North Cascades Health And Rehabilitation
Inspection history, citations, penalties and survey trends for this long-term care facility in Bellingham, Washington.
- Location
- 4680 Cordata Parkway, Bellingham, Washington 98226
- CMS Provider Number
- 505393
- Inspections on file
- 45
- Latest survey
- March 4, 2026
- Citations (last 12 mo.)
- 16 (1 serious)
Citation history
Health deficiencies cited at North Cascades Health And Rehabilitation during CMS and state inspections, most recent first.
A resident with bipolar disorder, agoraphobia, and anxiety, care-planned to feel safe and receive cares in pairs, reported that a contracted NAC provided peri-care alone, stroked the inner thigh, made the area excessively wet, and made sexually suggestive comments about the resident’s appearance and relationship status. The resident told another caregiver that the NAC’s peri-care was different, took longer, was gentle, and that the NAC’s comments made them feel very uncomfortable; the caregiver only switched room assignments and did not report the allegation or its reason to nursing staff. The allegation was not brought to the LPN/RCM and DON until the following day, contrary to the facility’s abuse policy requiring mandated reporters to immediately report allegations within two hours, allowing the NAC to continue working and to have ongoing access to residents during and after the alleged incident.
A resident with bipolar disorder, agoraphobia, and anxiety disorder, who was cognitively intact and dependent on staff for toileting and personal care, reported that a NAC made sexually inappropriate comments, touched them inappropriately, and sexually assaulted them during care. Multiple NACs learned of the resident’s allegations during their shifts and one NAC changed room assignments but none reported the suspected abuse as required by facility policy, which mandates immediate reporting of abuse allegations to authorities. The allegation was not entered into the state reporting system until the following day, and leadership later acknowledged that the report should have been made as soon as the first staff member was informed.
The facility failed to conduct thorough investigations into an alleged sexual abuse incident involving a resident with mental health diagnoses and dependence on staff for toileting, and a separate case of missing narcotic medication for another resident. In the abuse case, the DNS did not interview any day-shift staff despite documentation that the incident occurred on day shift, and did not obtain a statement from the NAC first informed of the allegation. In the narcotic case, the DNS did not review medication destruction forms, did not collect witness statements, and did not interview nurses who had recently worked the med cart, despite an RN’s report of missing narcotics and an established destruction process described by the ADON.
A resident with a seizure disorder and a lumbar fracture reported that antiseizure medications were repeatedly given late and not spaced as prescribed, with some nurses not understanding the importance of timely administration. The resident filed a grievance stating that one nurse was an hour late with evening meds, gave evening and HS antiseizure meds together, and omitted ordered pain medication. Audit review confirmed that an agency RN administered a scheduled morning dose of Divalproex DR nearly three and a half hours late, demonstrating failure to follow physician orders for medication timing.
Surveyors found that staff failed to immediately initiate CPR for two residents who were found unresponsive, not breathing, and without a pulse, despite one having a documented full-code POLST and the other having an unknown code status that, per policy, required CPR. The facility’s POLST binders were disorganized, with forms misfiled, located on the wrong floor, and containing conflicting CPR choices, and some staff believed code status was in the electronic care plan rather than the POLST binder. In one case, multiple RNs and an NP confirmed a resident had no pulse or respirations but did not start CPR, and EMS began compressions only after arriving minutes later. In the other case, an LPN and RNs did not perform CPR while two NACs without current CPR certification provided limited chest compressions, then stopped due to fatigue without nurses taking over, and EMS arrived to find CPR not in progress. These actions and inactions resulted in an Immediate Jeopardy citation under F678 for failure to provide basic life support, including CPR, prior to EMS arrival.
The facility failed to conduct a thorough investigation into an unexpected death following a fall involving a resident with serious medical conditions, including a bladder tumor, kidney disease, and vasovagal episodes. The incident report documented both a fall and an unanticipated death at the same time and stated the events were unwitnessed, despite multiple staff and a visitor providing statements that conflicted with this. Documentation lacked a clear timeline, identification of who performed CPR, duration of CPR, and names of involved staff. The DON did not notify the state hotline, was unaware that police had been called, did not review the police report, and relied on undocumented recollections and scribbled notes rather than complete written investigative records to rule out abuse or neglect.
A resident with hypertension, CKD, heart failure, vision deficit, and high fall risk experienced multiple falls and a significant injury after staff repeatedly administered antihypertensive medications outside ordered BP parameters and failed to update the fall care plan to address medication-related risks. The care plan focused on environmental and behavioral fall interventions but did not include specific strategies for cardiac BP medications despite the CAA identifying medications as a fall risk factor. Over time, the resident had several falls, including one associated with orthostatic hypotension and dehydration, and later sustained a forehead hematoma and L2 compression fracture after a fall they attributed to blood pressure issues. The MAR showed repeated administration of BP meds when diastolic BP was below the hold parameter, which staff later acknowledged as med errors. The facility’s post-fall investigation documented no injuries despite obvious facial trauma, left key assessment sections blank, lacked documentation of neuro checks, and did not analyze medications as a contributing factor, while interviews described the resident’s decline, ongoing dizziness, pain, and delayed call light response.
A resident with HTN, CKD, CHF, and a history of falls had multiple antihypertensive and diuretic medications ordered with specific BP hold parameters, but nursing staff administered these medications even when systolic or diastolic BP values were below the physician-ordered thresholds. On one such occasion, after receiving the medications despite a low diastolic BP, the resident became dizzy while standing at the sink, fell, and sustained a forehead hematoma and an acute L2 compression fracture. The resident and a representative reported ongoing problems with BP medications, including falls and dehydration, and the DON later acknowledged these administrations were medication errors that had not been identified as contributing factors during the initial fall investigation.
The facility failed to accurately identify and document a resident’s legal representative despite the resident having developmental delay, impaired cognition, and being described as an intermittently poor historian. The resident was listed as their own responsible party, and an outside agency case manager was recorded as the primary emergency contact and treated as a decision maker, even though this person was not the DPOA. The resident signed their own POLST and consents, and staff sought approvals and updates from the case manager, while the actual DPOA was neither documented nor contacted about care decisions or a hospital transfer related to a catheter issue.
A resident with a documented DNR status in hospital discharge paperwork experienced a cardiopulmonary emergency during which staff could not locate a POLST or clear code status in the unit POLST binder or EMR. Following facility policy, staff searched the binder and EMR but found no POLST, and the MAR only directed them to a disaster recovery binder that did not contain the form. On instruction from 911, staff initiated CPR until another nurse located hospital paperwork indicating the resident was DNR, at which point CPR was stopped. Review of records and interviews showed that many residents on the unit lacked POLSTs in the binder, POLST binders were incomplete and not consistently audited, code status was not displayed in the EMR per company policy, and some POLSTs/ADs were awaiting scanning or stored in locations not readily accessible to nursing staff. The report states that this failure to access and follow POLST instructions or ensure POLSTs were readily available placed residents at risk for receiving unwanted CPR, avoidable trauma, and other negative health outcomes.
Surveyors found that the facility failed to maintain complete and accurate medical records for two residents. One resident experienced a syncopal episode on the toilet that was reported to an LPN, who had a NAC obtain vital signs and observed poor color and fluctuating status in the wheelchair, but did not document the event, the assessment, the vital signs, or any provider notification in the clinical record. Another resident was sent to the hospital for urinary catheter reinsertion, yet no hospital records from that visit were initially present in the chart, and the hospital dictation was only obtained later. The HIM reported that nurses were typically responsible for obtaining hospital records, and the Interim DON stated that hospital visits and adverse events should be documented and accessible in the clinical record.
A facility with more than 120 beds did not employ a qualified full-time social worker, as the acting social services director lacked the required bachelor's degree or qualifications. The previous director had left, and although two new social service staff were hired, the deficiency persisted during the review period.
A resident repeatedly voiced concerns about pest control, laundry, and meal service, but the facility failed to document, log, or address these grievances. Staff interviews confirmed ongoing complaints, yet no records were found in grievance logs or the resident's medical record, resulting in unresolved issues and lack of follow-up.
Multiple allegations of abuse and neglect involving several residents with cognitive and physical impairments were not thoroughly investigated. The facility did not identify or interview all relevant staff or witnesses, relied on incomplete or unsigned statements, and failed to ask specific questions related to the incidents. Investigations were limited to general inquiries, resulting in incomplete assessments of the reported events.
Two residents did not receive care as ordered by their physicians, including missed weekly lab tests for one resident with a pressure wound infection and lack of CPAP therapy and regular weights for another with heart failure and pulmonary hypertension. Staff failed to follow up on missing lab results and did not ensure respiratory equipment or weight monitoring was provided as ordered.
A resident with a history of pressure ulcers and a current sacral wound infection did not receive wound care in accordance with physician orders, including omission of required wound packing and improper infection control practices by nursing staff. The resident was observed in positions contrary to discharge instructions, and wound care was performed without proper hand hygiene or adherence to infection control standards, resulting in soiled dressings and increased risk of contamination.
The facility failed to conduct thorough investigations for three residents and did not log a COVID-19 outbreak, placing residents at risk for repeat incidents and injury. A resident with severe cognitive impairment suffered a fracture during a transfer, with the investigation lacking necessary statements and a root cause analysis. Another resident experienced an unwitnessed fall, with the investigation missing witness statements and a thorough neurological assessment. A third resident was found on the floor after an unwitnessed fall, with the investigation lacking a neurological assessment. Additionally, the facility did not log a COVID-19 outbreak despite being aware of the first positive case.
