Northwoods Lodge
Inspection history, citations, penalties and survey trends for this long-term care facility in Silverdale, Washington.
- Location
- 2321 Schold Place Northwest, Silverdale, Washington 98383
- CMS Provider Number
- 505484
- Inspections on file
- 24
- Latest survey
- March 16, 2026
- Citations (last 12 mo.)
- 10
Citation history
Health deficiencies cited at Northwoods Lodge during CMS and state inspections, most recent first.
Two residents did not receive PT and OT services as outlined in their care plans due to missed sessions, delayed initiation of therapy, and limited weekend staffing. One resident experienced delays in brace management, and another left the facility against medical advice after filing a grievance about insufficient therapy services. Staff confirmed that absences and limited coverage contributed to the missed treatments.
A resident with severe cognitive impairment and high risk for pressure ulcers developed avoidable full-thickness wounds due to the facility's failure to implement adequate preventive measures and timely treatment. Despite initial assessments indicating high risk, the care plan lacked necessary interventions, and documentation was inconsistent, leading to hospitalization and surgical intervention.
The facility failed to properly monitor and maintain IV access devices for two residents. One resident with a midline catheter did not have documented measurements or assessments, and another with a PICC line lacked documentation of required measurements. These omissions risked negative health outcomes.
The facility failed to properly assess and document the use of mobility bars for three residents, leading to a deficiency in physical restraint use. A resident was unable to use the bars effectively due to limited motion, and the EHR lacked necessary documentation for consent, orders, and assessments. Staff acknowledged the oversight, which placed residents at risk of harm or entrapment.
The facility failed to maintain food safety and sanitation standards, with missing temperature logs, expired and moldy food items, and uncovered food during transportation. Staff interviews revealed a lack of adherence to protocols, placing residents at risk of foodborne illness.
The facility failed to implement proper infection control measures, including TBPs for AGPs, EBPs for residents with wounds or devices, and contact precautions. Additionally, the Legionella Water Management Program was outdated, and sharps containers were not replaced when full, increasing the risk of infection and cross-contamination.
The facility's antibiotic stewardship program failed to maintain accurate documentation for three residents, leading to inappropriate antibiotic use. A resident was prescribed antibiotics without a necessary culture, another had incorrect symptom onset dates and missing culture information, and a third lacked documentation of symptoms and culture results. Staff acknowledged these discrepancies and the failure to meet McGeer's Criteria.
The facility failed to conduct care conferences for several residents, including those who were cognitively intact and those with impairments. Residents and their representatives were not given the opportunity to participate in care planning, leading to a lack of involvement in their long-term care needs.
A resident who was cognitively intact and required assistance with bathing was not provided showers as per their preference, despite being scheduled for them. The facility's inability to accommodate the resident's mobility needs with a Hoyer lift led to the resident receiving bed baths instead. The administrator confirmed that the resident should have received showers if they could be transferred to a shower chair.
The facility failed to provide written transfer/discharge notices to two residents during their hospitalization. One resident, who was cognitively intact, and another who was moderately cognitively impaired, were transferred without documentation of the required notices. Staff members acknowledged the oversight, and the absence of these notices placed the residents and their representatives at risk of not making informed decisions.
The facility failed to provide written bed hold notices during hospital transfers for two residents, one moderately cognitively impaired and the other cognitively intact. Staff interviews confirmed that the bed hold policy was not followed during transfers, and the facility's administrator acknowledged the oversight.
A facility failed to implement a baseline care plan within 48 hours for a newly admitted resident requiring oral suctioning and NPO status. The plan lacked instructions for AGP precautions and oral care, which were acknowledged as necessary by the Resident Care Manager.
A facility failed to implement a comprehensive care plan for a resident with decreased upper extremity function and moderate cognitive impairment. The care plan lacked specific guidance on meal assistance, leading to the resident being unable to open food items and consume meals. Staff confirmed the care plan did not address the resident's cubital tunnel syndrome, affecting hand function, which was noted in hospital records.
A facility failed to re-assess and revise the care plan for a resident with fractures and diabetes, leading to inadequate skin care and bathing services. The care plan lacked specific instructions for interventions, and observations showed non-compliance with care directives. Additionally, the resident's urinary tract infection was not treated with antibiotics as required. Staff interviews revealed inconsistencies in understanding the resident's care needs, placing the resident at risk for skin impairment and diminished quality of life.
The facility failed to meet professional standards of practice for four residents. A resident refused multiple doses of a prescribed laxative without provider notification. Another resident received morphine sulfate outside the ordered pain parameters. A third resident's midline catheter lacked proper maintenance documentation. Lastly, a resident's partial albuterol dose was incorrectly documented as a full dose, and the provider was not notified.
The facility failed to implement both pharmacological and non-pharmacological interventions for bowel management for two residents, leading to a deficiency in care. One resident experienced chronic constipation due to long-term opioid use, with improper medication administration and lack of non-pharmacological interventions. Another resident had orders for PRN medications but experienced multiple days without bowel movements, with no interventions documented or administered.
