rails were installed perpendicular rather than parallel to the bed, contrary to proper installation procedures. Staff interviews indicated confusion and lack of clarity regarding responsibility for installation and ongoing maintenance, with maintenance staff stating that nursing staff were expected to tighten rails as needed, but the rails frequently became loose and were not consistently fixed. Additionally, there was a lack of communication and documentation regarding the maintenance and repair of bed rails. For instance, one resident reported a broken bed rail that had not been repaired for several days, and neither maintenance nor nursing staff were aware of the issue or had documented it in the maintenance log. These failures were observed across all reviewed residents who used bed rails, placing them at risk for injury, entrapment, and other negative health outcomes.
Medication Error Rate Exceeds Acceptable Threshold Due to Improper Administration
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, as required, resulting in a 20% error rate during observed medication passes. Specifically, staff did not adhere to proper administration protocols for ophthalmic drops, including failing to wait the required time between different eye medications and not instructing residents to apply gentle pressure to the tear duct or close their eyes after administration, as outlined in facility policy. Additionally, staff administered multiple medications in rapid succession without observing the necessary intervals between doses, and administered medications outside of the scheduled times indicated on the Medication Administration Record (MAR). Further deficiencies included administering an injectable medication for blood sugar coverage later than the physician-ordered time, without notifying the physician as required. In another instance, a staff member administered the wrong stool softener to a resident, giving a medication containing two stool softeners instead of the single stool softener that was ordered. These actions were confirmed as errors by facility leadership and staff, who acknowledged the importance of following physician orders and facility protocols to ensure correct medication administration.
Failure to Ensure Dishwasher Sanitation and Staff Reporting
Penalty
Summary
Facility staff failed to ensure that food was served under sanitary conditions due to inadequate monitoring and maintenance of the dishwasher's sanitation process. During a kitchen observation, the dietary manager tested the low temperature dishwasher and found that the chlorine test strips remained white, indicating an absence of sanitizer. The dietary manager attempted multiple tests with the same result and could not locate the log documenting the dishwasher's sanitation checks. The dishwasher staff member confirmed that the sanitizer test was low before breakfast and acknowledged that a white test strip meant no chemical was present, but did not report this issue to anyone. Further investigation revealed that the dietary manager had replaced the sanitizer bucket the previous day but was unaware of the need to prime the new bucket, resulting in the dishwasher not functioning with adequate sanitizer since that time. There was no documentation provided to show that staff had been educated or trained on how to replace the sanitizer bucket or what steps to take if inadequate sanitizer levels were detected. These failures resulted in the facility not meeting professional standards for food sanitation.
Failure to Obtain Resident Consent for Vaccinations, Psychotropic Medications, and Safety Devices
Penalty
Summary
The facility failed to obtain proper consent from residents or their representatives prior to administering vaccinations, psychotropic medications, and safety devices. Specifically, several residents received Covid-19, flu, and pneumonia vaccines without documented consent, and in some cases, there was no supporting documentation for historical vaccinations. For example, residents received vaccinations for the 2024/2025 season without signed consent forms, and in one case, a resident's name was typed on a consent form without a signature. Staff interviews confirmed that signed consents were expected but not obtained, and that documentation from the Department of Health was missing for some historical immunizations. In addition, the facility did not obtain consent prior to administering or changing doses of psychotropic medications for certain residents. Health records showed that dose changes for antipsychotic and antidepressant medications were made without obtaining consent from the residents or their representatives. In one instance, a consent form was completed 26 days after the medication dose was increased, and staff were unable to provide evidence of email notifications or signed consent forms for these changes. Staff interviews further confirmed that consent was not obtained as required prior to medication administration or dose changes. The facility also failed to obtain consent before implementing safety devices such as bed rails, bolstered air mattresses, and tilt-in-space wheelchairs. Observations and record reviews revealed that these devices were in use for multiple residents without evidence of consent from the residents or their representatives. In one case, a resident with severe cognitive impairment and a healthcare Power of Attorney had a bed rail applied without the POA being notified or providing consent. Staff interviews indicated a misunderstanding of the consent process, with some staff believing that providing a copy of a safety assessment constituted consent, even though the forms did not document actual consent.
Failure to Investigate and Resolve Resident Grievances Regarding Missing Personal Items
Penalty
Summary
The facility failed to ensure that grievances raised by residents were thoroughly investigated and resolved, as required by policy. For one resident, who was cognitively intact, multiple personal items including an Amazon Tablet were reported missing. The grievance log documented the concern but concluded it was resolved because the resident was uncertain about owning the tablet and it was not listed on the inventory. However, there was no evidence that staff attempted to verify whether the resident ever had the tablet or if the inventory was accurate. Further review revealed that the resident's inventory was missing from the designated binder, and the available documentation was incomplete, lacking identifiers and dates. Observation confirmed the resident possessed several items not listed on the inventory, and staff acknowledged that inventory records were not always reliable. Another cognitively intact resident reported a missing iPhone and expressed dissatisfaction with having to replace it with an android phone. The grievance log showed that the facility documented communication with the resident's family, who declined a replacement phone, but there was no follow-up with the resident regarding the outcome of the grievance. Staff confirmed that no direct follow-up occurred. These failures to maintain accurate inventories and to follow up with residents about their grievances resulted in unresolved concerns and incomplete grievance investigations.
Failure to Provide Timely Follow-Up, Skin Care, and Laboratory Monitoring
Penalty
Summary
The facility failed to ensure residents received appropriate follow-up care and treatment as ordered and required. One resident with a diabetic foot ulcer and a bone infection was referred for an infectious disease consult, but there was no documentation that the resident attended the scheduled appointment, nor were there any records of follow-up or recommendations from the consult. Staff confirmed the resident did not attend the appointment, despite the importance of evaluating for underlying infection. Two other residents did not receive proper skin assessments, monitoring, or treatment. One resident with a history of fractures, pressure ulcers, and functional limitations had visible signs of ingrown toenails and discharge, but had not seen a podiatrist since admission. Staff confirmed that these skin issues should have been identified and reported during daily treatments. Another resident with heart disease and lymphedema had physician orders for daily edema assessment and use of compression stockings, but was repeatedly observed without stockings and with significant swelling. Staff documentation of edema levels did not match the resident's actual condition during observations. Additionally, a resident with a diagnosis of vitamin D deficiency was prescribed a high-dose vitamin D supplement without any evidence that a vitamin D level was obtained prior to starting the medication. Staff interviews confirmed that a vitamin D level should have been checked before initiating supplementation, but this was not done. These failures resulted in missed or delayed care and incomplete monitoring for multiple residents.