The facility failed to complete PASRR evaluations timely for three residents, leading to potential delays in necessary mental health services. A resident with major depression and anxiety, and another with a traumatic brain injury, both required Level II evaluations after a 30-day exemption, but these were not documented. Another resident's Level I PASRR was delayed. Staff interviews revealed lapses in tracking and awareness of PASRR requirements.
A resident with severe cognitive impairment and a history of falls was not provided with the necessary assistance as per their care plan, leading to an avoidable accident. The resident attempted to return to their room with a cup of coffee without staff assistance, resulting in a fall. Interviews with staff confirmed the care plan was not followed, and there was no documentation to support that the required interventions were implemented.
The facility failed to assess and supervise two residents who engaged in smoking, leading to an unsafe environment and potential risk of injury. Despite a non-smoking policy, residents were observed smoking on the property without proper safety measures. The facility did not conduct smoking safety evaluations or develop care plans for these residents, contributing to the deficiency.
The facility did not complete annual performance reviews for six CNAs employed for over a year, potentially affecting their competency and resident care quality. The DON acknowledged the delay in evaluations.
An LPN at a facility was observed administering medications with a 91% error rate, as all medications were given more than one hour past their scheduled times. This affected multiple residents, with medications for blood sugar regulation, iron deficiency, and other conditions being administered late. Staff interviews revealed that assistance should have been sought if running late, and late administration should have been communicated to the provider and resident or POA.
A facility failed to provide a required transfer/discharge notice to a resident with congestive heart failure who was transferred to the hospital. The DON acknowledged that while a transfer form was sent to the hospital, it was not given to the resident, and no documentation of the notice was available.
The facility failed to provide written bed hold notices during hospital transfers for two residents, one with congestive heart failure and another with diabetes and an infection. The Director of Nursing and an LPN confirmed the lack of documentation and the failure to follow the process of offering and documenting bed hold notices, placing residents at risk of not being informed about their rights.
The facility failed to provide adequate assistance with ADLs for three residents, including bathing and nail care. A resident did not receive showers as per their care plan, and another resident's toenails were overgrown due to lack of proper care. Staff interviews revealed gaps in documentation and follow-up on missed care.
Two residents did not receive care according to professional standards, with one not receiving bowel medications or blood pressure medication as ordered, and another missing a CBC lab draw. The facility failed to follow protocols for medication administration and lab collection, leading to unmet care needs.
A facility failed to ensure proper communication with a dialysis center for a resident requiring dialysis services. The facility's policy required a Dialysis Transfer Form to document weights, lab results, medications, and follow-up care, but forms were often incomplete or missing. Staff interviews revealed a lack of awareness of the process for handling incomplete forms, and there was no evidence of follow-up communication with the dialysis center, placing the resident at risk for complications.
The facility failed to ensure residents were free from unnecessary psychotropic medications, lacking proper indications and consent. A resident was prescribed Olanzapine without a supporting diagnosis, another received Ativan and Risperidone without appropriate indications, and a third was given Sertraline without documentation for its use. This oversight placed residents at risk for medication-related complications.
A resident experienced a significant medication error when an LPN administered Lispro insulin four hours late, contrary to the prescribed schedule. The resident's blood sugar was taken hours before the insulin administration, and staff interviews revealed a lack of awareness and communication regarding the late medication pass.
The facility failed to properly store Schedule II-V controlled medications in the medication storage rooms on both floors. Controlled substances requiring refrigeration were placed in a non-permanently affixed black box inside the refrigerator, making them accessible to unauthorized individuals. This was confirmed by an LPN and the Administrator.
The facility failed to ensure proper infection control practices, including hand hygiene and PPE use, for residents on TBP and EBP. Staff did not wash hands with soap and water for a C. diff-positive resident, and a nurse did not wear a gown during a blood draw for a resident with a PICC line. Additionally, a nursing assistant used the same gloves for multiple tasks during catheter care, indicating a lapse in infection control protocols.
A resident's dentures were dropped, broken, and lost at the facility, leading to a deficiency in providing necessary dental services. Despite the facility's policy to replace or reimburse for lost or damaged dentures, there was a delay in addressing the issue, resulting in the resident experiencing discomfort and difficulty eating. The facility's staff had inconsistent responses regarding payment and insurance coverage, leading to a prolonged period without proper dental care.
The facility failed to maintain a clean environment on the first floor, with reports and observations of unclean conditions such as food under beds, sticky floors, and debris. The shower room had feces under a chair and hair on wheels. Staff reported limited cleaning hours and inconsistent practices, with maintenance logs showing unaddressed wall damage.
A resident with a history of falls and cognitive impairment experienced multiple falls due to the facility's failure to implement planned interventions, such as ensuring the call light was within reach and placing a reminder sign. Despite being at risk, these measures were not consistently executed, leading to repeated incidents.
The facility inaccurately entered direct care staffing data into the PBJ for the 4th Quarter of FY 2023, missing 106 required hours. The Administrator noted that contracted agency staff did not use the time clock, leading to the discrepancy. Guidance for accurate CMS PBJ reporting had been provided but not followed.
A resident with multiple health conditions left a facility AMA without receiving a reconciled medication list or home care setup. The facility staff failed to communicate effectively with the resident's family and primary care provider, resulting in the resident lacking necessary medications and follow-up care. The facility did not notify the VA, and the resident's family had to arrange follow-up appointments.
A resident developed avoidable Stage 3 and unstageable pressure injuries due to the facility's failure to monitor and assess skin conditions effectively. Despite having a care plan in place, staff inconsistencies in documentation and communication led to a lapse in pressure injury prevention and management, resulting in harm to the resident.
The facility failed to issue timely refunds to three discharged residents, as required by policy, due to a practice of withholding refunds until all insurance claims were processed. This resulted in significant refund amounts being delayed, placing residents at risk of financial hardship.
A resident experienced a decline in function, increased falls, and cognitive decline due to the facility's failure to ensure they were free from unnecessary psychotropic medications. Despite recommendations for gradual dose reduction, the facility continued administering medications like Seroquel and Ativan without proper justification or effective non-pharmacological interventions. Staff interviews revealed issues with communication and monitoring, leading to the deficiency.
The facility failed to timely notify a resident's POA about the start of an antibiotic for a respiratory infection and an unwitnessed fall. Staff discrepancies in documentation and communication led to the POA being unaware of these significant changes until visiting the facility the next day.
The facility failed to provide a newly hired LPN with credentials to document in the electronic medical record, leading to false documentation under an RN's credentials. This occurred over several days and involved multiple residents, violating the facility's policy on electronic signatures.
Failure to Protect Resident From Sexual Abuse and to Immediately Report Allegation
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident from sexual abuse and to immediately recognize and report an allegation of sexual abuse by a staff member. The facility’s abuse policy defined sexual abuse as non-consensual contact of any type with a resident, including unwanted intimate touching, and required all employees as mandated reporters to report allegations immediately, defined as as soon as possible but not later than two hours after an allegation is made. Despite this, a resident with diagnoses including bipolar disorder, agoraphobia, and anxiety disorder, and a care plan focus on impaired psychosocial well-being and feeling safe in the facility, reported sexually inappropriate touching and comments by a contracted NAC during peri-care. According to the facility’s investigation, the resident stated that the NAC entered their room to change their brief, stroked the inside of their thigh, commented that the resident was “hot,” made the peri area “very wet” with wipes, and responded to the resident’s objection by saying “that’s how it’s supposed to be.” The NAC also allegedly asked if the resident was single or married. The resident consistently repeated the same account of events, including specific details such as clothing color, and stated they would not feel comfortable if the NAC continued to work at the facility. The resident had previously informed another caregiver about feeling uncomfortable with the NAC’s care and comments, and that caregiver switched room assignments so the NAC would no longer care for the resident that day, but did not report the allegation or the reason for the room change to nursing staff. Staff interviews and documentation show that the allegation was not reported in accordance with the facility’s policy. One caregiver acknowledged being told by the resident that the NAC made them feel very uncomfortable, said they were skinny and beautiful, and provided peri-care differently—taking longer and being gentle—but only told the nurse they were switching rooms, without disclosing the resident’s statements. The LPN/Resident Care Manager documented the allegation the following day and reported being informed of the incident at the end of that day, and the DON stated they were notified later that same day by phone. During this time, the NAC reported having worked a double shift and providing care to the resident more than once, and stated they performed care alone and were unaware the resident required cares in pairs. The delay in recognizing and reporting the allegation meant the alleged perpetrator continued working with residents and retained access to the resident after the alleged sexual abuse.