A facility failed to follow safety precautions for enteral feeding for a resident with Inclusion Body Myositis and dysphagia. The resident reported increased GI upset and reflux due to inconsistent checks of enteral tube placement and gastric residuals by nurses. An RN was observed not performing these checks before administering a bolus feed, contrary to facility policy and the resident's care plan.
The facility failed to obtain physician orders for respiratory care for two residents, leading to potential risks. A resident using oxygen therapy had no documented physician's order, and another resident with a CPAP machine had no specific settings known by staff. The administrator acknowledged the oversight in obtaining necessary orders.
A resident with a preference against beef continued to receive beef meals despite multiple requests for substitutions. The facility's dietary staff acknowledged the oversight, as the resident's preferences were not properly updated in the kitchen records, leading to meal dissatisfaction.
A resident with severe cognitive impairment and a history of falls suffered a hip fracture due to inadequate supervision and inconsistent implementation of safety measures. Staffing shortages and a room change further contributed to the incident. Another resident was found outside the facility, highlighting a lack of proper monitoring and documentation.
The facility failed to thoroughly investigate allegations of abuse, neglect, and accident hazards for several residents, leading to deficiencies in care. A resident with severe cognitive impairment experienced a fall due to inadequate supervision and environmental hazards. Another resident was found in the parking lot, indicating a lapse in supervision, while a third resident reported rough treatment by male CNAs without proper investigation. A fourth resident's fall was not thoroughly investigated to determine the root cause.
The facility did not ensure timely treatment and care for residents with a history of falls and cognitive impairment. Following an unwitnessed fall, one resident experienced a significant change in cognition and status, showing signs of confusion, pain, and decreased oral intake. There was a delay in provider notification and inadequate neurological assessments, leading to an emergency hospital transfer with multiple fractures and severe sepsis. Similarly, two other residents at risk for falls did not receive consistent neurological assessments post-fall, with delays and incomplete documentation. Staff interviews revealed discrepancies in neuro check completion and communication with providers, despite existing facility policies.
Failure to Provide Scheduled PT and OT Services per Care Plan
Penalty
Summary
The facility failed to provide specialized rehabilitative services, specifically Physical Therapy (PT) and Occupational Therapy (OT), as outlined in the care plans for two residents. One resident, admitted with fractures to the left humerus and hip, was scheduled to receive OT five times per week but only received four sessions over eight days. This resident also experienced delays in having a hinged elbow brace removed due to lack of available therapists, despite a physician's order allowing for its removal during the day. Nursing staff did not remove the brace, stating they were not comfortable doing so without therapy staff present, even though the Rehabilitation Director later confirmed they could have performed the task. Another resident, admitted with hypercalcemia and functional decline, was to receive PT six times per week but only received five sessions over eleven days, with services starting three days after admission. This resident reported dissatisfaction with the lack of therapy services, submitted a grievance, and ultimately discharged against medical advice. Staff interviews confirmed that therapy sessions were missed due to staff callouts and limited weekend coverage, impacting the delivery of care as planned.
Failure to Prevent and Manage Pressure Ulcers
Penalty
Summary
The facility failed to implement adequate measures to prevent the development of avoidable pressure ulcers and to properly assess, monitor, and obtain timely treatment orders for a resident. The resident, who was admitted with conditions including blastocystitis, weakness, and polyneuropathy, was severely cognitively impaired and required extensive assistance for positioning and transfers. Initial assessments noted redness on the buttocks, but there was no documentation on whether the redness was blanchable, and the care plan lacked identified skin impairment risks or interventions. Despite a high-risk Braden score, the facility's documentation and interventions were insufficient. Nursing progress notes initially recorded redness and an open area on the resident's buttocks, but subsequent notes failed to consistently document skin-related concerns. By the time the resident was transferred to the hospital, they had developed multiple full-thickness wounds, including pressure injuries that required surgical intervention and intravenous antibiotics. The facility's failure to document detailed descriptions, staging, or measurements of the resident's wounds in the Electronic Health Record (EHR) contributed to the deficiency. Additionally, the care plan did not include necessary interventions such as pressure-reducing devices or a turning and repositioning program, which were crucial given the resident's high risk for pressure ulcers. The lack of consistent monitoring and appropriate interventions led to the resident's hospitalization and surgical treatment for pressure ulcers.
Failure to Monitor and Maintain IV Access Devices
Penalty
Summary
The facility failed to ensure proper monitoring and maintenance of intravenous (IV) access devices for two residents receiving IV therapy. For Resident 33, who was admitted with a midline catheter for IV antibiotic therapy, the facility did not document the required measurements and assessments. Specifically, there were no records of the midline external length or upper arm circumference being measured upon insertion or during weekly dressing changes. Additionally, the facility did not change the needleless injection caps weekly or assess the midline insertion site as required. Similarly, for Resident 103, who had a PICC line for IV medication, the facility did not document the arm circumference or external catheter length upon admission or during the resident's stay. Although staff signed off on changing the PICC dressing and performing measurements, there was no place provided to record these measurements, and they were not documented in the electronic health record. These omissions placed both residents at risk for potential negative health outcomes.