Failure to Provide Timely Vision Services
Penalty
Summary
Resident 30 was admitted to the facility with adequate vision and no need for corrective lenses according to the initial assessment. However, observations showed the resident had eyeglasses and reported difficulty reading, stating that everything appeared blurry. The resident indicated they had requested an eye exam several months prior, but it had not been scheduled or completed, and no one had followed up with them regarding this request. The resident also reported that their current glasses were over two years old and that they needed new ones. A review of the resident's records revealed that an eye appointment was scheduled but not attended due to the resident feeling ill, with a follow-up planned for the following month. However, there was no evidence that the follow-up or any vision services were provided. Staff interviews confirmed that the process to reschedule the appointment was overlooked, and the resident's need for vision services was not addressed until brought to staff attention by surveyors. This failure resulted in the resident not receiving necessary vision care or updated assistive devices.
Failure to Provide Consistent Pressure Ulcer Prevention and Care
Penalty
Summary
The facility failed to ensure that two of three sampled residents at risk for pressure ulcers received consistent and appropriate pressure-reducing measures and repositioning, as required by their care plans and physician orders. For one resident, health records indicated a physician order for an air mattress to be set at alternate level 5, with staff required to check the settings every shift. However, observations revealed the air mattress was set at float level 8, and staff confirmed this was not in accordance with the order. The resident also reported that staff did not consistently reposition them every two to three hours as required, and continuous observation showed the resident remained lying flat on their back for several hours. Staff interviews confirmed that repositioning was not performed per the care plan instructions. For another resident, records showed a care plan and physician order for an air mattress to be set at 165 pounds with a specific cycle time, and staff were to check the settings every shift. However, staff discovered the bed was set incorrectly at 340 pounds, contrary to the physician order. Staff interviews confirmed that the air mattress settings were not being monitored and maintained as required. These failures were observed and confirmed through interviews and record reviews, demonstrating a lack of adherence to established protocols for pressure ulcer prevention and care.
Failure to Provide Timely and Appropriate Foot Care and Podiatry Services
Penalty
Summary
The facility failed to provide necessary foot care and treatment in accordance with professional standards for three residents with diabetes and other complex medical conditions. One resident, who was cognitively intact and dependent on staff for lower extremity care, had not received podiatry services since admission, despite having a history of ingrown toenails and visible debris on the toenail bed. Staff interviews confirmed that diabetic residents should be referred to podiatry upon admission and seen quarterly, but this did not occur. Another resident, also cognitively intact with diabetes, had a significant gap in podiatry follow-up after an initial consult, with staff acknowledging that recommended follow-up visits were missed due to issues with the previous podiatrist and delays in arranging new services. A third resident with heart failure, end-stage kidney failure, diabetes, and a diabetic foot ulcer had multiple recommendations from a consulting wound provider and a physician's order for a podiatry referral, but there was no documentation that the referral was completed or that the resident was seen by a podiatrist. Staff confirmed that the resident had not received podiatry services as recommended, citing ongoing issues with arranging podiatry care. These findings were based on observations, interviews, and record reviews, and demonstrate a failure to ensure timely and appropriate foot care for residents at risk.
Failure to Assess and Implement Smoking Safety Measures
Penalty
Summary
The facility failed to identify, assess, and implement interventions to prevent accidents for a resident who was known to smoke. According to the facility's policy, all residents should be screened for smoking upon admission, and those who wish to continue smoking should have this reflected in their care plan, with smoking materials stored in a locked location. The resident in question was admitted with intact memory and communication, required assistance with transfers, toileting, and bed mobility, and used a wheelchair. Despite a social services evaluation identifying the resident as a smoker, no smoking assessment was completed, and the resident's record did not reflect their smoking status or any related interventions. The resident reported smoking once or twice daily and kept cigarettes and a lighter in a metal lock box in their room, which was confirmed by observation. Multiple staff members, including the Social Services Director, DON, Chief Nursing Officer, and Administrator, were unaware of the resident's current smoking activity or the presence of smoking materials in the room. The facility staff did not complete the required smoking assessment, and the resident's care plan did not address smoking, contrary to facility policy.
Failure to Ensure Valid Medical Justification and Assessment for Indwelling Catheter Use
Penalty
Summary
Facility staff failed to ensure that an indwelling urinary catheter for one resident had a valid medical justification or a plan for discontinuation, as required by facility policy. The resident, who was admitted with a diagnosis of renal insufficiency but without obstructive uropathy or neurogenic bladder, had a catheter placed during a prior hospitalization. Upon admission, the resident's Minimum Data Set (MDS) indicated the presence of the catheter, and a later MDS showed a new diagnosis of obstructive uropathy. However, there was no documentation supporting a history of untreatable urinary blockage or inability to void prior to hospitalization. Staff initiated a voiding trial and discontinued the catheter per provider order, but failed to document the number of times the resident urinated, the volume of urine output, or any post-void residuals. The catheter was reinserted after staff noted urinary retention, but there was no evidence that a urology consult was considered to confirm the need for continued catheter use. Additionally, there was no documentation of interventions to address the potential decline in bladder function due to prolonged catheter use. Staff interviews confirmed that required assessments and policy protocols were not followed.