Failure to Timely Report Sexual Abuse Allegation to State Agency
Penalty
Summary
The deficiency involves the facility’s failure to ensure timely reporting of a sexual abuse allegation to the State Agency in accordance with its abuse reporting policy and state and federal law. The facility’s policy, updated October 2022, required that all suspected or alleged abuse be reported immediately, and no later than two hours, when events involve allegations of abuse or result in serious bodily injury. Resident 1, admitted with bipolar disorder, agoraphobia, and anxiety disorder, had an admission MDS showing intact cognition, no refusal of care, no behaviors, and dependence on staff for toileting and personal care. The facility’s investigation documented that an alleged sexual allegation involving Resident 1 as the victim and a NAC (Staff H) as the alleged perpetrator occurred on 02/22/2026, but the allegation was not reported in the state Secure Reporting and Tracking System (STARS) until 02/23/2026 at 7:22 PM. Multiple staff members were informed of the allegation on the day it occurred but did not report it. Staff D, NAC, stated that during the 6:00 AM–2:00 PM shift on 02/22/2026, Resident 1 reported that Staff H made sexual comments and touched them inappropriately during care; Staff D only switched rooms with Staff H and did not report the allegation. During the 2:00 PM–10:00 PM shift on 02/22/2026, Staff E, NAC, was informed in shift report that Resident 1 had reported sexually inappropriate comments by Staff H and feeling uncomfortable, and Staff F, NAC, stated Resident 1 told them that Staff H had sexually assaulted them and made inappropriate comments during care; neither Staff E nor Staff F reported the allegation. The DON later stated the sexual allegation should have been reported immediately once the first staff member was informed, and the Administrator was unaware that multiple staff had knowledge of the allegation on 02/22/2026 and had failed to report it.
Failure to Conduct Thorough Abuse and Misappropriation Investigations
Penalty
Summary
The deficiency involves the facility’s failure to conduct thorough investigations into allegations of abuse and misappropriation, contrary to its own abuse investigation policy. The policy, updated in October 2022, requires the administrator/abuse coordinator to oversee investigations and ensure identification and interviews of the alleged victim, alleged perpetrator, witnesses, and others with knowledge of the allegation. Surveyors found that these requirements were not followed in two separate incidents involving alleged sexual abuse of one resident and missing narcotic medication for another resident. In the first case, a resident with bipolar disorder, agoraphobia, and anxiety disorder, who had intact cognition and was dependent on staff for toileting and personal grooming, reported that a staff member made inappropriate comments and touched them inappropriately while providing peri-care. The facility’s investigation identified a NAC as the alleged perpetrator and documented that the incident occurred on a specific date. The investigation included statements from two NACs and two nurses who worked the evening shift, as well as a statement from the Resident Care Manager. However, both NAC statements indicated the alleged incident occurred during the day shift, and no staff from that day shift were interviewed. A NAC identified in a witness statement as the first person to whom the resident reported the allegation was not interviewed, and no statement from this NAC was obtained. The DNS, who was responsible for completing the investigation, acknowledged not interviewing any day-shift staff and stated they had not conducted further interviews beyond the statements already gathered. In the second case, the facility failed to thoroughly investigate missing narcotic medication for another resident. An investigation report documented that during narcotic count it was determined that the resident’s narcotic medication was missing and that the facility could not establish the location of the medication or whether it was lost or mistakenly destroyed. The incident report included a police report for theft and an email from the DNS describing the medication as misplaced, which was inconsistent with the investigation documentation. The incident report contained no witness statements and no statements from nurses who had recently worked the medication carts. The ADON described an established medication destruction process and required documentation, but the DNS stated they had not reviewed any destruction forms faxed to the pharmacy and had not gathered witness statements or interviewed other nurses who had worked the medication cart prior to discovering the medication missing. A night-shift RN reported notifying the DNS about the missing narcotics and being instructed to copy the narcotic book page and place it in the DNS’s box, but did not see or meet the DNS before leaving the facility, further underscoring the lack of follow-through in the investigation.
Failure to Follow Physician Orders for Antiseizure Medication Administration
Penalty
Summary
The facility failed to ensure physician orders for medications were followed for a resident with a seizure disorder and a lumbar vertebral fracture. The resident’s care plan dated 01/14/2026 documented a seizure disorder with a goal for the resident to remain injury free from seizure activity. During an interview on 03/02/2026 at 9:30 AM, the resident reported that their antiseizure medications were late several times and that some nurses understood the importance of these medications while others did not. The resident stated they had spoken with an LPN (Staff M) about these concerns. In a separate interview on 03/02/2026 at 10:31 AM, Staff M stated they had met with the resident and discussed concerns about antiseizure medications being given at the same time rather than spaced apart as prescribed, and identified that an agency RN (Staff N) had administered the antiseizure medications at the same time. A grievance dated 01/29/2026, signed by the resident, documented that on 01/27/2026 the nurse was an hour late giving evening medications, administered evening and bedtime antiseizure medications together at 10 PM, and did not provide the resident’s pain medication. Review of the Medication Administration Audit Report from 01/31/2026 through 02/05/2026 showed that Staff N administered the resident’s Divalproex Sodium DR tablet, scheduled for 9:00 AM on 02/01/2026, at 12:29 PM, nearly three and a half hours late.
Failure to Initiate CPR and Maintain Accurate POLST/Code Status Information
Penalty
Summary
The deficiency involves the facility’s failure to ensure immediate initiation of CPR for two residents who were found unresponsive, not breathing, and without a pulse, despite having physician orders to attempt resuscitation or, in one case, an unknown code status that required CPR by policy. The facility’s CPR policy required licensed nurses to maintain current CPR certification and to initiate CPR for residents who requested it via advance directives or POLST, as well as for residents without a documented directive, while another staff member verified code status using a centrally located POLST binder. Surveyors found that the POLST binders on both floors were disorganized: some residents’ POLST forms were filed under the wrong room, one resident’s form was on the wrong floor, and several residents had duplicate POLSTs with conflicting CPR choices. Staff interviews showed confusion about where to find code status information, with at least one NAC believing it was in the electronic service plan rather than the POLST binder. For Resident 1, who had diagnoses including endocarditis and sepsis, a signed POLST documented a choice for full resuscitation/CPR if they had no pulse and were not breathing. On the morning in question, the resident experienced breathing difficulty; a NAC reported the resident calling for help, appearing short of breath, and being coached through breathing exercises while on oxygen, then assisted back to bed and reported to a nurse. Later, a therapist found the resident unresponsive in bed, not waking or responding even to a sternal rub, and notified nursing staff. Multiple licensed nurses and a nurse practitioner entered the room, assessed the resident, and confirmed absence of pulse and respirations. Although someone in the room stated the resident was a full code, no one initiated CPR while staff discussed or attempted to verify code status. EMS records showed that 911 was called and EMS arrived at the bedside 14 minutes after the call, at which time EMS personnel, not facility staff, initiated CPR. The facility’s own investigation and staff interviews confirmed that no licensed staff started CPR on Resident 1 despite the full-code POLST. For Resident 2, who had diagnoses including a bladder tumor, kidney disease, and vasovagal response, the facility’s incident report documented an unwitnessed fall and an unanticipated death at the same time. The report and associated statements lacked a clear timeline, did not specify who performed CPR, how long it was performed, or which staff were involved. EMS documentation indicated that EMS was notified early in the morning and arrived to find the resident unresponsive, with CPR having been initiated but then stopped, and it was unclear why CPR was not in progress upon EMS arrival. One LPN stated they helped another nurse move the resident back to bed and applied oxygen after finding a pulse, then went to the nurse’s station to look for the resident’s code status but could not locate it, and did not perform any CPR. Two NACs described being directed to start CPR: one placed a rescue board and counted respirations while the other performed 30–50 chest compressions, then stopped when nurses arrived and did not provide further direction. Neither NAC had current CPR certification on file, and one NAC stated they were the only person who provided compressions and stopped due to fatigue, with no nurse taking over. Another RN reported only assisting with locating code status and bringing the crash cart, without going to the resident’s room or assessing them. Facility leadership confirmed that CPR was required when code status was unknown, but staff did not consistently initiate or continue CPR in accordance with that expectation. The surveyors determined that these failures—delayed or absent initiation of CPR for residents found pulseless and not breathing, disorganized and inaccurate POLST binders, staff confusion about where to find code status, and reliance on uncertified NACs to perform CPR without nurse oversight—constituted noncompliance with the requirement to provide basic life support, including CPR, prior to EMS arrival, subject to physician orders and advance directives. The deficiency was cited at F678 and determined to be Immediate Jeopardy, beginning when the facility failed to perform CPR immediately for a resident with a physician order to initiate CPR.
Removal Plan
- Educating staff in emergency response
- Reviewing the facility CPR policy with staff
- Reviewing all residents' POLST forms for accuracy
- Ensuring CPR training is completed
- Implementing a plan of correction to sustain ongoing compliance
Failure to Thoroughly Investigate Unexpected Death and Potential Abuse/Neglect
Penalty
Summary
The facility failed to thoroughly investigate a potential abuse/neglect allegation related to an unexpected death for one resident. Facility policy required thorough investigations of potential, suspected, and alleged abuse or neglect, including identifying and interviewing individuals with knowledge of the event and maintaining complete documentation. Resident 2 was admitted with diagnoses including a bladder tumor, kidney disease, and vasovagal response and was receiving skilled services with a plan to return home. An incident report documented that the resident experienced a fall without fracture and an unanticipated death at the same time, 5:30 AM. The incident report included a nursing description, three staff witness statement forms, a visitor’s written statement, and a fall investigation checklist. However, the incident report documented that the fall and unanticipated death were not witnessed, which contradicted statements within the investigation. The investigation also contained a statement attributed to staff, without an associated signed statement, indicating that police and 911 were called after the resident was found on the floor, moved to bed, given oxygen, and then stopped breathing, at which point the crash cart was obtained to start CPR. The incident report did not include a timeline of events, did not identify who performed CPR, did not state how long CPR was performed, and did not list the names of staff involved. The DON stated that for an unexpected death they would expect an investigation to include staff witness statements, past medical history, and a thorough review of diagnoses, and acknowledged that the state hotline was not notified because the death was not considered suspicious. The DON further stated they were unaware that police had been notified and that the police report was not reviewed as part of the investigation. When asked how abuse or neglect was ruled out, the DON stated the resident was very ill and therefore the death was not unexpected, and also indicated that staff were interviewed but that this information existed only as scribbled notes and in their memory, not in the investigation record.
