North Bend Post Acute
Inspection history, citations, penalties and survey trends for this long-term care facility in North Bend, Washington.
- Location
- 219 Cedar Avenue South, North Bend, Washington 98045
- CMS Provider Number
- 505339
- Inspections on file
- 25
- Latest survey
- August 4, 2025
- Citations (last 12 mo.)
- 1
Citation history
Health deficiencies cited at North Bend Post Acute during CMS and state inspections, most recent first.
The facility failed to ensure RN coverage for at least eight hours a day on five occasions, primarily on weekends, due to staffing challenges. This deficiency was acknowledged by the Director of Nursing and was attributed to common staff call-outs and reliance on on-call nurses who may not be RNs.
The facility failed to designate a qualified Infection Preventionist (IP) to work onsite at least part-time, as required. Staff D, a Registered Nurse, was designated as the IP but worked offsite and only visited the facility occasionally. The facility's assessment did not determine the necessary onsite hours for the IP, leading to inadequate infection control oversight.
The facility failed to investigate and resolve grievances from residents, including requests for an air mattress and missing personal items. Incomplete grievance logs and forms, along with a breakdown in the grievance process, left residents without resolutions or explanations, risking frustration and diminished quality of life.
The facility failed to provide baseline Care Plans (CP) to six residents within 48 hours of admission, as required by policy. This deficiency was identified through interviews and record reviews, revealing that residents with complex medical conditions did not receive a CP or a summary, placing them at risk for unmet care needs. Staff confirmed that it was not the facility's practice to complete or provide baseline CPs.
The facility failed to ensure residents participated in care conferences and that care plans were updated to reflect person-centered care. Three residents did not receive required care conferences, and five residents had care plans that were not updated to reflect their current needs. Staff interviews confirmed the deficiencies in documentation and the need for accurate care plans.
The facility failed to provide adequate ADL assistance for six residents, leading to poor hygiene and grooming. Observations showed residents with long fingernails, unshaven facial hair, and inconsistent shower documentation. Despite care plans indicating the need for assistance, staff did not follow through, and documentation was lacking.
The facility failed to provide adequate care for residents with or at risk for pressure ulcers, as evidenced by improper documentation, lack of physician orders, and failure to implement specialist recommendations. A resident did not have a care plan for their high risk of PU development, another resident's wounds were not consistently measured or treated as recommended, and a wound VAC was used without proper orders. These deficiencies indicate a systemic issue in wound care management.
The facility failed to follow dietary orders and menu plans, resulting in residents receiving incorrect meal portions and components. A resident on a therapeutic diet did not receive large protein portions as prescribed, while another received meals with items they disliked and salt packets against their dietary restrictions. Staff interviews revealed a lack of awareness about correct portion sizes, impacting residents' nutritional intake.
The facility failed to serve food that was appetizing and at the proper temperature, as observed during meal services and a test tray. Residents reported the food was often cold, not well-cooked, and unappetizing. A test tray showed meatloaf at 117°F and hard, undercooked carrots at 99°F. The facility's dietician acknowledged the issue.
The facility failed to implement an effective Antibiotic Stewardship Program, leading to inappropriate antibiotic use for two residents. One resident received overlapping antibiotic courses for a suspected UTI without proper documentation, while another was treated for dysuria despite not meeting criteria for antibiotic use. The facility lacked a full-time Infection Preventionist, resulting in inadequate oversight and guidance.
The facility failed to maintain dignity during meal assistance for three residents. A staff member referred to a clothing protector as a 'bib' for one resident. Another resident experienced a delay in meal assistance, leading to frustration. A third resident was moved from their usual dining spot, disrupting their meal and social interaction.
The facility failed to provide required written transfer notices to residents and their representatives when residents were transferred to hospitals. This deficiency was identified for four residents, with staff confirming the absence of documentation and acknowledging the importance of such notifications for residents' rights.
The facility failed to provide written notification of its bed-hold policy to residents or their representatives during hospital transfers. Three residents were transferred without receiving the required information, as confirmed by the DON. This oversight occurred on multiple occasions, with no documentation of the bed-hold policy being offered.
The facility failed to ensure accurate MDS assessments for four residents, leading to potential risks for unmet care needs. A resident's MDS inaccurately reported no broken teeth and no need for oxygen therapy, despite evidence to the contrary. Another resident's MDS incorrectly coded aspirin as an anticoagulant. A third resident's significant weight loss was not reflected in the MDS, and a fourth resident's MDS failed to report functional limitations due to a stroke. These inaccuracies were confirmed by staff and observed during the survey.