Deficiency in Assessment and Documentation for Mobility Bars
Penalty
Summary
The facility failed to ensure proper assessment and documentation for the use of mobility bars for three residents, leading to a deficiency in the use of physical restraints. Resident 103, who was cognitively intact, was observed with bed mobility bars but was unable to effectively use them due to limited motion. The facility's Electronic Health Record (EHR) lacked documentation for consent, orders, risk and benefits assessments, or care plan information for the mobility bars. Staff Z, the Rehabilitation Director, acknowledged that the necessary assessments and consents were not completed at the time of installation, and no assessment was provided to document Resident 103's ability to use the bedrails. Similarly, Residents 8 and 33 were observed using mobility bars without proper documentation in their EHRs, including orders, care plans, assessments, or consents. Staff C, the Case Manager, confirmed the absence of these documents and acknowledged the need for assessments by the therapy department. The facility's administrator, Staff A, also recognized the lack of necessary documentation and assessments, which did not meet the facility's expectations. This oversight placed residents at risk of accidents, harm, or entrapment related to the use of mobility bars.
Deficiencies in Food Safety and Sanitation Practices
Penalty
Summary
The facility failed to adhere to professional standards in food storage, preparation, and service, which placed residents at risk of foodborne illness and unsanitary conditions. Observations revealed missing entries in the food storage and dishwasher temperature logs, indicating a lack of consistent monitoring. Expired food items, such as Worcestershire sauce and cooking wine, were found in the kitchen, and a moldy container of tartar sauce was observed in the walk-in refrigerator. Additionally, uncovered foods were transported to residents' rooms and dining areas, increasing the risk of contamination. Staff interviews highlighted a lack of awareness and adherence to proper food safety protocols. The Dietary Manager acknowledged the missing log entries and the presence of expired and moldy food items, admitting that these should have been addressed. Furthermore, the Dietary Manager admitted to not covering certain food items during transportation, which could lead to contamination. An incident involving a dietary aide using a non-sanitized pen after it was dropped on the floor further demonstrated lapses in maintaining sanitary conditions.
Inadequate Infection Control and Water Management Practices
Penalty
Summary
The facility failed to consistently implement transmission-based precautions (TBPs) for residents undergoing aerosol-generating procedures (AGPs). For Resident 105, who was on continuous AGP for suctioning, there was no indication on the AGP sign outside the room about the start or end of the procedure. Staff members entered the room without appropriate protective equipment, such as N-95 masks and eye protection. Similarly, for Resident 40, the AGP sign lacked necessary information, and staff entered the room without proper protective gear, unaware of the CPAP usage. Resident 33, who used a CPAP machine overnight, also had no AGP signage outside their room, leading to staff being uninformed about the precautions needed. The facility also failed to implement Enhanced Barrier Precautions (EBPs) for residents with wounds or indwelling medical devices. Resident 17, who had a leg wound, did not have EBP signage outside their room, and staff performed wound care without wearing gowns or practicing proper hand hygiene. Resident 33, who had a urinary catheter, IV, and drain, also lacked EBP signage, resulting in staff not wearing gowns during care. This lack of signage and protective measures increased the risk of cross-contamination and infection. Additionally, the facility's Legionella Water Management Program (LWMP) was outdated and did not meet current industry standards. The program lacked a comprehensive team, and the facility did not actively identify or manage hazardous conditions for Legionella growth. The LWMP diagram was incomplete, and there was no process for monitoring empty rooms or flushing faucets. Furthermore, sharps containers in several rooms were observed to be full, posing a risk of injury and infection. Staff failed to address the full containers promptly, despite being notified of the issue.
Inaccurate Antibiotic Stewardship Program Documentation
Penalty
Summary
The facility failed to maintain an accurate and complete antibiotic line listing as part of its antibiotic stewardship program, affecting three residents. For Resident 30, the facility prescribed Macrobid for a urinary tract infection without obtaining a necessary urine culture to confirm the presence of an organism susceptible to the antibiotic. The antibiotic line listing inaccurately recorded symptoms and culture dates, and the symptoms listed were inconsistent with the resident's condition, as they had a urinary catheter in place. Staff A admitted that the McGeer's Criteria were not met, and the provider was not notified of this discrepancy. Resident 354's antibiotic line listing contained errors, including incorrect symptom onset dates and missing culture information. The resident was prescribed antibiotics without documented symptoms or culture results to justify the treatment. Staff A acknowledged that the resident did not meet McGeer's Criteria and that the line listing should have included symptoms related to pneumonia, which were absent. For Resident 355, the antibiotic line listing lacked documentation of symptoms, culture results, and stop dates for the antibiotics. The resident was on antibiotics until discharge, but this information was not updated in the line listing. Staff A confirmed that without a culture, it was impossible to determine the organism's susceptibility to the antibiotic, and there was no documentation of a conversation with the provider when McGeer's Criteria were not met.