Failure to Prevent Falls and Medication Errors Related to Antihypertensives
Penalty
Summary
The deficiency involves the facility’s failure to maintain an environment free from avoidable accident hazards and to provide adequate supervision and monitoring for a resident with a known fall risk and complex medication regimen. The resident was admitted with hypertension, chronic kidney disease, heart failure, and vision deficit, and was assessed as high risk for falls. The Care Area Assessment (CAA) identified medications as a fall risk factor and directed staff to proceed to a fall-related care plan. The care plan included a problem related to mood and behavior medications with side effects such as dizziness, drowsiness, unsteadiness, blurred vision, and orthostatic hypotension, and a separate fall risk problem related to deconditioning. Interventions focused on environmental and behavioral strategies such as call light within reach, proper footwear, keeping the room free of clutter, and having the resident sit at the edge of the bed before standing. The care plan did not include a focus area or specific interventions related to the resident’s cardiac blood pressure medications, despite the identified medication-related fall risk. Beginning in early December, the resident experienced multiple falls. On one date, the resident fell, hit their head, underwent a neurological assessment, CT scan, and lab work, and one blood pressure medication was discontinued, but there were no new fall interventions or care plan updates. A subsequent fall occurred several days later with no new orders or care plan changes. Additional falls in early January included an event where the provider documented orthostatic hypotension with a significant drop in blood pressure upon standing and positive signs of dehydration, for which the resident received IV fluids. The resident also slid from a wheelchair and had another fall the following day, again without new orders, interventions, or care plan revisions. A pharmacist review later noted frequent falls and frequent medication order changes due to dizziness, weakness, and falls, yet the care plan was not updated to address actual falls or medication side effect monitoring. On a mid-January date, the resident fell in their room, struck their face, and complained of back pain, later being diagnosed in the emergency department with a right forehead hematoma and an acute L2 vertebral compression fracture. The ED report documented that the resident stated they fell because of their blood pressure. Review of the Medication Administration Record (MAR) showed the resident had three blood pressure medications with parameters to hold doses if the diastolic blood pressure was below 60, but the medications were administered when the blood pressure was 112/58 on the day of the fall, and on multiple other occasions when the diastolic reading was below the ordered parameter. These administrations were later acknowledged by facility staff as medication errors that should not have occurred. The facility’s incident investigation for the mid-January fall documented no apparent injuries at the time of the incident and no injuries post-incident, left pain and level-of-consciousness sections blank, and left the predisposing factors section blank. Although the investigation stated that neurological checks were done, there was no documentation of these checks in the report or medical record, and medication risk factors previously identified in the CAA were not reviewed as part of the post-fall investigation. Interviews further described the resident’s decline and ongoing symptoms. The resident representative reported problems and overdosing with blood pressure medications since admission, frequent falls, dehydration requiring fluids, and that the resident had become weaker and in pain, impacting their ability to participate in therapy. Nursing staff explained that the electronic medication system required entry of vital signs but did not prevent administration outside ordered parameters, and that it was the nurse’s responsibility to hold medications when indicated; they confirmed that the administrations outside parameters were errors and that the provider should have been notified. Staff also reported the resident had been sleeping more, staying in bed, and not eating breakfast. The resident described ongoing dizziness, new problems with blood pressure and blood pressure medications, a fall associated with feeling dizzy at the sink, and persistent back pain after being told they had broken their back. The resident also reported using the call light as instructed but stated it usually took at least half an hour for staff to respond. The DON acknowledged that administering blood pressure medications outside ordered parameters constituted medication errors and that these errors and medication as a contributing factor were not identified during the fall investigation.
Failure to Follow Antihypertensive Parameters Leading to Fall and Injury
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident was free from significant medication errors when nurses did not follow physician-ordered blood pressure parameters for multiple antihypertensive medications. The resident had hypertension, chronic kidney disease, congestive heart failure, and a history of falls, and was ordered furosemide, hydralazine, and lisinopril at 11:00 AM with specific instructions to hold each medication if systolic blood pressure or diastolic blood pressure fell below defined thresholds. Review of the Medication Administration Record showed that on several dates, including when the resident’s diastolic blood pressure was below 60 or systolic blood pressure was below 110 as specified in the orders, staff still administered one or more of these medications instead of holding them and notifying the provider. Staff interviews confirmed that the electronic system did not prevent administration outside parameters and that it was the nurse’s responsibility to review the full order and hold medications when vital signs were outside the ordered range. On one of the days when medications were administered despite a diastolic blood pressure below the ordered parameter, the resident experienced dizziness while standing at the sink, attempted to turn and sit on the bed, and fell, striking the face and later being found to have a right forehead hematoma and an acute L2 compression fracture. The resident reported ongoing back pain and described having a lot of problems with blood pressure and blood pressure medications. The resident’s representative reported concerns about overdosing with blood pressure medications since admission, stating the resident had falls, dehydration requiring fluids, and increased weakness due to mismanagement. The Director of Nursing acknowledged that administering blood pressure medications outside the ordered parameters constituted medication errors and that these errors were not identified during the investigation of the resident’s fall, and medication was not identified as a contributing factor at that time.
Failure to Accurately Identify and Use Resident’s Legal Representative
Penalty
Summary
The deficiency involves the facility’s failure to maintain an accurate designation of a legal representative for a resident with developmental delay, as required by its advance directives policy. The policy states that during admission the facility must identify the resident’s primary decision maker or legal representative and invoke this person when the resident is unable to make relevant health care decisions. The resident was re-admitted with a diagnosis of developmental delay and was documented in the medical record as their own responsible party, with an outside agency case manager listed as the first emergency contact and identified as family. No Durable Power of Attorney (DPOA) documentation was located in the record. The resident’s care plan noted impaired cognition related to developmental delay, directing staff to use yes/no questions and one-step instructions, and a provider note described the resident as an intermittently poor historian who communicated more by body language, with family assisting. Despite this, the facility’s records showed the resident signed their own POLST and other consents. Social services documented contacting the outside agency case manager to schedule a care conference, and an admission note recorded that this case manager approved a room move. In interviews, the case manager stated the resident had a DPOA and that the facility sought questions and updates from the case manager even though they were not the DPOA and had no right to make decisions. The LPN/Resident Care Manager reported concern at admission and again when reviewing the POLST, noting that the case manager told them the resident could sign for themself and that admissions and the business office should verify any DPOA. The Interim DON stated they were unaware of any DPOA and believed social services should confirm DPOA status. The identified DPOA reported having served in that role for a couple of months, never receiving calls from the facility, and learning of the resident’s catheter incident and hospital transfer only through the case manager, rather than directly from the facility.
Failure to Maintain Accessible and Accurate POLST/Code Status Information During CPR Event
Penalty
Summary
The deficiency involves the facility’s failure to ensure that Physician Orders for Life-Sustaining Treatment (POLST) and advance directives were readily accessible and accurately reflected in the electronic medical record (EMR) for use during emergencies. Facility policy required that POLST or advance directive forms be placed in a central, accessible binder on each unit and used to direct care during a code event, with a staff member assigned to obtain the resident’s code status from the binder. The policy also stated that residents have the right to formulate an advance directive and that, during admission, it is determined whether an advance directive is in place and a POLST is offered or assistance provided in completing one. Despite these policies, the facility did not maintain an effective system to ensure that POLSTs were consistently available in binders or accurately documented in the EMR. Resident 2, who had been admitted from the hospital, had a hospital discharge summary indicating a Do Not Resuscitate (DNR) status and referencing an advance care planning note. On the night of the incident, staff were summoned when Resident 2 was found on the floor, initially warm with a palpable radial pulse, short of breath, and later becoming unresponsive with no pulse. Staff attempted to locate the resident’s code status by checking the POLST binder and the EMR but were unable to find a POLST or any clear code status documentation. The Medication Administration Record directed staff to see a disaster recovery binder for advanced directives and code status, but no POLST for Resident 2 was present in the unit’s POLST book, and there was no documentation in the clinical record that code status had been discussed or that a POLST was in the chart. During the emergency, 911 was called, and the operator instructed staff to initiate CPR because no POLST could be located. CPR was started by staff and continued until paramedics arrived. While this was occurring, another nurse located information in the hospital discharge paperwork indicating that Resident 2 was DNR and wished for no CPR, at which point CPR was stopped. A collateral contact, the spouse of Resident 2’s roommate, reported that staff had verbally indicated the resident was DNR and that medics repeatedly asked for the POLST, which was reportedly only available online in the hospital file; medics later confirmed the hospital had a DNR on file and then stopped life-saving measures. Review of the second-floor POLST book showed that 23 of 52 residents on the unit had no POLSTs available, and multiple staff interviews confirmed that POLST binders were incomplete, not up to date due to room moves and workload, and that code status was not displayed in the EMR per company policy. Staff also reported that some POLSTs and advance directives were awaiting scanning, were stored in financial folders, or were otherwise not readily accessible to nursing staff, contributing to the inability to promptly verify Resident 2’s code status during the event. Additional interviews revealed systemic issues in the facility’s process for handling POLSTs and advance directives. Staff described that upon admission, nurses were expected to obtain POLSTs, review them with residents, and then send them for provider signature, after which copies were to be placed in binders and scanned into the EMR. However, staff acknowledged that there were missing POLSTs, a backlog of forms to be scanned, and inconsistent auditing of POLST binders, with some binders not audited for weeks. It was also noted that only certain floors were audited regularly and that some advance directives might be placed in financial folders that nurses would have difficulty accessing. At the time of surveyor observation, POLST binders were located at the reception desk, out of reach of nurses, while they were being audited, further limiting immediate access. These actions and inactions resulted in the facility’s failure to have an accurate, accessible system for code status information, directly affecting the care provided to Resident 2 during a cardiopulmonary emergency. The report states that this failure to access and follow POLST instructions for CPR or ensure the POLST was readily available for Resident 2 placed residents at risk for receiving unwanted CPR against their known wishes, avoidable trauma, and other negative health outcomes.