The facility failed to ensure accurate PASRR assessments for residents with mental health conditions, affecting four residents. One resident with schizophrenia required a Level II evaluation, which was not found in their records. Another resident's PASRR inaccurately showed no SMI indicators despite having anxiety and depression. Two other residents had incomplete or inaccurate PASRRs, missing essential information and failing to reflect their mental health diagnoses.
The facility failed to develop comprehensive care plans for three residents, leading to inadequate care. A resident with dietary needs and skin issues lacked measurable goals and care plan details. Another resident with complex medical conditions had a care plan without measurable nutritional goals. A third resident with respiratory failure did not have their oxygen use addressed in their care plan. Staff acknowledged the need for improvements.
The facility failed to monitor behaviors of residents on antipsychotic medications, as seen with a resident who received such medication daily without documented behavior monitoring. Additionally, a nurse did not follow physician orders for wound care on another resident, and there was a lack of documentation for the release of a deceased resident's body to a mortuary.
The facility failed to implement an effective discharge planning process for two residents, risking unsafe discharge and diminished quality of life. One resident was not discharged home despite healed wounds and no updated discharge planning, while another was discharged without a physician's order or communication with the receiving facility.
A resident at risk for pressure ulcers reported a rash that was not regularly monitored by nursing staff. Despite orders for weekly skin evaluations, the last documented assessment was nearly two weeks prior, and daily evaluations did not report any skin conditions. The DON expected weekly assessments and documentation, but these were not consistently performed.
The facility failed to implement restorative programs for two residents, leading to deficiencies in maintaining their range of motion and mobility. One resident, post-stroke, was not provided with the prescribed splinting, while another resident with complex medical conditions did not receive the agreed-upon restorative therapy. Staff interviews and record reviews confirmed the lack of program implementation.
A facility failed to provide necessary social services interventions for a resident with depression who showed signs of self-harm. Despite receiving antidepressant and antianxiety medications, the resident's PHQ-9 assessment indicated thoughts of self-harm, but no further assessments or interventions were documented. The Social Services Director was unaware of the assessment, and the Director of Nursing expected further interviews and interventions, which were not conducted.
The facility failed to submit accurate direct care staffing information to CMS for Q1 2024, as required by PBJ reporting. A discrepancy of 170 census days was found between the facility's reported census and the MDS census summary. The administrator acknowledged inaccuracies and suspected a clerical error in the MDS submission.
Failure to Provide RN Coverage for Required Hours
Penalty
Summary
The facility failed to ensure that a Registered Nurse (RN) was on duty for at least eight hours a day for five days within a 31-day period. This deficiency was identified through a review of the facility's Daily Nurse Staff Documentation, which showed that on specific dates, there was no RN present for the required duration. The absence of an RN on these days, which were weekends, placed residents at risk for delays in assessments, identification of changes in condition, and provision of care that exceeded the scope of practice for Licensed Practical Nurses (LPNs). Interviews with facility staff revealed that the staffing coordinator was responsible for scheduling and finding substitutes when staff called out, which was a common occurrence on weekends. The Director of Nursing acknowledged the difficulty in meeting the RN requirement on weekends and confirmed the facility's failure to provide the necessary RN coverage. The reliance on an on-call nurse who may not hold an RN license further contributed to the inability to meet the federal regulation requiring RN supervision for eight hours daily.
Failure to Designate Onsite Infection Preventionist
Penalty
Summary
The facility failed to designate a qualified staff member to serve as the Infection Preventionist (IP) and ensure that the IP worked onsite at least part-time, as required by the Facility Assessment. This deficiency was identified during an interview and record review, where it was revealed that Staff D, a Registered Nurse, was designated as the IP but worked offsite and only visited the facility occasionally. The Director of Nursing, Staff B, confirmed that Staff D had completed the CDC Nursing Home Infection Preventionist Training Course but did not fulfill the onsite work requirement of at least 20 hours per week based on the facility's census. Further investigation showed that the facility's assessment, dated 08/28/2024, did not determine the necessary amount of time the IP needed to be onsite to meet the infection control needs of the residents. The Administrator, Staff A, acknowledged that Staff D only visited the facility once a month, with the last visit being on 02/17/2025 for eight hours. This lack of consistent onsite presence by the IP placed residents at risk for unmet infection control issues and inadequate oversight of staff infection control practices.