Failure to Conduct Care Conferences for Residents
Penalty
Summary
The facility failed to ensure that residents and/or their representatives were offered the opportunity to participate in care conferences, which is a critical component of person-centered care planning. This deficiency was identified for five out of six sampled residents. Resident 21, who was cognitively intact, reported not having a care conference since admission, and the facility's records confirmed this absence. Similarly, Resident 156, who was moderately cognitively impaired, had a care conference scheduled but it was canceled without documentation of the rationale. Resident 154, also cognitively intact, was not contacted to set up a care conference despite expressing interest in discharge planning. Resident 40, with moderate cognitive impairment, requested a care conference, but it was not scheduled. Resident 25, who was severely cognitively impaired, had a representative who had to reach out to the case worker to understand the discharge plan, as no care conference had been held. The facility's administrator acknowledged these oversights, indicating that the lack of care conferences did not meet the facility's expectations. These failures placed residents at risk of a diminished quality of life by not involving them in their long-term care planning.
Failure to Honor Resident's Bathing Preferences
Penalty
Summary
The facility failed to honor the bathing preferences of a resident, identified as Resident 103, who was cognitively intact and required assistance with bathing and transfer. Despite being scheduled to receive showers on specific days, Resident 103 was given bed baths instead. The resident expressed a desire for showers but was informed that due to mobility issues and the inability of the Hoyer lift to fit in the shower room, they could only receive bed baths. Staff D, the Resident Care Manager, explained that residents who required a Hoyer lift and could not transfer would receive bed baths. However, the facility's administrator, Staff A, stated that residents should receive showers if they could be transferred to a shower chair, aligning with their preferences. The discrepancy between the resident's preference and the facility's actions led to the deficiency, as the expectation was for Resident 103 to receive showers as per their preference.
Failure to Provide Transfer/Discharge Notices for Hospitalized Residents
Penalty
Summary
The facility failed to provide a written transfer/discharge notice to two residents, identified as Residents 30 and 40, during their hospitalization. Resident 30, who was cognitively intact, was transferred to the hospital without documentation of a transfer/discharge notice being offered or provided. Staff E, the Admissions Coordinator, acknowledged that the notice should have been sent with the resident at the time of transfer, but was unable to confirm if it was done. Staff A, the Administrator, confirmed that the notice should have been completed in the electronic health record system, Point Click Care, but found no evidence of its completion. Similarly, Resident 40, who was moderately cognitively impaired, was transferred to the hospital without documentation of a transfer/discharge notice. Staff G, the Resident Care Manager, was unsure if the notice was reviewed with the resident or their representative, and Staff E confirmed the absence of a transfer notice. Staff A also did not find any documentation of the notice being completed. This lack of documentation and communication placed the residents and their representatives at risk of not being able to make informed decisions about the transfers.
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 WAC 388-97-0120 (4). Resident 40, who was moderately cognitively impaired, was transferred to the hospital and returned without any documentation in the Electronic Health Record (EHR) indicating that a bed hold notice was offered or provided. Staff interviews revealed that the bed hold policy was only addressed upon admission and not during hospital transfers, which was acknowledged as a mistake by the facility's administrator. Similarly, Resident 30, who was cognitively intact, was also transferred to the hospital and returned without a bed hold notice being documented in their EHR. The Admissions Coordinator confirmed that a bed hold notice should have been sent with the resident at the time of transfer, but it was not found. The facility's administrator confirmed that the bed hold notices should be offered during hospital transfers and acknowledged the oversight in both cases.
Failure to Implement Baseline Care Plan for New Admission
Penalty
Summary
The facility failed to develop and implement a baseline care plan within 48 hours of admission for Resident 105, who was reviewed for new admission. This deficiency involved the omission of critical care instructions for the resident, who was admitted with orders for oral suctioning, an aerosol-generating procedure (AGP), and an NPO (nothing by mouth) status. The baseline care plan did not identify the need for suctioning or AGP precautions, nor did it address the resident's NPO status. Additionally, there were no instructions provided to staff on how to perform oral care for the resident given their NPO status, such as using moistened toothettes or specifying who should provide the care. Staff D, the Resident Care Manager, acknowledged that these elements should have been included in the baseline care plan.