Failure to Maintain Complete and Accurate Medical Records for Adverse Event and Hospital Visit
Penalty
Summary
The deficiency involves the facility’s failure to maintain complete, accurate, and accessible medical records for two residents. For Resident 2, an incident report documented that the resident experienced a syncopal episode on the toilet around 2:00 AM, after which a nurse checked vital signs, kept the resident up in a chair for 30 minutes, and then returned the resident to bed. The clinical record, including progress notes, did not contain any documentation of the syncopal episode, the assessment, the vital signs, or whether the provider was contacted. In an interview, the LPN responsible for the resident that night stated that a NAC reported the resident had passed out during a bowel movement on the toilet, that the resident’s color was not good, and that the resident was up and down in their wheelchair. The LPN stated they had the NAC take vital signs, which were at baseline, and that no further assessment was done beyond asking the resident questions and taking vitals. The LPN acknowledged they did not document the episode or notify the provider and stated they should have charted it but did not before the resident died at 5:30 AM. For Resident 3, the deficiency centers on missing hospital documentation following a hospital visit for reinsertion of a urinary catheter. Review of the clinical record showed there were no hospital records from that visit at the time of the initial review. When the HIM was asked to obtain the hospital records, the dictation from the hospital visit was later obtained and added to the record. In interviews, the HIM stated that nurses were usually responsible for obtaining hospital records after hospital visits, and the Interim DON stated that hospital visits and adverse events such as syncope should be documented in the clinical record and accessible. The survey findings concluded that the facility failed to ensure a system was in place to keep residents’ records complete, accurate, accessible, and systematically organized, as required by WAC 388-97-1720.
Failure to Employ Qualified Social Worker for Facility Size
Penalty
Summary
The facility failed to employ a qualified full-time social worker as required for a facility licensed for more than 120 beds. At the time of review, the facility had 122 available beds, but the acting social services director did not possess a bachelor's degree or the necessary qualifications for the position. The previous social service director left employment on 11/3/2025, and the current acting director assumed the role the same day without meeting the qualification requirements. Two new social service staff were hired on 12/15/2025, but there was no indication that a qualified social worker was in place during the period reviewed. These findings were confirmed through interviews and review of facility records.
Failure to Document and Address Resident Grievances
Penalty
Summary
The facility failed to establish and maintain a system to ensure that resident grievances were properly initiated, logged, addressed, and resolved in a timely manner. One resident repeatedly verbalized multiple concerns and grievances regarding their care, including issues with pest control, the cleaning of linen and clothing after pests were found, and dissatisfaction with meal service, specifically being served cold meals. Despite these repeated complaints, there was no documentation of the grievances in the facility's grievance logs for the relevant months, nor any record of the concerns or meetings in the resident's electronic medical record. Interviews with staff confirmed that the resident had voiced numerous complaints, including missing or damaged clothing and ongoing dissatisfaction following a pest control incident. Staff members, including the social worker, resident care manager, and administrator, were unable to locate any grievance logs or documentation related to the resident's concerns. This lack of documentation and follow-up prevented the facility from identifying care trends and determining the effectiveness of any actions taken to resolve the grievances, resulting in the resident repeatedly reporting the same issues without resolution.
Failure to Conduct Thorough Abuse and Neglect Investigations
Penalty
Summary
The facility failed to conduct thorough investigations into multiple allegations of abuse and neglect involving five residents. In the case of two cognitively impaired residents, one alleged inappropriate touching by their roommate. The investigation did not identify which staff member initially received the report, and the original reporter was not asked to provide a written statement. The investigation relied solely on statements from the two residents, both of whom had significant cognitive impairment, and did not include interviews with other staff or witnesses who may have had relevant information. For another resident receiving hospice care, a fall resulted in a head injury. The resident's roommate later alleged that a nursing assistant had been rough and verbally harsh, contributing to the fall. The investigation included general questions to other residents about their care but did not specifically address the allegation. No interviews were conducted with other staff who may have had knowledge of the incident, and the statement from the accused nursing assistant was not signed or dated. Additional allegations of rough treatment and verbal aggression by the same nursing assistant were made by two other residents. These investigations also lacked specific interviews with the accused staff member regarding the allegations, did not include targeted questions to other residents, and failed to gather statements from other staff who might have relevant information. The facility's approach was to ask general, open-ended questions rather than specific ones related to the incidents, and the investigations were incomplete as a result.
Failure to Follow Physician Orders for Labs, Weights, and Respiratory Care
Penalty
Summary
The facility failed to provide care and services in accordance with professional standards and person-centered care plans for two residents. One resident, re-admitted with a sacral pressure wound infection and a history of pressure ulcers, had physician orders for weekly laboratory tests, including ESR, while on IV antibiotics. The medical record showed that after an initial high ESR result, a subsequent test was not completed due to a laboratory issue, and there was no documentation of follow-up for the missing result. The weekly ESR order was later discontinued by the provider without explanation or documentation regarding the missing test or the rationale for discontinuation. Another resident, admitted with diagnoses including liver failure, heart failure, and pulmonary hypertension, had physician orders for daily weights and CPAP therapy at night. The resident reported not receiving weekly weights or CPAP since admission, despite documentation in the MAR indicating CPAP was provided. Observations confirmed the absence of a CPAP device in the resident's room, and the last recorded weight was over a month prior. Staff interviews revealed a lack of awareness of the resident's heart failure diagnosis and uncertainty regarding the process for obtaining a CPAP device, despite existing orders.
Failure to Follow Wound Care Orders and Infection Control Procedures for Pressure Ulcer
Penalty
Summary
The facility failed to provide care and services in accordance with professional standards for a resident with a history of multiple pressure ulcers, including a sacral wound infection. Upon re-admission, the resident had specific wound care orders, including cleansing with wound cleanser, applying medicated foam and Dakin's solution-moistened gauze as packing into the wound and undermining/tunneling, and securing with bordered gauze. Observations revealed that these orders were not consistently followed, as wound packing was omitted during dressing changes, despite the orders specifying its use. The resident was also observed lying on their back, contrary to discharge instructions to offload pressure from the wound, and reported difficulty maintaining side positioning due to discomfort and lymphedema in the left leg. During wound care observation, a registered nurse was seen donning gloves from their uniform pocket without performing hand hygiene between glove changes, and using supplies from their uniform, which is considered unclean. The nurse did not apply packing to the wound bed as ordered, and there was confusion regarding the current wound care orders. The resident expressed awareness of the need for packing and frequent dressing changes due to stool contamination, but the nurse denied that packing was part of the current orders. The wound dressing was also observed to be soiled with stool, and the dressing technique covered the resident's anus, potentially increasing the risk of further contamination. Interviews with nursing staff and management confirmed that the wound care orders included packing with Dakin's solution and that this should be done with every dressing change. Staff acknowledged the challenges posed by the resident's anatomy and frequent incontinence, which contributed to wound contamination. Infection control breaches were noted during wound care, including improper glove use and lack of hand hygiene, and staff did not demonstrate awareness of these issues during the surveyor's observation.
Inadequate Investigations and Unlogged COVID-19 Outbreak
Penalty
Summary
The facility failed to conduct thorough investigations for three residents and did not log a COVID-19 outbreak, placing residents at risk for repeat incidents and injury. Resident 1, who had severe cognitive impairment and was dependent on staff for transfers, suffered a fracture to the left foot after a transfer incident. The investigation into this incident was inadequate, lacking statements from all involved staff and a root cause analysis, and did not rule out abuse or neglect. The care plan did not accurately reflect the resident's required level of care. Resident 2, with severe cognitive impairment and a history of falls, experienced an unwitnessed fall while returning to their room with a cup of coffee. The investigation was incomplete, missing witness statements and a thorough neurological assessment, and failed to rule out abuse or neglect. The care plan intervention to assist with transfers and ambulation overnight was not followed, contributing to the incident. Resident 3, who had moderate cognitive impairment and was at risk for falls, was found on the floor after an unwitnessed fall. The investigation lacked a neurological assessment and did not provide evidence to support the root cause analysis. Additionally, the facility did not log a COVID-19 outbreak in February 2025, despite being aware of the first positive case and notifying the local health department and state reporting agency. The facility's failure to conduct thorough investigations and log the outbreak demonstrates a lack of adherence to policies and protocols.