Failure to Resolve Resident Grievances
Penalty
Summary
The facility failed to thoroughly investigate and resolve grievances identified through resident council meetings, affecting several residents. Resident 35 repeatedly requested an air mattress since admission but was not informed of the facility's decision or the reason for denial. The Director of Nursing stated that Resident 35 was not eligible for an air mattress due to the lack of an appropriate condition, but this was not communicated to the resident after the initial discussion. Additionally, the grievance was not logged, and the resident was left without a resolution or explanation. Resident 14 reported damage to personal electronic items caused by a housekeeper, but despite an initial acknowledgment and partial resolution, the resident did not receive updates or a complete resolution for over a month. The grievance form for this incident was incomplete, lacking follow-up documentation and a resolution date. Similarly, Resident 39's grievance about missing black leggings was not logged or resolved, leaving the resident uncertain about the status of their concern. The facility's grievance logs and forms from late 2024 to early 2025 were incomplete, with many grievances not assigned for investigation or concluded. Staff A acknowledged a breakdown in the grievance process due to changes in staff responsibilities, resulting in incomplete documentation and unresolved grievances. This failure to address grievances promptly and effectively placed residents at risk for frustration and a diminished quality of life.
Failure to Provide Baseline Care Plans to Residents
Penalty
Summary
The facility failed to provide baseline Care Plans (CP) to six residents within 48 hours of their admission, as required by the facility's policy. This deficiency was identified through interviews and record reviews, which revealed that Residents 23, 25, 7, 58, 40, and 55 did not receive a baseline CP or a summary of it. The absence of these care plans meant that the residents and/or their representatives were not informed of the initial plan for their care and services, placing them at risk for unmet care needs. The facility's policy mandates that a baseline CP be developed within 48 hours of admission and that a written summary be provided to the resident or their representative in an understandable manner and language. Interviews with staff, including the Director of Nursing, confirmed that it was not the facility's current practice to complete or provide baseline CPs to residents or their representatives. This lack of documentation and communication was evident in the records of the six residents, who had various complex medical conditions requiring skilled nursing care. For instance, Resident 23 was admitted after surgery, Resident 25 had multiple complex diagnoses including heart failure and respiratory failure, and Resident 7 had pressure ulcers and a spinal cord injury. The failure to provide baseline CPs was a systemic issue affecting the facility's ability to meet the immediate needs of newly admitted residents.
Deficiencies in Care Conferences and Care Plan Updates
Penalty
Summary
The facility failed to ensure that residents participated in care conferences and that care plans were updated and revised to reflect person-centered care. Specifically, three residents did not receive or participate in care conferences as required. Resident 23, who was admitted to the facility, reported not having any care conferences since admission, with the last documented conference occurring six months prior. Resident 58, admitted with complex medical diagnoses, had no documentation of a care conference since admission. Resident 20 had only one care conference documented over a six-month period, despite expectations for quarterly conferences. Additionally, the facility did not update or revise care plans for five residents to reflect their current needs and conditions. Resident 7's care plan lacked specific directions for mobility devices and assistance levels, despite requiring a two-person assist and mechanical lift for transfers. Resident 25's care plan did not specify the resident's broken teeth, which were known to staff since admission. Resident 53's care plan failed to specify the resident's drug allergies, and Resident 58's care plan did not reflect the resident's NPO status, despite a physician's order. Resident 8's care plan was not updated to include the presence of an indwelling catheter, which was observed during multiple assessments. Interviews with staff, including the Social Services Director and Director of Nursing, confirmed the expectations for care conferences and care plan updates. Staff acknowledged the deficiencies in documentation and the need for care plans to accurately reflect residents' current conditions and care requirements. These failures 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 six residents, specifically in the areas of cleanliness and grooming. Residents who were dependent on staff for assistance with shaving, bathing, and nail care were observed with long fingernails, unshaven facial hair, and in some cases, long toenails. These observations were made over several days, indicating a pattern of neglect in personal hygiene care. Resident 8, who had impairments and required assistance, was observed multiple times with long fingernails and unshaven. Resident 22, with right-sided weakness, was also observed with long fingernails and toenails, and unshaven, despite requiring assistance. Resident 41, who had paralysis and required extensive assistance, was similarly observed with long fingernails and unshaven. These residents did not exhibit behaviors of rejecting care, yet their care plans were not followed. Resident 27, with severe cognitive impairment, was observed with long facial hair and had not received a shower since a specific date, despite only two documented refusals. Resident 55, with moderate impairment, was observed with long, broken, and dirty fingernails, and the documentation for nail care was incomplete. Resident 37, who was totally dependent on staff for bathing, had discrepancies in shower documentation, indicating a lack of consistent care. Staff interviews confirmed expectations for care were not met, and documentation was lacking.