Failure to Ensure Adequate Nutrition and Hydration Services
Penalty
Summary
The facility failed to ensure residents maintained acceptable nutritional status and did not consistently provide or document hydration services. For one resident with a history of brain injury and diabetes, significant weight fluctuations were observed without timely reweighs or assessments. The resident experienced a rapid weight gain followed by a substantial loss, with gaps in weight documentation and no assessment or intervention for these changes. The care plan lacked specific interventions for when to weigh or reweigh the resident, when to report weight deviations, or what constituted a safe, measurable weight loss goal. Staff interviews confirmed that reweighs and assessments were not performed as expected when significant weight changes occurred. Two other residents were not consistently offered or provided hydration services. One resident, who had no memory impairment or swallowing difficulties, reported that staff did not routinely bring water and that they often had to request a water pitcher, which was not always provided. Observations confirmed that staff did not offer hydration during care, and the resident had to ask for water. Another resident, with severely impaired decision-making ability and a care plan indicating the need for hydration support, was observed without any fluids available in their room. Staff interviews revealed that the expectation was for water pitchers to be provided to all residents every shift and as needed, and that residents should not have to request hydration. However, these expectations were not met, as evidenced by the lack of hydration services observed and reported by the residents. The failure to provide consistent hydration and to monitor and respond to significant weight changes placed residents at risk for dehydration and unaddressed weight loss.
Failure to Properly Store, Label, and Remove Medications
Penalty
Summary
Surveyors observed that drugs and biologicals were not stored in accordance with accepted professional standards in two medication carts and one medication room. In Medication Cart A, discontinued topical treatments for a resident were found, as well as a topical treatment for another resident who no longer had an order for it. In Medication Cart B, medications belonging to residents who had been discharged for several months were still present, along with a bottle of medication lacking a resident name, prescribing physician, or directions for use. Additionally, a Hemoccult test fluid was stored with oral medications, and several discontinued or unlabeled topical treatments and an irrigation solution without a resident name were found. Staff interviews confirmed that these medications and treatments should have been removed when discontinued or when residents were discharged, but this was not done. In the medication room, an open, undated bottle of injectable medication for Tuberculosis testing and a vaccine syringe for a resident that was dispensed but not administered were found in the refrigerator. Fifteen bags of intravenous antibiotics for a resident with a discontinued order were also present, with staff confirming that the medication should have been destroyed after discontinuation. Additionally, a resident was observed to have unsecured bottles of vision supplements and multivitamins at their bedside on multiple occasions, and staff acknowledged that these should have been secured in a lockbox and reported. These findings demonstrate failures in medication storage and labeling, as well as in the timely removal and destruction of discontinued or unassigned medications.
Failure to Maintain Complete and Accurate Medical Records for Residents
Penalty
Summary
The facility failed to maintain complete and accurate medical records for multiple residents, as required by accepted professional standards. Specifically, physician orders were not clear or accurate, assessment documents did not accurately reflect resident conditions, behaviors were not properly monitored, personal inventories were not updated or available, informed consents were not signed or dated, and resident inventory lists were incomplete. For several residents with complex medical conditions, including diabetes, documentation of podiatry consults and services was either missing from the records or not scanned in a timely manner. For example, one resident's podiatry consult was not scanned into the record until several months after the service, and another resident's consult was not present in the record at all. Staff interviews confirmed that consults were not consistently entered into the residents' records as required. Record reviews for both sampled and supplemental residents showed that documentation supporting podiatry services was absent for a significant number of residents who had received such services. Staff confirmed that these records were not available in the residents' files, despite the services having been provided. The lack of complete and accurate clinical records placed residents at risk of not having their needs met, as there was no documentation to support that necessary medical services had occurred.
Infection Control Program Deficiencies: Hand Hygiene, PPE, and Personal Care Item Storage
Penalty
Summary
The facility failed to establish and maintain an effective infection prevention and control program, as evidenced by multiple observed lapses in infection control practices. Staff did not consistently perform hand hygiene before and after resident care, with three out of three staff observed failing to do so. In several resident rooms, personal care items such as basins, urinals, and denture cups were found unlabeled, unbagged, and improperly stored, including on the floor or without lids. Staff interviews confirmed that these items should have been labeled, bagged, and stored appropriately to prevent contamination. During medication administration, a nurse was observed placing multiple medication containers directly on a resident's bed without a barrier and then returning the containers to the medication cart without cleaning them, creating a risk of cross-contamination. The same nurse was also seen placing a hand-held inhaler from their pocket into the medication cart. The DON confirmed that staff are expected to use barriers to prevent cross-contamination during medication passes. Additionally, staff were observed not wearing required surgical masks properly in resident care areas, with some staff wearing masks below their noses or not at all, despite facility policy requiring mask use in these areas. Further observations revealed that staff did not perform hand hygiene between glove changes or between clean and dirty care tasks, particularly during catheter and enteral feeding care. In one instance, a CNA changed gloves without hand hygiene while providing catheter care, and another staff member entered a resident's room to provide enteral feeding care without performing hand hygiene or wearing their mask correctly. Staff interviews confirmed that hand hygiene was expected at key points during resident care, but these practices were not consistently followed.
Inadequate Surety Bond Coverage for Resident Trust Accounts
Penalty
Summary
The facility failed to ensure that the personal funds of 21 out of 24 residents with trust accounts were adequately covered by a surety bond. The surety bond purchased by the facility was for an amount not to exceed $21,000, effective on 06/30/2021. However, the total balance of the trust accounts as of 03/18/2024 was $33,771.68, which exceeded the bond limit. This discrepancy was confirmed by the Business Office Manager, who acknowledged that the surety bond should cover more than the total amount in the trust accounts. This failure placed residents at risk of being unable to recover their money in the event of loss from their accounts.
Failure to Inform and Assist Residents with Advance Directives
Penalty
Summary
The facility failed to ensure that residents were informed and provided written information concerning their rights to accept, refuse, or formulate an Advance Directive (AD) for six residents. This deficiency was identified through interviews and record reviews, revealing that the facility did not follow its policy of determining whether a resident had an AD upon admission and offering information if they did not. The policy also required documentation of whether an AD was executed and each offering of information, which was not consistently followed for the residents reviewed. For instance, Resident 60 had complex medical conditions and was dependent on dialysis, but there was no AD or Durable Power of Attorney (DPOA) paperwork in their record, and the staff did not follow up with the resident's representative to assist in initiating an AD. Similarly, Resident 44, who had multiple medical conditions including a stroke and brain injury, was not offered assistance to initiate an AD, and there was no AD or DPOA paperwork in their record. Resident 28, who had complex medical conditions including uncontrolled blood sugars and heart failure, also did not have an AD or DPOA, and staff did not communicate with them about initiating an AD. Resident 30, who had chronic pain, heart disease, memory impairment, anxiety, and mood disorder, had no follow-up documentation to support that assistance was offered to formulate an AD. Resident 226, who had a systemic infection, lung disease, and malnutrition, was not provided education or offered assistance to initiate an AD. Lastly, Resident 3, who had heart failure, end-stage kidney failure requiring dialysis, and a lower leg fracture, did not have documentation indicating they were provided information regarding ADs. Staff interviews confirmed that the facility did not consistently follow up or offer assistance to residents to formulate ADs, as required by their policy.