Failure to Implement Comprehensive Care Plan for Resident with Self-Care Deficits
Penalty
Summary
The facility failed to develop and implement a person-centered comprehensive care plan for Resident 13, who was admitted with decreased function in the upper extremities and moderate cognitive impairment. The care plan, dated 12/17/2024, identified self-care deficits and a potential nutritional risk but did not provide specific guidance on the level of assistance required during meals. This lack of detailed instructions led to Resident 13 being unable to open a protein drink and a cocoa packet during breakfast and being unable to cut a chicken breast during lunch, resulting in the resident not consuming the meals. Observations on 01/08/2025 revealed that Resident 13 struggled with meal consumption due to their inability to open food items and the call light being out of reach. Staff V, a CNA, confirmed that the task list, which is based on the care plan, did not specify the assistance needed for meals. Additionally, Staff C acknowledged that Resident 13's history of cubital tunnel syndrome, which affects hand function, was noted in hospital discharge records but was not addressed in the care plan. This oversight placed the resident at risk for decreased intake and a diminished quality of life.
Failure to Re-assess and Revise Care Plan for Resident
Penalty
Summary
The facility failed to re-assess and revise the care plan for a resident, identified as Resident 23, who was admitted with fractures of the left shoulder and hip, and type 2 diabetes with neuropathy. The care plan, dated 12/04/2024, indicated a risk for skin impairment due to surgical incision, left shoulder sling, and immobility, with interventions such as floating bilateral heels and using an arm sling. However, there were no specific directions for the ON/OFF schedule of the sling, and assistive devices were not included in the care plan. Observations revealed that the resident's heels were not floated, and foam boots were not in place, despite being signed off in the Treatment Administration Record. Additionally, the care plan did not include the foam boots, and the resident reported discomfort from their use. The care plan also failed to address the resident's urinary tract infection adequately, as no antibiotics were being administered despite the condition being noted. Furthermore, the resident expressed a desire for showers but only received bed baths, contrary to the care plan's instructions for bathing services. Staff interviews revealed confusion about the resident's bathing capabilities, with discrepancies between the care plan and staff understanding. These failures in care planning and execution placed the resident at risk for skin impairment, delayed care services, and diminished quality of life.
Failure to Meet Professional Standards of Practice
Penalty
Summary
The facility failed to ensure that services provided met professional standards of practice for four residents. Resident 105, who was admitted with severe hypoglycemia, fecal impaction, and as a Clostridium difficile carrier, refused polyethylene glycol doses multiple times over a 12-day period. Despite this pattern of refusal, there was no documentation indicating that the provider was notified, which was confirmed by the Resident Care Manager. Resident 304 had a physician's order for morphine sulfate extended release to be administered for pain levels of 6-10, but the medication was administered six times for pain levels below the ordered parameters, including a pain level of 0 on one occasion. Resident 33 received intravenous ertapenem via a midline catheter for 28 days, but there were no orders or documentation for essential midline maintenance and monitoring tasks, such as measuring the external length and upper arm circumference, changing injection caps, assessing the insertion site, or flushing the midline. Resident 49 had an order for albuterol nebulization as needed for a cough, but during an observation, the resident requested to stop the treatment early. The nurse documented a full dose instead of the partial dose given and failed to notify the provider, which was acknowledged as not meeting expectations by the Administrator/Director of Nursing Services.
Failure in Bowel Management for Two Residents
Penalty
Summary
The facility failed to implement both pharmacological and non-pharmacological interventions for bowel management for two residents, leading to a deficiency in care. Resident 45, who was admitted with a diagnosis of a wedge compression fracture and required pain medication, experienced chronic constipation due to long-term opioid use. Despite having orders for docusate sodium and senna, the resident's bowel elimination record showed multiple days without bowel movements, and both medications were improperly administered on the same day. Additionally, PRN medications were not ordered until several weeks after admission, and no non-pharmacological interventions were documented or implemented in the care plan. Similarly, Resident 8, who was cognitively intact and able to communicate needs, had orders for PRN medications including MiraLax, bisacodyl suppository, and mineral oil enema for bowel management. However, the resident's bowel record indicated several instances of three consecutive days without bowel movements, and no PRN medications were administered during these periods. Staff interviews confirmed the lack of pharmacological and non-pharmacological interventions, and the facility's expectations for bowel management were not met, as documented interventions were absent.
Failure to Follow Enteral Feeding Safety Precautions
Penalty
Summary
The facility failed to ensure safety precautions were followed prior to administering enteral nutrition for Resident 105, who was reviewed for enteral nutrition. The facility's policy required licensed staff to check enteral tube placement and gastric residuals before each feeding and medication administration. However, it was observed that these checks were not consistently performed, placing the resident at risk for adverse outcomes such as increased abdominal distention, reflux, and aspiration. Resident 105, who was cognitively intact and had a diagnosis of Inclusion Body Myositis and dysphagia, required enteral feeding to meet nutritional needs. The resident reported experiencing increased gastrointestinal upset and reflux since admission, which they attributed to the inconsistent checks of their enteral tube placement and gastric residuals by facility nurses. During an observation of Resident 105's bolus feeding, a registered nurse did not check the enteral tube placement or the resident's gastric residual prior to administering the bolus feed or flushes, as ordered. This was confirmed by the Resident Care Manager, who acknowledged that the checks should have been performed. The resident's enteral orders specified the administration of Jevity 1.5 and Osmolyte 1.5 via enteral tube at specific times, with instructions to check residuals and tube placement before feeding and medication administration. Despite these orders, the failure to adhere to the facility's policy and the resident's care plan led to the deficiency identified in the report.