Deficiencies in Pressure Ulcer Care and Management
Penalty
Summary
The facility failed to provide necessary care and services for four residents at risk for or with existing pressure ulcers (PUs), as per professional standards of practice. Resident 49, who was at high risk for PU development, did not have a care plan in place addressing this risk. Despite being assessed with a Stage 1 PU, there were no documented physician orders for prophylactic treatment, and the wound was not properly documented or included in the discharge summary. Additionally, the resident's collateral contact reported an open area on the tailbone upon transfer to another facility. Resident 14, who had multiple PUs and a diabetic foot ulcer, did not receive consistent wound measurements or follow-up care as recommended by a wound specialist. The facility failed to implement the specialist's recommendations, such as using an air loss mattress and ensuring proper footwear. Observations showed the resident without an air loss mattress and wearing gym shoes instead of diabetic shoes, with the resident reporting worsening wounds. Resident 7 had a wound VAC ordered but lacked proper physician orders for its settings once supplies were received. The VAC was observed in use without documented orders. Resident 25's wound care was not performed according to physician orders, with incorrect application of treatments and a lack of timely wound measurements. These deficiencies highlight a systemic failure in the facility's wound care management, placing residents at risk for deterioration in their skin conditions.
Failure to Follow Dietary Orders and Menu Plans
Penalty
Summary
The facility failed to adhere to its own policies regarding meal preparation and serving, which resulted in residents not receiving meals that met their prescribed dietary needs. Observations and interviews revealed that the facility did not follow the planned breakout menus during meal service, leading to residents receiving incorrect portion sizes and meal components. For instance, Resident 53, who was on a therapeutic diet with large protein portions due to recent weight loss, was served meals that did not align with the dietary orders, such as receiving only one piece of plain fish instead of the specified Panko crusted fish with large portions. Additionally, Resident 25, who had dietary restrictions including no added salt and double protein portions, was served meals that included items they disliked, such as tomatoes, and received salt packets contrary to their dietary orders. This resident expressed frustration with the kitchen service, highlighting ongoing issues with receiving meals that did not meet their dietary preferences and restrictions. Similar issues were observed with other residents, such as Resident 30 and Resident 40, who also received meals that did not comply with their dietary orders, including incorrect portion sizes and the inclusion of salt packets when not allowed. Interviews with staff, including the Director of Nursing and the Dietary Supervisor, confirmed the expectation that menus should be followed to maintain residents' nutritional status. However, the staff was unaware of the correct scoop sizes to use for large portions, indicating a lack of training or communication regarding dietary requirements. The Registered Dietician also emphasized the importance of following menus to ensure accurate nutrition calculations for residents. These failures placed residents at risk for inadequate nutritional intake and unmet dietary needs.
Deficiency in Food Temperature and Palatability
Penalty
Summary
The facility failed to serve food that was appetizing in appearance, palatable, and at the proper temperature, as observed during meal services and a facility test tray. Interviews with four residents revealed consistent complaints about the food being cold, not well-cooked, and unappetizing. Resident 25 reported that the food was almost always cold, while Resident 23 stated that the food was not cooked well and was cold upon delivery. Resident 12 mentioned that the food was not appetizing, with issues such as toast being either too hard or not toasted enough, and meals not being served hot. Resident 45 described the food as horrible and noted that staff sometimes could not identify the food being served. A test tray observation on March 4, 2025, showed that the meatloaf was served at 117 degrees Fahrenheit, and the buttered carrots were at 99 degrees Fahrenheit and were very hard and undercooked. The facility's registered dietician, Staff P, acknowledged awareness of resident concerns regarding cold food and indicated that the facility was working to address the issue. These findings indicate a failure to provide meals that meet the required standards for temperature and palatability, potentially affecting residents' nutritional intake and satisfaction with meals.