Failure to Complete PASRR Evaluations Timely
Penalty
Summary
The facility failed to ensure the completion of the Pre-Admission Screening and Resident Review (PASRR) forms according to federal guidelines for three residents. Resident 5, who was admitted with major depression disorder and anxiety, had a Level I PASRR indicating a need for a Level II evaluation, with a 30-day exemption. However, no Level II evaluation was documented after the exemption period expired. Similarly, Resident 6, admitted with a traumatic brain injury, also required a Level II evaluation after a 30-day exemption, but no documentation was found. Resident 4, admitted with anxiety and depression, had a Level I PASRR completed five days post-admission, indicating a delay in the required screening process. Interviews with facility staff revealed lapses in the PASRR process. Staff L, the Social Services Director, acknowledged the oversight in tracking exemptions and the delay in completing the Level I PASRR for Resident 4. Staff B, the Director of Nursing, was unaware of the residents' need for Level II evaluations and the expiration of their exemptions. These deficiencies in the PASRR process placed residents at risk of not receiving timely mental health services, as required by federal regulations.
Failure to Implement Fall Prevention Care Plan
Penalty
Summary
The facility failed to ensure that fall prevention care plans were implemented for a resident, leading to an avoidable accident. Resident 2, who was admitted with diagnoses including vascular dementia, COPD, and heart failure, had a care plan indicating a high risk for falls due to deconditioning and balance problems. The care plan required staff assistance with transfers and ambulation overnight. However, on the night of the incident, Resident 2 was found on the floor after attempting to return to their room with a cup of coffee, without staff assistance as outlined in the care plan. Interviews with facility staff revealed that Resident 2 was not supposed to transfer themselves, and there was no documentation to show that the care plan was followed. Staff E, an LPN/RCM, confirmed the lack of documentation, and Staff B, the Director of Nursing Services, acknowledged that the care plan should have been followed, confirming the absence of evidence in the investigation to support that the care plan was adhered to. This oversight placed all residents at risk for unmet care needs and a diminished quality of life.
Failure to Ensure Safe Smoking Practices for Residents
Penalty
Summary
The facility failed to ensure that residents who engaged in smoking were assessed for adequate supervision to prevent injury from burns and to provide a safe environment, necessary devices, and supplies to safely smoke. This deficiency was observed in two residents who were reviewed for smoking. The facility's policy stated that it was a non-smoking facility, yet residents were found smoking on the property without proper supervision or safety measures in place. This failure potentially placed all residents at risk for injury related to unsafe smoking practices and constituted an Immediate Jeopardy. Resident 66, who had a history of nicotine dependence and was on nicotine replacement therapy, was observed smoking on the sidewalk outside the facility. Despite the facility's non-smoking policy, Resident 66's room and hallway smelled heavily of cigarette smoke, and the resident admitted to smoking off the property and keeping cigarette butts in their pockets due to the lack of disposal receptacles. The facility had not conducted a smoking safety evaluation or developed a care plan addressing the resident's nicotine dependence, despite the resident's high risk to smoke due to recent stressors and impaired mobility. Similarly, Resident 78, who also had a history of nicotine dependence, was observed smoking unsupervised on the sidewalk outside the facility. The resident reported going outside to smoke multiple times a day and keeping cigarette butts in their pocket until they could dispose of them inside the facility. Like Resident 66, there was no smoking safety evaluation or care plan in place for Resident 78, despite their known smoking habits and nicotine replacement therapy. The facility's lack of assessment and planning for these residents' smoking habits contributed to the unsafe environment and potential risk of injury.
Removal Plan
- Initiated safe smoking evaluations for residents.
- Conducted skin assessments for burns.
- Performed room inspections to ensure cigarette butts were properly disposed of.
- Provided a safe smoking location with a safe disposal receptacle.
- Educated Residents 66 and 78 on the safe smoking location and safe disposal of cigarette butts in the smoking receptacle.
- Instructed residents to turn in their smoking paraphernalia when they return to the building.
- Educated staff to ensure awareness of the new smoking safety plan.
- Directed staff to ask residents to show that they do not have any cigarette butts on their persons when they returned from smoking.
Failure to Complete Annual CNA Performance Reviews
Penalty
Summary
The facility failed to ensure that annual performance reviews were completed for six Certified Nursing Assistants (CNAs) who had been employed for more than one year. This deficiency was identified through interviews and record reviews conducted on January 22, 2025. The CNAs affected were Staff F, G, H, I, J, and K, with hire dates ranging from 2006 to 2023. During an interview, the Director of Nursing Services, Staff B, acknowledged that the facility was behind on completing these evaluations. This oversight had the potential to negatively impact the competency of the CNAs and the quality of care provided to residents.
High Medication Error Rate Due to Late Administration
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, as evidenced by a 91% error rate observed during a medication pass. Staff P, an LPN, was responsible for administering medications to several residents, including Resident 46, Resident 12, Resident 6, and Resident 25. During these observations, Staff P administered medications significantly later than the prescribed times, with all medications being given more than one hour past their scheduled administration. This delay in medication administration was acknowledged by Staff P, who stated that medications are considered late if administered more than one hour after they are due. The report details specific instances of late medication administration for each resident. For Resident 46, medications ordered for 7:00 AM, 8:00 AM, and 9:00 AM were administered at 12:07 PM. Similarly, Resident 12's medications, due at 7:30 AM and 8:00 AM, were given at 12:16 PM. Resident 6's medications, scheduled for 8:00 AM and 10:00 AM, were administered at 12:49 PM, and Resident 25's medications, due at 8:00 AM, were given at 12:55 PM. Interviews with Staff P, the Resident Care Manager, and the Director of Nursing Service revealed that staff were expected to seek assistance if running late with medication passes, and that late administration should be communicated to the provider and the resident or their POA. The failure to adhere to these protocols contributed to the high medication error rate observed.
Failure to Provide Transfer/Discharge Notice
Penalty
Summary
The facility failed to provide the required notice of transfer or discharge to a resident at the time of their transfer to the hospital. Resident 50, who was admitted with diagnoses including congestive heart failure affecting fluid balance, experienced a change in condition and was transferred to the emergency department. Upon review of the clinical record, it was found that there was no documentation indicating that the required transfer or discharge notice had been provided to the resident. During an interview, the Director of Nursing Services acknowledged that while a transfer form was completed and sent to the hospital, it was not provided to the resident themselves, and they were unable to produce the notice or documentation of review for Resident 50.
Failure to Provide Bed Hold Notices During Hospital Transfers
Penalty
Summary
The facility failed to provide written bed hold notices at the time of transfer to the hospital for two residents, which is a requirement under the regulations. Resident 50, who was admitted with congestive heart failure, experienced a change in condition and was transferred to the emergency department. Upon review of Resident 50's clinical record, there was no documentation of a bed hold notice being provided at the time of transfer. The Director of Nursing Services (DNS) confirmed that the process involves reviewing the bed hold notice with the resident or following up with the family, but they were unable to produce any documentation of this process being followed for Resident 50. Similarly, Resident 72, who was admitted with diabetes and a left lower extremity infection, was transferred to the hospital for an infection. The clinical record review showed no documentation of a bed hold notice being offered or provided. Staff interviews revealed that the facility did not obtain a bed hold for Resident 72, and the Licensed Practical Nurse (LPN) stated that they are supposed to offer and document the bed hold offer when residents are sent to the hospital. This lack of documentation and failure to provide the required notices placed the residents at risk of not being informed about their right to hold their bed during hospitalization.
Failure to Provide Adequate ADL Assistance
Penalty
Summary
The facility failed to provide adequate assistance with activities of daily living (ADLs) for three residents who were dependent on staff for care. Resident 58, who required one-person assistance for bathing, was not provided with showers according to their care plan, which specified showers on Sundays and Wednesdays. Documentation showed that Resident 58 received significantly fewer showers than scheduled, with no records of attempts to provide bathing after refusals. Similarly, Resident 68, who also required one-person assistance for bathing, did not receive showers as per their care plan, with documentation indicating only one shower in January. Staff interviews revealed that there were no specific shower aides, and missed showers were not consistently reassigned or documented. Resident 20, who had advanced dementia and diabetes, required extensive assistance with ADLs, including nail care. Observations revealed that Resident 20's toenails were thick, overgrown, and growing in various directions, indicating a lack of proper nail care. The Treatment Administration Record (TAR) showed weekly diabetic nail care was supposed to be completed by Licensed Nurses, but there was no documentation of care or refusals. Interviews with staff indicated that Resident 20 was supposed to be seen by a podiatrist, but there was no documentation of a recent visit, and the facility had not facilitated an appointment with an outside provider. The facility's failure to provide necessary ADL assistance, including bathing and nail care, placed the residents at risk for unmet care needs and poor hygiene. The lack of documentation and follow-up on missed care further contributed to the deficiency. Staff interviews highlighted gaps in the facility's processes for ensuring that residents received the care outlined in their individualized care plans.