Failure to Maintain Homelike Environment and Adequate Facilities
Penalty
Summary
The facility failed to ensure a clean, comfortable, and homelike environment for residents across all four halls. Observations revealed considerable scrapes and black marks on the walls behind beds, multiple dents and scraped paint on baseboards, and wallpaper peeling off in hallways. Interviews with the Maintenance Director confirmed that maintaining the facility's walls was a chronic problem. Additionally, the use of an institutional-style overhead paging system was observed multiple times, which detracted from the homelike environment. The Chief Nursing Officer acknowledged the importance of reducing institutional characteristics to respect the residents' home-like setting. Further deficiencies were noted in the condition of window treatments and water temperature in resident bathrooms. One resident's window blinds were broken, allowing intense sunlight to enter the room, which was problematic as the resident sunburned easily. The Maintenance Director confirmed the need for repair. Additionally, multiple residents reported cold water in their bathrooms, with observations confirming water temperatures as low as 80.7 degrees Fahrenheit. The Maintenance Director admitted awareness of the issue since August 2023, attributing it to an unresolved valve problem.
Failure to Notify Ombudsman of Resident Hospital Transfers
Penalty
Summary
The facility failed to ensure that the Office of the State Long-Term Care Ombudsman (LTCO) received required resident discharge information for three residents who were discharged to the hospital. This failure prevented the Ombudsman's office from having the opportunity to educate and advocate for the residents regarding the discharge process. The facility's policy required that the LTCO be provided with a copy of the transfer/discharge notices for hospitalized residents, but this was not followed for Residents 60, 49, and 42. Resident 60 was discharged to an acute hospital twice, and there was no documentation indicating that the LTCO was notified for either discharge. Resident 49 was transferred to the hospital due to shortness of breath and low blood-oxygen levels, but again, there was no documentation of LTCO notification. Resident 42, who had medical conditions including unstable blood sugar levels and malnutrition, was transferred to the hospital for further evaluation due to increased confusion, but the facility could not provide documentation showing LTCO notification for this hospitalization either. In interviews, staff members confirmed that the facility's ombudsman notification process was not being followed. The Social Services Director admitted to not completing the state's LTCO notification process or maintaining communication logs in the facility's record. Both the Administrator and the Chief Nursing Officer stated that they expected the social services department to notify the ombudsman of residents' transfer/discharge to the hospital as required, but acknowledged that this was not being done. This lack of compliance with the notification process was a clear deficiency in the facility's operations, as it failed to meet the regulatory requirements for resident discharge notifications.
Failure to Provide Bed Hold Policy Notification
Penalty
Summary
The facility failed to provide written notice of the bed hold policy to residents and/or their representatives at the time of transfer or within 24 hours for three residents. Resident 60 was discharged to an acute hospital twice, and there was no documentation indicating whether the resident or their representative accepted or declined a bed hold for both occurrences. Resident 49 was transferred to the hospital for shortness of breath and low blood-oxygen levels, but the bed hold portion of the transfer/discharge notice did not indicate whether the resident accepted or declined a bed hold. Resident 42 was transferred to the hospital for increased confusion, and the bed hold portion of the transfer/discharge notice also did not indicate whether the resident accepted or declined a bed hold. In an interview, the Assistant Director of Nursing stated that it was the resident's right to be notified of the facility's bed hold policy to make an informed decision. The current bed hold electronic form did not support or ensure resident rights were safeguarded because it lacked an option to select a choice. Both the Administrator and Chief Nursing Officer confirmed that the facility's bed hold process was not conducted as required, and the electronic form did not include an acknowledgment of the resident/representative's choice regarding their bed hold status.
Inaccurate MDS Completion for Multiple Residents
Penalty
Summary
The facility failed to ensure the accurate completion of the Minimum Data Set (MDS) for eight residents, leading to discrepancies in their assessments. For Resident 55, the MDS inaccurately reflected the amount of nutrition received via a feeding tube, despite physician orders and medication administration records indicating the resident received 100% of their caloric intake through the tube. Staff D, the MDS Specialist, acknowledged the error, attributing it to a contractor completing part of the MDS remotely. This inaccuracy was confirmed through interviews and record reviews. For Residents 6, 7, 15, 27, 44, and 60, the MDS inaccurately indicated that these residents received nutrition through feeding tubes, despite no physician orders for tube feeding. Staff D confirmed that these sections of the MDS should have been marked with dashes instead of values, as the residents did not use feeding tubes. This error was identified through a review of physician orders and interviews with staff. Resident 42's MDS inaccurately reported the resident's vision status, failing to reflect a diagnosis of diabetic eye disease and visual disturbances. Despite medical records and observations indicating significant vision impairment, the MDS did not accurately capture this condition. Staff D and other facility staff acknowledged the importance of accurate MDS completion for care planning and confirmed the inaccuracies in Resident 42's assessment.
Failure to Update Care Plans and Conduct Care Plan Meetings
Penalty
Summary
The facility failed to ensure Care Plans (CPs) were updated and/or revised as needed to reflect person-centered care for three residents and failed to provide CP meetings for three other residents. For Resident 15, the CP was not updated to include treatment with an anti-seizure medication despite physician orders indicating the need for such medication. Staff B, the Director of Nursing (DON), acknowledged the importance of updating CPs for accuracy and confirmed the oversight in Resident 15's CP. Resident 276's CP contained incorrect information, including another resident's name and inaccurate details about their toileting needs. Despite recommendations from hospital and facility occupational therapy evaluations for the use of a bedside commode, the CP did not reflect these needs. Interviews with Resident 276 and staff confirmed the inaccuracies and the need for updates to the CP. Similarly, Resident 226's CP did not capture the use of supplemental oxygen, which was observed and documented in physician orders. Staff C confirmed the omission and the necessity for revision. Additionally, the facility failed to conduct CP meetings for three residents. Resident 71, Resident 28, and Resident 44 did not have documented CP meetings since their admission or for an extended period, as confirmed by interviews and record reviews. Staff O, the Social Services Director, acknowledged the importance of CP meetings for resident involvement and confirmed the lack of documentation and scheduling for these meetings. This failure left residents at risk for unmet care needs and inappropriate care.