Deficiency in Antibiotic Stewardship Program
Penalty
Summary
The facility failed to establish an effective Antibiotic Stewardship Program, which is crucial for promoting appropriate antibiotic use and reducing unnecessary prescriptions. The program's policy required nursing staff to monitor antibiotic initiation and conduct a review within 48-72 hours to assess the response and review lab results. However, the policy lacked specific criteria for determining appropriate antibiotic usage. The facility did not have a full-time Infection Preventionist, relying instead on an offsite Infection Preventionist who visited monthly. This setup led to inadequate oversight and guidance on antibiotic use. For Resident 8, the facility's records showed that the resident was prescribed multiple courses of antibiotics for a suspected urinary tract infection (UTI) without proper documentation or adherence to McGeer's criteria. The resident received antibiotics from 12/14/2024 to 12/19/2024, and again from 12/17/2024 to 12/21/2024, despite the lack of documentation to justify the continuation of the first antibiotic course. The final urine culture report indicated an infection, but the facility failed to document the rationale for overlapping antibiotic treatments. Resident 35 was prescribed a seven-day course of antibiotics for dysuria, but the facility's records showed that McGeer's criteria were not met. A urinalysis conducted on 12/24/2024 revealed no infection, yet there was no documentation of staff consulting with the provider to discontinue the antibiotics. The offsite Infection Preventionist acknowledged that Resident 35 did not meet the criteria for antibiotic treatment and that staff failed to review the order appropriately. This oversight highlights the facility's deficiency in managing antibiotic prescriptions effectively.
Failure to Maintain Dignity During Meal Assistance
Penalty
Summary
The facility failed to maintain and promote dignity during meal assistance for three residents. For Resident 27, a staff member referred to a clothing protector as a 'bib' while assisting the resident to the dining room for lunch. This terminology is considered undignified and does not respect the resident's right to a dignified existence. Resident 112 experienced a delay in receiving assistance with their meal. After being served, the resident attempted to access their food but was unable to do so as staff moved the tray out of reach, promising to return after passing other trays. This left the resident frustrated and attempting to get out of their wheelchair to reach the tray. Assistance was not provided until nearly 10 minutes later. Additionally, Resident 57 was moved from their usual dining spot to a different table, facing away from others, disrupting their meal and social interaction. These actions collectively demonstrate a failure to uphold the residents' dignity and self-determination during dining services.
Failure to Provide Written Transfer Notices
Penalty
Summary
The facility failed to provide required written notices to residents and their representatives at the time of transfer or discharge to an acute care hospital, as mandated by their policy. This deficiency was identified for four residents who were transferred to hospitals with the anticipation of return. The facility's policy required that the transfer/discharge notice be provided in a language and manner understandable to the resident and their representative, including the specific reason for the transfer, the effective date, and information on how to obtain an appeal form. However, the facility did not adhere to this policy, as evidenced by the lack of documentation of written notifications for Residents 9, 1, 41, and 37. Interviews with facility staff, including the Social Services Director and the Director of Nursing, confirmed the absence of written discharge notices for these residents. Staff acknowledged the importance of providing such notifications to uphold residents' rights. Despite the facility's policy stating that notices should be provided as soon as practicable in cases of urgent medical needs, there was no evidence that this was done for the residents reviewed. This oversight placed residents at risk of being discharged without proper communication regarding their care and preferences.
Failure to Provide Bed-Hold Policy Notification
Penalty
Summary
The facility failed to provide written notification of its bed-hold policy to residents or their representatives at the time of transfer to a hospital or within 24 hours, as required by policy. This deficiency was identified for three residents who were transferred to acute care hospitals. Resident 9 was transferred on November 7, 2024, but there was no documentation indicating that the resident or their representative received the required bed-hold policy information. Staff B, the Director of Nursing, confirmed this oversight during an interview. Similarly, Resident 1 was discharged to a hospital on June 8, 2024, and there was no record of a bed-hold notification being provided. Staff B acknowledged the lack of documentation and stated that nursing staff should have offered and documented the bed-hold notification. Resident 37 was transferred to a hospital on two occasions, April 2, 2024, and May 28, 2024, without any progress notes or documentation of a bed-hold offer. Staff B confirmed that the bed-hold policy was not offered for these discharges.