Failure to Obtain Physician Orders for Respiratory Care
Penalty
Summary
The facility failed to obtain physician orders for the use of a continuous positive airway pressure (CPAP) machine and oxygen therapy for two residents, leading to potential risks for unmet care needs and respiratory complications. Resident 21, who was cognitively intact, was observed using a nasal cannula with an oxygen concentrator set at 2.5 liters per minute, yet there was no physician's order documented in the Electronic Health Record (EHR) for this oxygen therapy. Staff members confirmed that an order was necessary for administering oxygen, but none was found for Resident 21. Resident 40, diagnosed with Obstructive Sleep Apnea and moderately cognitively impaired, had a CPAP machine at their bedside. Although an order was placed for the CPAP machine to be used at night and during naps, the specific settings were not known by the staff because the machine was rented and preset. The facility administrator acknowledged that an order for the CPAP settings should have been placed upon admission, but it was only recently added.
Failure to Accommodate Resident Dietary Preferences
Penalty
Summary
The facility failed to provide food that accommodated the preferences and allergies of Resident 30, who was cognitively intact and had been admitted to the facility. Despite the dietitian visiting Resident 30 multiple times to document their food preferences, including a request to substitute beef with fish due to a preference against beef, the resident continued to receive meals containing beef. This was confirmed through observations and interviews, where Resident 30 expressed dissatisfaction with the meals and reported receiving beef stew and meatballs made with beef, despite their stated preferences. The dietary staff, including the Dietary Manager and Dietitian, acknowledged the oversight in not updating Resident 30's dietary preferences in the kitchen records. The Dietitian confirmed that Resident 30 had previously complained about receiving beef and should not have been served beef items. The Dietary Manager provided dietary change slips that documented Resident 30's request to replace beef with fish, yet the resident still received beef meals, indicating a failure in the communication and implementation of dietary preferences within the facility.
Inadequate Supervision and Documentation Lead to Resident Falls
Penalty
Summary
The facility failed to provide the necessary level of supervision to prevent avoidable accidents for residents, particularly for one resident who experienced a fall resulting in a hip fracture. This resident, who had severe cognitive impairment and a history of falls, was not consistently monitored as required by their care plan. The care plan specified one-to-one supervision and the use of a sensor alarm, but these interventions were not consistently implemented. On the night of the fall, staffing shortages led to inadequate supervision, and the resident's sensor alarm was not in place. The resident had been moved to a room further from the nurses' station, which reduced the ability for frequent visual checks. This move, combined with the lack of consistent one-to-one supervision, contributed to the resident's fall. The facility did not have a standard form for assessing fall risk or documenting interventions, leading to inconsistent implementation of safety measures. The staff on duty were not able to provide the required supervision due to being assigned multiple residents, including others who also required one-to-one supervision. Additionally, the facility failed to document the supervision provided to another resident who was found outside the facility, indicating a lack of proper monitoring and documentation. The facility's failure to document and implement the necessary supervision interventions placed residents at risk for injury and diminished quality of life. The lack of a comprehensive assessment and consistent intervention implementation highlights the deficiencies in the facility's approach to fall prevention and resident safety.
Inadequate Investigation of Abuse and Neglect Allegations
Penalty
Summary
The facility failed to thoroughly investigate allegations of abuse, neglect, and accident hazards for several residents, leading to deficiencies in care. Resident 1, who had severe cognitive impairment and was at risk for falls, experienced a fall due to the absence of a one-to-one sitter, a wet floor, and a recent room change. The investigation did not fully evaluate these contributing factors or obtain statements from all potential witnesses, including the staff responsible for the missing bed alarm. Resident 2, with moderate cognitive impairment, was found in the facility parking lot, indicating a lapse in supervision. Despite the incident, the facility could not provide documentation of a thorough investigation. Similarly, Resident 3, who had no cognitive impairment, reported rough treatment by male CNAs, but the investigation failed to identify the staff involved or update the resident's care plan to reflect their request for no male agency staff. Resident 4, with moderate cognitive impairment, reported a fall in the bathroom, resulting in pain and bruising. The investigation did not include interviews or a summary to determine the root cause of the fall. In all cases, the facility's investigations were incomplete, lacking thorough evaluations and necessary documentation, which compromised resident safety and care quality.