Failure to Provide Adequate ADL Assistance
Penalty
Summary
The facility failed to provide adequate assistance with Activities of Daily Living (ADLs) for several residents who were dependent on staff for their care. Resident 46, who had impaired memory and depression, was observed on multiple occasions with long, dirty fingernails and thick, curled toenails. Despite the care plan indicating the need for assistance with personal hygiene, staff did not clip the resident's nails or notify social services for podiatrist care. Staff interviews confirmed that the required nail care was not provided as per the facility's policy. Resident 9, who had severe memory impairment, depression, and functional limitations, was observed with black, decayed teeth and food residue in their mouth. The care plan required staff to assist with oral hygiene, but observations and interviews revealed that the resident's teeth were not being brushed adequately. The resident's representative also reported that the resident's teeth were frequently unclean during visits. Resident 30, who had memory impairment and anxiety, was observed with long, jagged fingernails and wearing the same stained clothes for two consecutive days. The care plan indicated the need for assistance with personal hygiene and dressing, but staff interviews and observations confirmed that the resident did not receive the necessary help. Similarly, Resident 27, who had moderate memory impairment and required total assistance with personal hygiene, was observed with dirty fingernails. Despite the resident's request for nail cleaning, staff did not provide the required care, as confirmed by observations and staff interviews.
Failure to Provide Restorative Nursing Services
Penalty
Summary
The facility failed to ensure restorative nursing services were provided for three residents, leading to a risk of diminished Range of Motion (ROM), loss of function, and other negative health outcomes. Resident 7, who had a left-hand contracture, was observed multiple times without the required splint, despite a physician's order and care plan indicating the need for daily splinting. Resident 7 confirmed that nursing staff never applied the splint to their left hand. Resident 55, who had right-sided paralysis and a contracture, was also observed without the necessary splint on several occasions. The resident stated they did not recall staff ever splinting their hand, and a Certified Nursing Assistant (CNA) confirmed that they never assisted with the splint because it was the responsibility of the restorative aide. The care plan and physician's order both required daily splinting, which was not followed. Resident 44, who had functional limitations on the left side of their body, was observed multiple times without the required splint on their left hand. The resident stated that the restorative aide never applied the splint, and their family had to learn how to do it themselves. The restorative aide admitted to not providing the splinting program as assigned. The care plan indicated the need for splinting three to six times per week, which was not adhered to, as confirmed by the staff interviews and observations.
Failure to Ensure Communication with Dialysis Center
Penalty
Summary
The facility failed to ensure ongoing communication and collaboration with the kidney center regarding dialysis treatment and services for two residents, leading to unmet care needs and potential health risks. For Resident 60, the facility did not consistently complete and return dialysis communication forms as required by physician orders. Only four communication forms were found for February and March 2024, and two of these were incomplete. There were no progress notes indicating that nursing staff followed up with the dialysis center to obtain the necessary post-dialysis paperwork, as confirmed by the Assistant Director of Nursing (ADON) and other staff members during interviews. Similarly, for Resident 3, the facility did not receive post-dialysis paperwork from the dialysis center on multiple occasions. Staff documented that the paperwork was not received on every dialysis day from March 1 to March 19, 2024, but there were no progress notes showing that nursing staff followed up with the dialysis center to obtain the missing paperwork. Interviews with various staff members, including the Director of Nursing (DON) and the Chief Nursing Officer (CNO), confirmed that the post-dialysis paperwork was important for communication and monitoring the resident's health status, but it was not consistently obtained or documented. These failures in communication and documentation placed both residents at risk for unmet care needs and potential medical complications. The facility's policy required coordination with the dialysis center to ensure residents' treatment needs were met, but this was not consistently followed, as evidenced by the incomplete and missing communication forms and the lack of follow-up by nursing staff. The deficiency was identified through interviews and record reviews conducted by surveyors.
Failure to Ensure Residents Receive Prescribed Diets
Penalty
Summary
The facility failed to ensure that residents received the diet prescribed to them, as evidenced by the case of Resident 52 and five other residents. Resident 52, who had medical conditions including heart failure, high blood pressure, and diabetes, was observed to have been served a breakfast tray that included items high in salt and sugar, contrary to their dietary restrictions. Despite having a care plan and physician orders for a Consistent Carbohydrate (CCHO) diet, Resident 52 received regular sugar packets and ham, which they identified as inappropriate for their condition. Interviews with staff revealed that the resident's dietary preferences and restrictions were not adequately documented or followed, leading to the provision of incorrect food items. Additionally, during lunch preparation, multiple residents with CCHO diet orders were served incorrect desserts. Staff K, responsible for preparing the trays, served pears instead of the prescribed half portion of cake to residents with CCHO diet orders. This error was observed for five residents, and interviews with dietary staff confirmed that the dietary orders were not followed as expected. The facility's dietary manager acknowledged the mistake and attributed it to staff nervousness. These incidents highlight a failure in the facility's processes to ensure that dietary orders are accurately followed, putting residents at risk for inappropriate diets and related health issues.
Deficiencies in Food Storage and Handling
Penalty
Summary
The facility failed to store and prepare food under sanitary conditions in its kitchen, placing residents at risk for consuming expired or spoiled foods and potential exposure to food-borne illness. Observations revealed that handwashing sinks lacked paper towels, leading staff to use cloth rags to dry their hands, which were not sanitary. Additionally, an extractor fan above the steam table was covered in a layer of blackish dust and grease, which had the potential to contaminate resident meals. The facility's cold storage contained improperly labeled and stored food items, including a slimy and spoiled bag of shredded lettuce, a frozen, undated bag of cubed ham with freezer burn, and a refrigerated, open, undated ham loaf. Staff interviews confirmed that these foods were stored inappropriately and should have been disposed of. The facility also failed to properly handle food brought in by visitors. A reusable plastic container of bean stew was observed in a resident's room without a date of receipt or the resident's name. This container remained in the room for several days, indicating that it was not stored correctly according to the facility's policy. Staff interviews revealed that the nursing department was responsible for handling food brought by guests, but the food in the resident's room was not managed appropriately. These deficiencies highlight significant lapses in the facility's food handling and storage practices, which could lead to serious health risks for residents.