Failure to Administer Medications and Conduct Lab Tests as Ordered
Penalty
Summary
The facility failed to provide care and treatment in accordance with professional standards for two residents, leading to unmet care needs and potential medical complications. Resident 58, who was admitted with high blood pressure, dementia, and constipation, did not receive bowel medications as ordered by the physician despite having multiple periods without a bowel movement. Additionally, Resident 58's blood pressure medication, Hydralazine, was not administered as ordered when the resident's systolic blood pressure exceeded 160. These lapses in care indicate a failure to adhere to the prescribed treatment plan. Resident 68, admitted with high blood pressure and anemia, did not have a Complete Blood Count (CBC) lab draw performed as ordered by an Advanced Registered Nurse Practitioner. The Director of Nursing was unaware of the missed lab and found no documentation indicating that the ARNP was notified. The facility's protocol for bowel management and medication administration was not followed, as evidenced by the lack of documentation and action regarding the residents' care needs. This deficiency was noted as a repeat issue from a previous Statement of Deficiency.
Failure in Dialysis Communication and Documentation
Penalty
Summary
The facility failed to ensure proper communication and collaboration with the hemodialysis center for a resident requiring dialysis services. The facility's policy required the completion of a Dialysis Transfer Form to document pre- and post-dialysis weights, lab results, medications, and follow-up care. However, the facility did not consistently complete these forms or ensure they were returned from the dialysis center, leading to missing documentation for specific dates. Resident 335, who was admitted to the facility and received dialysis three times a week, had missing Dialysis Transfer Forms for certain dates. Interviews with staff revealed a lack of awareness and understanding of the process for handling incomplete forms. The facility's records showed missing entries for post-dialysis weights and vital signs, and there was no documentation of follow-up communication with the dialysis center when forms were incomplete. The Director of Nursing Services acknowledged the expectation for nurses to assess residents post-dialysis, obtain vital signs, and ensure the completion of the Dialysis Transfer Form. However, there was no evidence of documented follow-up with the dialysis center when forms were incomplete. This lack of documentation and communication placed the resident at risk for unidentified medical complications.
Inappropriate Use of Psychotropic Medications
Penalty
Summary
The facility failed to ensure that three residents were free from unnecessary psychotropic medications, as required by regulations. The facility did not provide appropriate indications for the use of these medications, nor did it obtain proper consent that included a discussion of the risks and benefits. This oversight placed the residents at risk for medication-related complications and unnecessary use of psychotropic drugs. Resident 68 was admitted with diagnoses including bipolar disorder and hyperactivity disorder. Despite having no documented signs of psychosis, the resident was prescribed Olanzapine, an antipsychotic, with a conflicting diagnosis of schizophrenia. The resident's clinical record did not support this diagnosis, indicating a lack of proper justification for the medication. Resident 72, who was cognitively intact and showed no signs of psychosis, was prescribed Ativan for agitation and aggression, which are inappropriate indications. Additionally, Risperidone was prescribed without a documented diagnosis or indication. Resident 26, diagnosed with Alzheimer's and anxiety, was prescribed Sertraline for generalized anxiety disorder, but there was no documentation supporting the use of an antidepressant for this condition. The facility's failure to document and justify the use of these medications was a repeat deficiency.
Significant Medication Error with Insulin Administration
Penalty
Summary
The facility failed to ensure that a resident was free from significant medication errors, specifically concerning the administration of Lispro insulin. The package insert for Lispro insulin indicates that it should be administered as prescribed to avoid low blood sugar, with a specific onset and peak time. However, during an observation, a Licensed Practical Nurse (LPN) was seen administering the resident's 8:00 AM dose of Lispro insulin four hours late, at 12:07 PM. The Medication Administration Record (MAR) confirmed that the insulin was documented as administered at 1:16 PM, further indicating a delay. Additionally, the resident's blood sugar was taken at 6:00 AM, well before the insulin administration, which is not in line with best practices for insulin administration. Interviews with staff revealed a lack of awareness and communication regarding the late administration of medications. The LPN acknowledged that administering medications an hour late is considered a medication error and admitted to taking blood sugars in the morning upon arrival rather than immediately before insulin administration. The Resident Care Manager (RCM) was unaware of the late medication administration and stated that nurses should seek help if needed. The Director of Nursing Services (DON) mentioned that staff should be checked for assistance needs and that the provider should be notified if medications are administered late to provide further direction.
Improper Storage of Controlled Substances in Medication Rooms
Penalty
Summary
The facility failed to ensure that drugs and biologicals were stored in accordance with state and federal laws in the medication storage rooms on both the 1st and 2nd floors. Specifically, Schedule II-V controlled medications, which have a high potential for abuse and may lead to severe psychological or physical dependence, were not stored in a separate locked compartment that was permanently affixed. During an observation and interview, it was noted that controlled substances requiring refrigeration were placed in a black box inside the refrigerator, which was not permanently affixed, thus making them accessible to unauthorized individuals. This issue was confirmed by Staff U, an LPN/Resident Care Manager, and later by Staff A, the Administrator, who acknowledged that the required secure storage was not in place on both floors.
Infection Control Deficiencies in Hand Hygiene and PPE Use
Penalty
Summary
The facility failed to ensure compliance with Infection Prevention and Control Guidelines, particularly in the use of appropriate hand hygiene and Personal Protective Equipment (PPE) for residents on Transmission-Based Precautions (TBP) and Enhanced-Barrier Precautions (EBP). In one instance, a resident in a room on contact precautions for Clostridium Difficile (C. diff) infection did not have proper signage instructing staff to wash hands with soap and water, as required for C. diff cases. Staff members were observed using alcohol-based hand rub (ABHR) instead of washing with soap and water after exiting the room, contrary to guidelines. Additionally, staff failed to adhere to EBP protocols for a resident with a peripherally inserted central catheter (PICC). A registered nurse was observed performing a blood draw without wearing a gown, which is required for high-contact activities involving residents with indwelling devices. The nurse later acknowledged the oversight after consulting with the infection preventionist. Furthermore, during catheter care for a resident with a suprapubic catheter, a nursing assistant was observed using the same gloves for multiple tasks, including handling the catheter, adjusting the resident's blanket, and touching various surfaces in the room. This practice contravenes infection control protocols, which require changing gloves between tasks to prevent cross-contamination. The staff member was unable to articulate the correct procedure when questioned, indicating a gap in training or adherence to infection control practices.
Failure to Address Lost and Damaged Dentures
Penalty
Summary
The facility failed to promptly address the issue of a resident's dentures being dropped, broken, and subsequently lost, which led to a deficiency in providing necessary dental services. The facility's policy required action within three days of notification of lost or damaged dentures, but this was not adhered to. The resident, who had no natural teeth and relied on full dentures, experienced discomfort and difficulty eating due to the chipped and lost dentures. Despite the facility's policy to reimburse or replace dentures lost or damaged within the facility, there was a lack of timely action and documentation regarding the incident. The resident's family member reported the chipped denture to the facility, and an appointment was scheduled for a new set of dentures. However, the process was delayed due to issues with insurance coverage and the facility's reluctance to pay for the dentures, citing the age of the dentures and insurance coverage. The facility's social services and business office were involved in discussions with the dental clinic, but the issue remained unresolved for several months, causing the resident to experience anxiety and difficulty eating. Interviews with staff revealed inconsistencies in the facility's handling of the situation. The Director of Nursing Services stated that the facility would typically pay for repairs or replacements if dentures were damaged by staff, but the Administrator and Social Services Director indicated that they were relying on insurance coverage. The facility's failure to document the incident and promptly address the resident's needs resulted in a prolonged period without proper dental care, impacting the resident's quality of life.
Facility Fails to Maintain Clean and Homelike Environment
Penalty
Summary
The facility failed to maintain a clean and homelike environment on the first floor, as evidenced by multiple observations and interviews. Family members and residents reported unclean conditions, including food items under beds, sticky floors, and debris such as straws and wrappers. Observations confirmed these reports, with dark debris along floor edges and stains on walls. A significant issue was noted in the shower room, where a brown substance resembling feces was found under a shower chair, along with hair wrapped around the chair's wheels and debris on the floor. Interviews with staff revealed inconsistencies in cleaning practices. Staff D, a Restorative Aide, acknowledged the presence of feces in the shower room and noted the absence of cleaning supplies, despite signs reminding staff to clean after use. Staff E, the Administrator, confirmed the unsanitary conditions and mentioned recent maintenance efforts, such as power washing and plans to regrout the shower room. However, the maintenance log showed no reports of wall damage or sheetrock issues for the past three months, indicating a lack of documentation and follow-up on maintenance needs. Housekeeping staff reported limited cleaning hours and a structured deep cleaning schedule, which may have contributed to the inadequate cleanliness. Staff A, a housekeeper, described a workload that included both regular and deep cleaning tasks within a constrained timeframe, with hours fluctuating based on resident census. The housekeeping manager confirmed that deep cleaning was scheduled monthly, but the observed conditions suggest that this schedule was insufficient to maintain a clean environment. Maintenance logs from late August indicated several wall damage issues, but these were not addressed promptly, further contributing to the deficiency.