Deficiency in Timely Treatment and Care Post-Fall
Penalty
Summary
The facility failed to ensure residents received timely treatment and care in accordance with professional standards of practice, leading to a deficiency in care. In the case of Resident 1, who had a history of falls and cognitive impairment, the facility did not promptly address a significant change in cognition and status following an unwitnessed fall. Despite documented signs of confusion, pain, and decreased oral intake, there was a lack of timely provider notification and inadequate neurological assessments. This failure resulted in Resident 1 being emergently transferred to the hospital with multiple fractures and severe sepsis, indicating a lapse in monitoring and response to changes in condition. Similarly, for Resident 2 and Resident 3, both at risk for falls and cognitively impaired, the facility did not consistently perform neurological assessments following unwitnessed falls. Neuro checks were delayed, not completed at recommended intervals, and lacked proper documentation. Resident 2 reported a fall hours after it occurred, with delayed initiation of neuro checks, while Resident 3 had a significant delay of over 14 hours before neuro checks were initiated post-fall. These deficiencies in timely assessment and monitoring post-falls put residents at risk for undetected injuries, complications, and compromised quality of care. Staff interviews revealed discrepancies in the completion and documentation of neuro checks, with staff acknowledging lapses in assessment and communication with providers. Despite facility policies outlining the frequency and protocol for neurological assessments post-falls, there was a failure to consistently adhere to these guidelines, leading to gaps in care delivery and missed opportunities for early intervention. The lack of thorough and timely assessments following changes in residents' conditions highlights systemic issues in monitoring and responding to residents' needs effectively.
Latest citations in Washington
A resident with cerebral palsy and a court-appointed guardian experienced multiple episodes of nausea, vomiting, loose stools, abdominal discomfort, fatigue, and later refusal of meals and medications, leading to changes in the care plan including close monitoring, lab testing, and IV fluid administration. Despite a facility policy recognizing court-appointed guardians as resident representatives with decision-making authority, staff did not document any notification to the guardian during these changes in condition or treatment decisions. The guardian reported not being contacted when the resident stopped eating or developed stomach issues and felt the facility did not respect the guardianship, while the DON acknowledged there were multiple missed opportunities to notify the guardian of the resident’s change from baseline.
A resident with depression, anxiety, moderate cognitive impairment, and urinary incontinence, care-planned for q2h checks and assistance with toileting, was found by a visitor to be soaking wet, unusually agitated, and reporting they had been told to wait to be changed and referred to with a derogatory remark. The visitor filed a written grievance alleging abuse/neglect related to delayed incontinence care and removal of the resident’s tablet as a consequence. Although an incident report noted that the matter was reported to the state and that the resident was not soaking wet, a CNA who actually changed the resident later reported the resident’s brief, pants, wheelchair, and socks were soaked and that the resident was acting timid and repeatedly saying they had to sit for five minutes, but this CNA was never interviewed. The DON acknowledged not investigating the resident’s behavior or interviewing this CNA, and the grievance official acknowledged the facility did not fully investigate or communicate findings and resolution to the complainant, resulting in a failure to follow the facility’s grievance policy.
A resident with dementia, respiratory failure, and heart failure developed new shortness of breath with an O2 sat of 90%, and a physician ordered transfer to the ED for tx and eval. An RN completed an SBAR, notified the MD and family, and reported to the oncoming nurse that the resident needed ED transfer and that paramedics should be contacted, then left the facility. Instead of calling 911 for this emergent respiratory distress, staff arranged non-emergent transport through a contracted ambulance service, resulting in the resident remaining at the facility for several hours without pickup until the dispatcher later instructed staff to call 911. The DON stated that 911 is expected to be used for emergent conditions and the contracted service only for non-emergent transport.
A resident with anoxic brain injury, dysarthria, and documented lack of decisional capacity alleged physical abuse and expressed fear of their identified representative, yet social services only reported the allegation to the state and did not complete an incident report, revise the care plan, or implement protective interventions. The same representative continued to be treated as the resident’s decision-maker and visited frequently, with staff noting suspicious odors of foreign substances and concerns about possible illicit substance use. Psychiatry later documented concern that the representative was providing illicit substances, and the resident was subsequently hospitalized for altered mental status and overdose, after which the representative was banned. Key staff, including the DON, unit manager, and administrator/abuse coordinator, were unaware of the initial abuse allegation, and social services did not timely explore or clarify legal decision-making authority or alternative representation for the resident.
A resident with severe cognitive impairment, osteoarthritis, and spinal spondylosis, care planned for 2-person Hoyer transfers, was being moved by two CNAs using a mechanical lift when one corner loop of the sling became disengaged, causing the resident to fall about four feet, strike the floor and the lift, and sustain head abrasion, multiple rib fractures, and lumbar vertebral fractures. Facility policy required staff to verify secure sling attachment, examine hooks, clips, fasteners, and strap stability, and ensure the sling bar was sound before lifting, but during this transfer the sling loop detached despite staff believing it was properly fastened and hearing it click into place; post-incident assessment showed the loop had come loose, the sling appeared in good condition, and a CNA later reported thinking one of the round metal disks on the lift might have been slightly loose, while maintenance logs documented no prior concerns with the lifts or slings.