Insufficient Nursing Staff and Delayed Call Light Response
Penalty
Summary
The facility failed to have sufficient nursing staff to provide timely assistance with toileting and call light response, as evidenced by multiple resident interviews, grievance forms, call light reports, and staff interviews. Residents reported waiting for extended periods, sometimes over an hour, for assistance, particularly during night shifts. This led to residents having to use bedpans or bedside commodes on their own, lying in soiled undergarments, or even urinating in bed due to the lack of timely help. Specific instances included Resident 52 waiting two and a half hours for assistance after 3:00 AM, Resident 276 lying in soiled undergarments all night, and Resident 277 urinating in bed at 3:30 AM due to delayed response times. The facility's call light reports corroborated these claims, showing significant delays in response times, often exceeding 15 minutes, which was the expected response time as stated by the facility's Director of Nursing (DON) and Chief Nursing Officer (CNO). For example, Resident 277's call light was answered 18 minutes later at 2:49 AM, 25 minutes later at 8:57 AM, and 23 minutes later at 11:04 PM on different occasions. Similarly, Resident 276's call light was answered 19 minutes later at 8:14 PM and 39 minutes later at 6:36 AM on different days. These delays were consistent with the residents' complaints and highlighted the facility's staffing issues. Additionally, the facility failed to ensure that Restorative Nursing Programs (RNPs) were provided to residents as required. Observations showed that Residents 7, 55, and 44 did not have their prescribed splints applied to their hands as directed by their physicians' orders. Staff interviews revealed that restorative aides were sometimes pulled to work the floor instead of performing their restorative duties, further contributing to the unmet care needs of the residents. This lack of sufficient staffing and failure to adhere to care plans placed residents at risk for unmet care needs and other negative health outcomes.
Failure to Implement and Document Comprehensive Care Plans
Penalty
Summary
The facility failed to ensure a person-centered comprehensive Care Plan (CP) was developed and implemented for three residents. For Resident 30, the facility did not implement CP interventions, specifically assigning only female staff to the resident, which was not followed as a male CNA was assigned to the resident. This oversight occurred despite the resident's CP being updated after an incident where the resident was found with bruises of unknown origin, likely from using a stationary bicycle in the therapy gym. The male CNA assigned to Resident 30 was unaware of the CP intervention, indicating a communication breakdown within the facility's staffing process. For Residents 226 and 71, the facility failed to develop and document a discharge CP. Resident 226, who had clear speech and understood communication, was not involved in discussions about their care and was unaware of their discharge status, leading to feelings of insecurity about returning home. The Social Services Director confirmed that the discharge plan had changed but was not documented in the resident's medical records. Similarly, Resident 71, who also had clear speech and intact memory, was not informed about their discharge plan and had not seen social services staff or had a CP meeting regarding their care. The lack of a documented discharge CP for both residents indicates a failure in the facility's discharge management process. These deficiencies highlight the facility's failure to adhere to its policies on care planning and discharge management, resulting in unmet care needs and increased anxiety for the residents. The facility's policies required personalized CPs and communication of resident goals and status through care conferences and meetings, which were not adequately followed in these cases.
Failure to Ensure Privacy and Dignity for Residents
Penalty
Summary
The facility failed to provide care and services that ensured privacy and maintained resident dignity for two residents. Resident 46, who had multiple medical conditions and impaired memory, was observed on multiple occasions lying in bed wearing only a brief with the door and privacy curtain open, allowing others to see them. Despite Resident 46's preference to not wear clothes, this preference was not documented in their comprehensive Care Plan, and staff did not provide the necessary privacy measures. Interviews with staff revealed that they were aware of the resident's preferences but failed to document them and did not ensure privacy by closing the door or pulling the privacy curtain. Resident 276, who was admitted to the facility after a fall resulting in a fractured pelvis, was independent with activities of daily living prior to the fall. However, after admission, the resident was incorrectly assessed as being incontinent and was not provided with appropriate toileting assistance. The resident reported being left in dirty underwear overnight and being told to use their diaper instead of being assisted to the toilet. Staff interviews confirmed that the resident's preferences and needs were not properly addressed, and the resident's right to use the toilet was not respected, leading to a lack of dignity and proper care.
Failure to Provide Required Medicare Non-Coverage Notice
Penalty
Summary
The facility failed to provide the Skilled Nursing Facility Notice of Medicare Non-coverage (SNF-NOMNC) to a resident, as required by their policy. The policy mandates that the NOMNC be given to all Medicare beneficiaries at least two days before the end of their Medicare-covered Part A stay. In this case, the resident was admitted under Medicare A benefits and discharged to the community without receiving the required notice. The resident's medical records did not show that the NOMNC was provided at least two days prior to the last covered day, which was confirmed by the Social Services Director during an interview. The resident's Admission Minimum Data Set (MDS) indicated they were admitted under skilled Medicare A benefits, and their benefits ended on the same day they were discharged. A physician's progress note showed the resident was ready for discharge once their antibiotic therapy was completed. Despite this, the facility did not provide the NOMNC, which is crucial for informing residents about their right to an expedited appeals process. The Social Services Director acknowledged the oversight, stating that the notice should have been provided but was not.
Failure to Address Resident Grievances
Penalty
Summary
The facility failed to initiate and complete a thorough grievance investigation for two residents who voiced concerns. Resident 42 reported a missing white blouse/shirt to a Certified Nursing Assistant (Staff S), who claimed to have filled out a grievance form and handed it to the Social Services Director (Staff O). However, the grievance was not logged, and Staff O stated they did not receive the form, resulting in no resolution for the lost property. Resident 42 had clear speech and understood communication, as indicated by their Annual Minimum Data Set (MDS) assessment. Resident 71, who also had clear speech and intact memory according to their Admission MDS, complained about environmental noise affecting their sleep due to a roommate's constant yelling. Despite moving rooms, the issue persisted, and no grievance investigation was initiated for Resident 71. The facility's Grievance Logs did not show any record of Resident 71's complaint, although another resident in the same room had filed a grievance about the noise, which was resolved. Staff interviews revealed a lack of follow-through in the grievance process, highlighting a failure to address and resolve the residents' concerns adequately.