Failure to Implement Fall Prevention Interventions
Penalty
Summary
The facility failed to implement an intervention to reduce the risk of falls for Resident 6, who was at risk due to deconditioning, gait, and balance problems. Despite being identified as at risk for falls, the care plan interventions, such as ensuring the call light was within reach and placing a sign to remind the resident to call for assistance, were not consistently implemented. Resident 6 experienced multiple falls, with six incidents reported since their admission, indicating a lack of adequate supervision and intervention. Resident 6, who had a history of encephalopathy, seizure disorder, Parkinsonism, and pain, was readmitted to the facility following hospitalization. The resident was assessed to have moderately impaired cognitive function and required assistance with activities of daily living, mobility, and transfers. Despite these assessments, the facility's interventions were not effectively executed, as evidenced by the repeated falls and the absence of a sign in the resident's room to remind them to use the call light for assistance. Interviews with staff confirmed the lack of implementation of the planned interventions. Staff H, an LPN, and Staff G, the DNS, acknowledged the absence of the sign in Resident 6's room, which was a critical intervention identified to prevent further falls. The failure to implement these interventions placed Resident 6 at continued risk of falls and potential injury.
Inaccurate PBJ Staffing Data Entry
Penalty
Summary
The facility failed to ensure accurate entry of direct care staffing data, including both contract and agency staff, into the Payroll Based Journal (PBJ) for the 4th Quarter of Fiscal Year 2023. This resulted in a discrepancy of 106 hours short of the required staffing hours. During an interview, the Administrator, identified as Staff A, explained that the contracted agency staff were not using the time clock, which led to their hours not being captured in the PBJ report. Additionally, the Nursing Home Policy & Program Manager had previously provided the facility with guidance for accurate and timely CMS PBJ data reporting, which was not adhered to.
Failure to Ensure Safe Discharge for Resident Leaving AMA
Penalty
Summary
The facility failed to ensure a safe and orderly discharge for a resident who left against medical advice (AMA). The resident, who had a history of a heart attack, acute appendicitis, high blood pressure, diabetes, gastroesophageal reflux disease, depression, and post-traumatic stress disorder, was admitted with a care plan that included providing a reconciled medication list and setting up post-discharge care. However, the resident expressed a desire to leave before being cleared for discharge, and the facility did not adequately communicate with the resident's family or set up necessary home care services. The resident's discharge was abrupt, and they left without their medications or a copy of the AMA discharge paperwork. The facility's staff, including the Registered Nurse/Resident Care Manager and the Social Services Director, were unsure if the resident's primary care provider was notified of the discharge. The Social Services Director admitted to not making a home care referral, as they planned to discuss discharge on a later date. The resident's family reported that the facility did not release the resident's medications and failed to set up home care, leaving the resident without necessary medications for a week. Interviews with facility staff revealed a lack of coordination and communication regarding the resident's discharge. The Administrator acknowledged that the expectation was to do as much as possible for residents before they left AMA, including providing medications and attempting to set up home health care. However, there was uncertainty about whether these actions were completed for the resident. Additionally, the facility did not notify the United States Department of Veterans Affairs (VA) of the resident's discharge, and the resident's family had to arrange follow-up appointments and inform the VA of the resident's situation.
Failure to Prevent and Monitor Pressure Injuries
Penalty
Summary
The facility failed to adequately monitor, assess, and implement interventions to prevent avoidable pressure injuries for a resident, leading to the development of a Stage 3 pressure injury on the rib area and two unstageable pressure injuries on the sacrum. The resident, who had a history of type 2 diabetes mellitus, peripheral vascular disease, and major depressive disorder, was initially admitted with a Stage 3 pressure injury to the sacrum, which was later reported as resolved. However, upon discharge, new pressure injuries were identified, indicating a lapse in ongoing skin assessments and interventions. The care plan for the resident included interventions such as following facility protocols for skin breakdown prevention and treatment, administering treatments and medications as ordered, and monitoring skin status for changes. Despite these measures, the facility's records and interviews with staff revealed inconsistencies in the documentation and communication regarding the resident's skin condition. Staff interviews indicated that there was a lack of awareness and follow-up on the resident's pressure injuries, with some staff believing the injuries had resolved, while others were unaware of any new developments. The facility's failure to maintain accurate and consistent documentation and communication regarding the resident's skin condition contributed to the oversight. Staff members, including registered nurses and nursing assistants, were not effectively coordinating or verifying the resident's skin assessments, leading to a discrepancy between the facility's records and the actual condition of the resident's skin upon discharge. This deficiency placed the resident at risk of harm and highlighted a systemic issue in the facility's pressure injury prevention and management practices.
Failure to Provide Timely Refunds to Discharged Residents
Penalty
Summary
The facility failed to provide the required refunds to three residents or their representatives within the mandated 30 days following the residents' discharge. This deficiency was identified through interviews and record reviews, revealing that the facility's policy, updated in May 2007, required refunds to be processed within 30 days from the date of a resident's death or discharge. However, the policy also included a handwritten note indicating that refunds would be delayed until Medicare Part B payments were received. This practice was confirmed by the Business Office Manager, who stated that the corporate office would not release funds until all insurances had been billed, a process implemented after a change in facility ownership. The account histories of the affected residents showed significant refund amounts due: $1,784.00 for one resident, $9,409.03 for another, and $687.81 for the third. Despite requests for refunds being submitted to the corporate office, no refunds had been issued at the time of the report. This failure to provide timely refunds placed the residents and their representatives at risk of financial hardship, as noted in the findings. The deficiency was referenced under WAC 388-97-0300 (6)(c).
Failure to Ensure Resident Free from Unnecessary Psychotropic Medications
Penalty
Summary
The facility failed to ensure that a resident was free from unnecessary psychotropic medications, which led to a decline in their function, increased falls, and a decline in cognition. The resident, who was admitted with diagnoses including parkinsonism, dementia, anxiety disorder, and depression, was prescribed multiple psychotropic medications without adequate person-centered behavioral interventions or appropriate indications for use. The resident's care plan included interventions for anxiety and depression, but these were not effectively implemented or monitored, leading to the continued use of medications like Seroquel and Ativan without proper justification. Observations and interviews revealed that the facility did not adequately monitor the resident's behaviors or the side effects of the medications. Despite recommendations for gradual dose reduction and discontinuation of certain medications, the facility continued to administer them, resulting in the resident experiencing multiple falls and a significant decline in cognitive function. The resident's family expressed concerns about over-sedation, and staff interviews indicated a lack of clarity and communication regarding medication orders and behavioral interventions. The facility's failure to implement non-pharmacological interventions and ensure appropriate medication use placed the resident at risk for medication-related complications. Staff interviews highlighted issues with the review and implementation of provider recommendations, as well as inconsistencies in monitoring and documenting the resident's behaviors and medication effects. The lack of a coordinated approach to managing the resident's care contributed to the deficiency identified in the report.
Failure to Notify POA of Resident's Condition Changes
Penalty
Summary
The facility failed to ensure timely notification of a resident's Power of Attorney (POA) regarding significant changes in the resident's condition. Specifically, the facility did not promptly inform the POA about the initiation of an antibiotic treatment for a respiratory tract infection and an unwitnessed fall. The resident, who had diagnoses including dementia, a fractured hip, and depression, was found face down on the floor next to their bed, and the family was not notified until the following day. This lapse in communication was confirmed through interviews with staff and the POA, who reported being unaware of the fall and the resident's increased confusion until visiting the facility the next day. Staff interviews revealed discrepancies in documentation and communication practices. Staff B, a Registered Nurse, documented that the family was notified of the fall and the new medication orders, but later admitted that another nurse, Staff A, had used their credentials to make the entry. Staff A, a Licensed Practical Nurse, assumed the family had been notified and only informed the POA of the fall and respiratory infection treatment when they visited the facility the next day. This failure to follow proper notification protocols placed all residents at risk of their POAs not being informed of significant changes in their condition.
Failure to Provide Credentials to New LPN Resulting in False Documentation
Penalty
Summary
The facility failed to ensure that a newly hired LPN, Staff A, received their credentials to document in the electronic medical record before working independently. As a result, Staff A falsely documented nursing notes, medication administration records (MAR), and treatment administration records (TAR) under the credentials of Staff B, an RN. This practice was against the facility's policy, which mandates that each staff member must use their own credentials and not share them with others. Staff A and Staff B had both signed attestation statements acknowledging their understanding and agreement to this policy, which includes disciplinary actions for non-compliance. The review of the nurse's working schedules and charting records revealed that Staff A documented under Staff B's credentials for multiple residents over several days. Interviews with Staff A and Staff B confirmed that Staff A used Staff B's login credentials to chart and administer medications and treatments. Staff A stated that they were instructed by Staff D from Human Resources to use Staff B's credentials, and Staff B reluctantly provided them. Staff A also mentioned that the administration staff had them change the charting on one chart related to an allegation but did not correct the rest of the charting done under Staff B's credentials. Interviews with other staff members, including Staff D, Staff E, and Staff F, revealed a lack of clarity and communication regarding the issuance of credentials for newly hired staff. Staff D mentioned that it typically takes about five days to receive new credentials from the IT department, but the request can be expedited. Staff F stated they were unaware that Staff A did not receive their credentials and assumed the request had been processed. The issue was discovered during an investigation into a resident's fall, leading to the realization that Staff A had been using Staff B's credentials for documentation and medication administration.
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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