Inaccurate MDS Assessments for Multiple Residents
Penalty
Summary
The facility failed to ensure the Minimum Data Set (MDS) accurately reflected the status of four residents, leading to potential risks for unmet care needs and diminished quality of life. For Resident 25, the MDS inaccurately reported no broken teeth and no need for oxygen therapy, despite observations and records indicating otherwise. The resident had broken teeth prior to admission, which were not documented, and was observed using oxygen continuously, contrary to the MDS report. Resident 53's MDS inaccurately coded aspirin as an anticoagulant medication, although the resident was not receiving any anticoagulant during the assessment period. This discrepancy was confirmed by the MDS Nurse, who acknowledged the error upon reviewing the resident's records. Similarly, Resident 1's MDS failed to reflect significant weight loss, as the resident had lost almost 48 pounds over six months, a fact that was known to the Director of Nursing and the dietitian. For Resident 41, the MDS inaccurately reported no functional limitations in range of motion, despite the resident having right-side weakness and contractures due to a stroke. Observations and interviews confirmed the resident's inability to move their right arm and leg, contradicting the MDS report. The Rehab Director and Director of Nursing both acknowledged the inaccuracies in the MDS, highlighting the need for accurate assessments to plan appropriate care.
Inaccurate PASRR Assessments for Residents with Mental Health Conditions
Penalty
Summary
The facility failed to ensure accurate Pre-Admission Screening and Resident Review (PASRR) assessments for residents with mental health conditions, leading to deficiencies in the care provided to four residents. Resident 23, who had diagnoses of anxiety, depression, and schizophrenia, was identified as needing a Level II evaluation due to Serious Mental Illness (SMI) indicators, but no such evaluation was found in their records. Similarly, Resident 53's Level 1 PASRR inaccurately indicated no SMI indicators, despite the resident having anxiety and depression requiring medication. Staff C acknowledged the inaccuracies and the need for updated assessments. Resident 1's PASRR also failed to identify SMI indicators, despite the resident's diagnoses of anxiety and depression and the use of related medications. Additionally, Resident 27's PASRR was incomplete, lacking any indication of mood or anxiety disorders, and was missing essential information such as the name of the person completing the form and the date. Staff C confirmed the inaccuracies in these assessments, which were not updated as required, leading to a failure in meeting the residents' mental health needs.
Failure to Develop Comprehensive Care Plans for Residents
Penalty
Summary
The facility failed to develop comprehensive care plans for three residents, which placed them at risk for inadequate care. Resident 53 required assistance with eating, was on a therapeutic diet, and was at risk for pressure ulcers. However, the care plan did not include measurable goals for nutritional status or address the resident's skin picking behaviors, recurrent lesions, or dental issues. Despite a physician's order to monitor skin conditions, these aspects were not incorporated into the care plan. Staff B acknowledged the need for measurable goals and the inclusion of the resident's dental and skin conditions in the care plan. Resident 58, who was admitted with complex medical diagnoses and required a feeding tube, also had a care plan lacking measurable goals for nutritional status. Similarly, Resident 25, diagnosed with respiratory failure and requiring continuous oxygen, did not have a care plan addressing their respiratory status and oxygen use. Staff B confirmed the expectation that care plans should include goals and interventions for identified conditions, which was not met for these residents.
Failure to Monitor Antipsychotic Use and Document Care Procedures
Penalty
Summary
The facility failed to monitor and document the behaviors of residents receiving antipsychotic medications, as observed in the cases of three residents. Resident 8, who was admitted with conditions including non-Alzheimer's dementia, depression, and anxiety, received antipsychotic medication daily without any documented monitoring of behaviors related to the medication. Staff interviews revealed that there was no documentation to justify the use of antipsychotic medication for Resident 8, and staff acknowledged the importance of monitoring behaviors but failed to do so. Additionally, the facility did not clarify physician orders for wound care for Resident 25, who was at risk for pressure ulcers. During an observation, a nurse applied castor oil ointment incorrectly, not following the physician's order. Furthermore, for Resident 61, who was on hospice and passed away in the facility, there was no physician order obtained to release the body, nor was there documentation of the release to a mortuary. Staff interviews confirmed these documentation lapses, indicating a failure to adhere to required procedures.