Failure to Complete Significant Change in Status Assessment (SCSA) MDS
Penalty
Summary
The facility failed to identify the need for and complete a Significant Change in Status Assessment (SCSA) Minimum Data Set (MDS) for one resident, referred to as Resident 15. According to the report, Resident 15 experienced a significant decline in their condition, including an acute onset change in mental status, hallucinations, and increased assistance needs for daily activities. Despite these changes, the facility did not complete a SCSA MDS within the required 14 calendar days, as mandated by the Centers for Medicare & Medicaid Services Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual. The last MDS assessment for Resident 15 was completed on 11/25/2023, which did not indicate these significant changes, and the subsequent quarterly MDS on 02/25/2024 highlighted the decline but did not prompt a SCSA MDS. Staff D, the MDS Coordinator, acknowledged the oversight during an interview, stating that they realized the need for a SCSA MDS only after completing the 02/27/2024 Quarterly MDS. Despite recognizing the significant decline in Resident 15's condition, Staff D did not initiate a SCSA MDS, even after consulting with their regional nurse. This failure to act left Resident 15 at risk for unmet care needs and inappropriate care. The deficiency was identified based on interviews and record reviews, including progress notes that documented Resident 15's hallucinations and changes in condition.
Failure to Revise PASRR Assessments for Mental Health Changes
Penalty
Summary
The facility failed to ensure that Pre-Admission Screening and Resident Review (PASRR) assessments were revised to reflect mental health changes for two residents. Resident 7 had a Level 1 PASRR completed in June 2022, which indicated the need for a Level 2 evaluation due to diagnoses including traumatic brain dysfunction, depression, and psychotic disorder. Despite the care plan goal for a Level 2 PASRR evaluation to be completed by August 2022, no Level 2 PASRR was found in Resident 7's record. The Social Services Director confirmed the absence of follow-up documentation for the required Level 2 evaluation. Resident 44 had a Level 1 PASRR updated in January 2023, which did not indicate the need for a Level 2 evaluation despite the resident's diagnoses of brain cancer, dementia, and psychotic disorder with delusions. The resident's behaviors worsened, and they received antipsychotic medication daily. A psychiatrist's progress note in March 2024 highlighted the resident's irritability and anxiety, recommending continued monitoring for psychotic features. The Social Services Director acknowledged that the Level 1 PASRR was inaccurate and required revision to refer to a Level 2 evaluation based on the resident's current mental status.
Failure to Follow Physician's Orders and Proper Documentation
Penalty
Summary
The facility failed to ensure that physician's orders (POs) were clarified and followed for several residents, leading to potential risks for unmet care needs and inappropriate care. For Resident 6, the facility did not provide clear parameters for administering non-narcotic and narcotic pain medications, resulting in the resident receiving narcotic pain medication for mild pain. Similarly, Resident 30's wander guard alarm was placed on the left ankle instead of the right ankle as per the order, and nurses incorrectly signed off on the treatment administration record (TAR) without verifying the correct placement and skin integrity. The facility also failed to measure orthostatic blood pressure as ordered for Residents 15 and 7. Resident 15's blood pressure readings showed no change with changes in elevation, which was unusual and suggested incorrect documentation. Resident 7's blood pressure readings also showed no change from lying to sitting, indicating potential inaccuracies in documentation. Staff interviews confirmed that the measurements were likely not performed correctly, and the documentation did not reflect the residents' actual conditions. Additionally, the facility did not follow orders for Residents 55 and 52. Resident 55's artificial nutrition was not administered according to the specified schedule, and the feeding pump was often found off with incorrect labeling. Resident 52 received a diuretic medication despite having a heart rate below the ordered parameter, and the physician was not notified as required. These failures highlight significant lapses in adhering to physician's orders and proper documentation, putting residents at risk for adverse health outcomes.
Failure to Provide Appropriate Care and Services
Penalty
Summary
The facility failed to provide timely and appropriate care for Resident 15, who had a lump on the right side of their neck. Despite a physician's order for an ultrasound on 10/24/2023, the ultrasound was not performed until 03/06/2024, over four months later. This delay was due to a breakdown in communication between the nurse manager, medical records department, and transportation coordinator. The lump was eventually found to be a 1.9 x 1.0 x 1.7 centimeter mass, and the resident was referred to a specialist only after the delayed ultrasound was completed. Resident 30, who had thin and fragile skin, was observed with an adhesive dressing on their right forearm, which was not in accordance with the prescribed treatment for dermatitis. The treatment administration record showed that nurses signed off on the treatment as completed, but they did not use the correct dressing materials as ordered. This discrepancy was confirmed by the Assistant Director of Nursing, who acknowledged that the nurses did not follow the physician's orders, potentially compromising the resident's skin condition. Resident 52, who self-administered insulin injections, was not assessed for their ability to do so safely. The resident's medical records did not show a self-administration assessment, and the medication administration record indicated that the injection site was not being rotated as required. The Chief Nursing Officer confirmed that an assessment should have been completed before allowing the resident to self-administer insulin, and that the nurses should have ensured proper rotation of injection sites to prevent skin bruising and tissue damage.
Failure to Provide Vision Care Services
Penalty
Summary
The facility failed to ensure that residents with vision deficits were assessed and provided with assistive devices to maintain their vision abilities. Specifically, Resident 42, who had a diagnosis of diabetic eye disease and complained of seeing double, was not provided with an eye consultation to address their need for new prescription eyeglasses. Despite the resident's clear speech and understanding, and the importance of reading materials to them, the facility did not follow through with the necessary vision care services. The resident was observed squinting while reading, indicating that their current eyeglasses were no longer appropriate. The facility's policy on vision and hearing care, revised in May 2023, stated that the social services department would identify residents needing eye examinations and coordinate routine services. However, the Social Services Director was unaware of Resident 42's need for vision care services, and the resident was not listed for routine vision services. The Chief Nursing Officer confirmed that the resident's vision deficit was not properly assessed during the MDS completion. This oversight placed Resident 42 and other residents at risk for unmet care needs and a decreased quality of life.