Deficient Discharge Planning for Two Residents
Penalty
Summary
The facility failed to develop and implement an effective discharge planning process for two residents, leading to potential risks for unsafe discharge and diminished quality of life. Resident 23, who was admitted for short-term care with a surgical wound, expressed frustration about not being discharged home after their wound healed. Despite the resident's desire to return home and the healing of their wound, there was no documentation of a quarterly care conference or any updated discharge planning in their records. The Social Services Director acknowledged the lack of documentation and stated that guardianship services were being pursued for Resident 23, but no records confirmed this action. Resident 60 was discharged to a home/community setting without a physician's order, and there was no documentation of communication with the receiving facility to ensure continuity of care. The Director of Nursing confirmed the expectation for a physician's order and progress notes documenting communication with the receiving facility, but these were absent in Resident 60's records. This lack of proper discharge documentation and communication highlights the facility's failure to adhere to its discharge policy, potentially compromising resident safety and care continuity.
Failure to Monitor and Document Skin Condition Changes
Penalty
Summary
The facility failed to monitor and identify changes in a resident's skin condition in a timely manner, specifically for a resident who was at risk for developing pressure ulcers and had existing pressure ulcers upon admission. The resident, who was cognitively intact, reported having a rash under their right-side abdominal fold and right armpit for a couple of weeks. During a wound care observation, a Licensed Practical Nurse (LPN) noted large areas of red, inflamed skin with drainage, but the resident indicated that nursing staff only checked the rash areas when prompted by the resident. The resident's medical records showed a previous order for antifungal powder, which was discontinued after the rash was resolved, and an order for weekly skin evaluations to prevent skin breakdown. However, the last documented skin assessment was nearly two weeks prior, and there was no documentation of a scheduled skin check. Additionally, daily skilled evaluation forms completed by staff did not report any skin conditions. The Director of Nursing (DON) stated that it was expected for nursing staff to complete and document weekly skin assessments and notify the DON and provider if new areas were identified.
Failure to Implement Restorative Programs for Residents
Penalty
Summary
The facility failed to provide a restorative program for two residents, leading to a deficiency in maintaining or improving their range of motion and mobility. Resident 41, who had a stroke resulting in paralysis on one side of their body, was observed multiple times without the prescribed splint on their contracted right hand. Despite being discharged from occupational therapy with a referral for a restorative nursing program, the staff did not implement the recommended splinting schedule. Interviews with the Rehab Director and Director of Nursing confirmed that the restorative program was not executed as required. Resident 23, with complex medical conditions including an infection and amputation, was assessed to have functional limitations in their lower extremities and required a wheelchair for mobility. Although a restorative program was discussed and agreed upon, there was no documentation of an evaluation or initiation of such a program. Despite physician orders to evaluate and start restorative therapy, the facility did not follow through, as confirmed by staff interviews and record reviews.
Failure to Address Self-Harm Risk in Resident with Depression
Penalty
Summary
The facility failed to provide necessary social services interventions for a resident who was reviewed for unnecessary medications. The resident, who had a diagnosis of depression and was receiving antidepressant and antianxiety medications, showed multiple symptoms of depression according to the PHQ-9 assessment. The assessment indicated that the resident had thoughts of self-harm for two to six days during the 14-day look-back period. However, there was no documentation of further assessments, monitoring, or interventions related to the positive response to self-harm, nor was there any indication that the provider was notified. Interviews with staff revealed that the Social Services Director, who was new to the position, was unaware of the assessment and did not conduct the necessary follow-up. The Director of Nursing stated that they expected staff to further interview the resident about any self-harm statements and implement appropriate interventions, but this was not done. Observations showed the resident lying in bed with eyes closed on multiple occasions, and the resident expressed a desire to go home but acknowledged an inability to care for themselves.
Inaccurate PBJ Staffing Data Submission
Penalty
Summary
The facility failed to submit complete and accurate direct care staffing information to the Centers for Medicare and Medicaid Services (CMS) for the first quarter of 2024, as required by the Payroll Based Journal (PBJ) reporting system. The discrepancy was identified through a review of the PBJ data submitted by the facility, which showed a reported census total of 5235. However, the CASPER Report 1704S - Daily Minimum Data Set (MDS) Census Summary indicated a total census sum of 5065, revealing a discrepancy of 170 census days. The inconsistency was noted on multiple days across January, February, and March 2024, indicating that the facility's reported census did not match the MDS census summary on several occasions. During an interview, the facility's administrator, Staff A, acknowledged that the PBJ submission was managed at a corporate level and admitted to inaccuracies in the census numbers. Staff A suggested that the facility's electronic health records provided a more accurate census total compared to the MDS reported numbers, suspecting a clerical error in the MDS census submission. This failure to provide accurate staffing information potentially impacted the accuracy of the nursing home's staffing level data collected by CMS, which could affect the provision of resident care and services.
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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