Failure to Implement Ordered Pressure Ulcer Interventions
Penalty
Summary
The facility failed to ensure that a resident with medically complex diagnoses, including Diabetes Mellitus and multiple Stage 4 pressure ulcers, received the ordered interventions for pressure ulcer prevention and treatment. Specifically, the resident had a physician's order for an air mattress to be set at 270 pounds, but observations on two separate occasions showed the mattress was set at 360 pounds, making it firmer than ordered. This discrepancy was confirmed by a Licensed Practical Nurse (LPN) who was unaware that checking the mattress pressure setting was part of their responsibilities. The Director of Nursing (DON) acknowledged the importance of setting the air mattress correctly to prevent the development of additional pressure ulcers. Despite a label on the air mattress pump directing staff to set it at 270 pounds, the incorrect setting persisted until it was manually adjusted by the LPN after unlocking the settings. The failure to follow the physician's order for the air mattress setting placed the resident at risk for further complications related to pressure ulcers.
Failure to Prevent Accidents and Ensure Resident Safety
Penalty
Summary
The facility failed to identify, assess, and implement interventions to prevent accidents for three residents. One resident who smoked was not assessed for smoking safety, and staff were unaware that the resident kept smoking materials in their jacket. The facility policy required smoking assessments upon admission, quarterly, and as needed, but this was not followed, leaving the resident at risk for smoking-related accidents. Another resident was found using a bolster air mattress that was not assessed for safety. The resident had difficulty transferring into their wheelchair due to the raised bolsters, which hindered their movement. The facility policy required a thorough evaluation by the Interdisciplinary Team before using any safety device, but this was not done, compromising the resident's safety. A third resident, who was at risk for elopement, was found without their wander guard alarm for several days. The facility's policy required staff to check the placement of the wander guard alarm twice daily, but this was not documented for multiple days. The resident was observed without the alarm, and staff confirmed its absence. The facility failed to implement immediate safety checks and additional monitoring as required by their policy, leaving the resident at risk for elopement.
Failure to Provide Appropriate Respiratory Care
Penalty
Summary
The facility failed to ensure that two residents received respiratory care consistent with professional standards of practice. Resident 176 was observed receiving supplemental oxygen at two liters per minute (LPM) via a nasal cannula without a physician's order. Staff confirmed that there should have been a physician's order for the oxygen administration, but none was present. This oversight indicates that the staff did not follow the facility's policy requiring a physician's order prior to administering oxygen therapy. Resident 226 was observed receiving three LPM of supplemental oxygen via a nasal cannula, despite having a physician's order for only two LPM on a PRN (as needed) basis. Additionally, the humidifier bottle attached to the oxygen concentrator was empty, which could lead to nasal dryness and discomfort. The facility's records did not show documentation of the PRN oxygen administration, and staff did not notify the physician about the resident's continuous use of supplemental oxygen. This lack of documentation and communication with the physician further highlights the facility's failure to adhere to proper respiratory care protocols.
Failure to Address Resident Refusals and Medication Management
Penalty
Summary
The facility failed to provide medically-related social service interventions for two residents, leading to significant deficiencies in their care. Resident 226, who was admitted for skilled rehabilitation services, had multiple therapy refusals documented in their records. Despite the resident's need for continued therapy, the facility did not follow up to determine the reasons behind the refusals, resulting in the early termination of skilled care benefits. The interdisciplinary team (IDT) did not collaborate effectively to address the resident's barriers to therapy participation, such as dizziness, pain, and physical readiness, which contributed to the cessation of necessary rehabilitation services. Resident 52, who had chronic pain and was prescribed multiple pain medications, frequently refused these medications. The facility's staff did not notify the physician or consulting pharmacist about the resident's refusals, which is a critical step in reassessing and adjusting the care plan to better manage the resident's pain. The lack of communication and follow-up regarding the resident's medication refusals led to the continued administration of unnecessary medications and inadequate pain management. Interviews with facility staff, including the Social Services Director, Director of Rehabilitation, and Chief Nursing Officer, revealed a lack of processes and collaboration to address resident refusals and ensure appropriate care. The facility's failure to implement a system for managing refusals and supporting residents' needs resulted in unmet care needs and decreased quality of life for the affected residents.
Expired and Unsecured Medications Found in Medication Room
Penalty
Summary
The facility failed to ensure expired medications were disposed of timely and controlled pain medications were properly secured. During an observation of the medication room, 10 single-dose syringes of Covid-19 injectable medication with a beyond use date of 03/14/2024 were found inside the medication refrigerator, and 13 swab collection tubes that expired on 10/31/2023 were found in the overhead cabinet. Additionally, a plastic bag containing various expired medications, including blood pressure, nerve pain, antidepressant, and antianxiety medications, was found in an unlocked drawer. Among these expired medications were 21 tablets of narcotic pain medications, which were also unsecured. Staff M, the Infection Preventionist, acknowledged that expired medications and collection tubes should be discarded to ensure resident safety and avoid false test results. Staff M also stated that medications meant to be returned to the pharmacy should not be left forgotten and that controlled substances must be kept locked at all times. The Administrator, Staff A, emphasized the importance of auditing the medication storage room for expired medications and ensuring that controlled substances are always secured to maintain staff accountability.
Failure to Ensure Prompt Dental Care for Residents
Penalty
Summary
The facility failed to assess and ensure prompt dental care and services for two residents, leading to unmet dental needs and diminished quality of life. Resident 42, who had broken teeth and required assistance with oral care, had not seen a dentist since admission despite multiple recommendations for dental interventions, including extractions and cleanings. The facility's records showed no follow-up on these recommendations, and the Social Services Director confirmed the lack of dental care and the need for improvement in the dental tracking process. Resident 46, who had impaired memory and required maximal assistance with oral care, was observed without teeth or dentures. Despite a dental consultation recommending urgent follow-up for very loose teeth, there was no documentation of any follow-up care. The Social Services Director confirmed the absence of follow-up and acknowledged that the staff failed to assess and act on the dental recommendations. Both cases highlight significant lapses in the facility's dental care coordination and documentation processes.
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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