The facility failed to revise and individualize care plans to reflect current needs and preferences for multiple residents, including one cognitively intact resident with hemiplegia, hemiparesis, and mononeuropathy who had bilateral shoulder surgery and could not tolerate BP measurements on the upper arms but preferred forearm readings. Despite repeatedly informing staff, this preference was not documented in the care plan or Kardex, and direct care staff and the RN/UM were unaware of it. Another cognitively intact resident with hemiplegia, contractures, and weakness reported they were supposed to get out of bed for two hours daily, but some NACs did not know this, even though the MAR/TAR contained an order to document times up and back to bed. The surveyors concluded that care plans were not accurately revised for several residents, placing them at risk for unidentified and unmet care needs and diminished quality of life.
Surveyors found that two residents with hemiplegia, hemiparesis, weakness, and contractures did not receive restorative nursing services, including ROM exercises and splint/brace or orthotic assistance, after therapy discharge. Although PT and OT discharge summaries documented established restorative ROM and transfer programs, recommended PROM to affected extremities, and recommended splint/brace use and assistance with orthotic wear, these recommendations were not entered as restorative referrals in the EHR. As a result, the residents’ care plans and records showed no restorative programs, and both residents reported that therapy and restorative exercises had stopped, while the DON, rehab director, and MDS coordinator confirmed they were unaware of and had not implemented the recommended restorative services.
A resident with cancer, cognitive impairment, and declining strength experienced multiple unwitnessed falls, most occurring while attempting to toilet or move toward the bathroom, culminating in a fractured ankle requiring ED treatment. Although assessments identified fall and incontinence risks and the facility’s policy required individualized interventions, the comprehensive care plan lacked a toileting plan and did not include several interventions that were discussed in incident investigations, such as consistent wheelchair placement and frequent rounding for bathroom assistance. Staff reported relying on verbal reminders and education to use the call light, despite acknowledging the resident’s impulsivity and failure to call for help, and the resident’s bed remained furthest from the bathroom while repeated bathroom-related falls occurred without the trend being recognized or addressed in the care plan.
A resident with a history of acute urinary retention and acute kidney injury had a Foley catheter deemed permanent by the hospital, with instructions that it not be removed in the SNF. At a later urology visit, the catheter was removed, and the resident returned with no new orders documented. Facility staff did not document bladder assessments, post-void residuals, or urine output, and CNA documentation showed the resident did not void that evening. Over the next day, the resident had vomiting, poor intake, altered level of consciousness, tachycardia, hypotension, and no documented wet briefs. A bladder scan eventually showed more than 2000–2500 mL of retained urine, and a new catheter drained a large volume. The resident and a roommate reported moaning, crying out in pain, and repeatedly alerting staff that the resident was not urinating and that the catheter was not draining, while nurses documented catheter care when no catheter was in place and later had to flush and replace the catheter due to continued complaints.
Surveyors found that nurses and nurse aides did not consistently administer medications according to professional standards and facility policy. Multiple residents reported that agency nurses were slow with medications, did not fully follow instructions, and often gave routine meds late. Observations showed an LPN administering expired Humalog/Lispro insulin well past the scheduled time, an LPN giving several scheduled meds (including Tizanidine) late and all at once, and an RN attempting to give sliding-scale insulin nearly two hours late, which a resident refused after already eating. Another resident received Methocarbamol two hours late after questioning the RN, and a resident on scheduled Tramadol had doses given without timely documentation, with a discrepancy between the narcotic count and pills remaining. These events demonstrated failures in timely administration, use of non-expired medications, and immediate, accurate MAR and narcotic documentation.
Failure to Notify Court-Appointed Guardian of Resident’s Clinical Changes
Penalty
Summary
The deficiency involves the facility’s failure to notify a resident’s court-appointed guardian of significant clinical changes and care decisions, contrary to its own policy and state requirements. The facility’s policy on Resident Representatives, revised 02/2021, states that a resident representative includes a court-appointed guardian or conservator and that the facility treats the representative’s decisions as those of the resident to the extent delegated or required by the court. Resident 1, admitted with cerebral palsy, had a Superior Court guardianship letter dated 02/07/2025 indicating a guardian of person and conservator of the estate with full authority, identifying Collateral Contact 1 (CC1) as the guardian. Despite this, multiple clinical events and changes in condition were documented without any corresponding documentation that CC1 was notified. Progress notes and provider notes show that Resident 1 experienced an episode of nausea and vomiting, frequent loose stools, abdominal discomfort, bloating, worsening fatigue, generalized weakness, and later refusal of meals and medications over at least a 24-hour period, with observations that the resident appeared frailer, more fatigued, and had no energy or interest to talk. The provider developed care plans including close monitoring for deterioration, sending stool to the lab, and later initiating IV fluids for rehydration, with a plan to call family/POA for discussion. However, there was no documentation that the guardian was notified at any of these points, including when IV fluids were started. CC1 reported that they were not contacted when the resident stopped eating or developed stomach issues, and expressed that the facility did not respect their guardianship and that involvement in care planning took too long. The DON confirmed on record review that there were many opportunities to notify the guardian when the resident’s condition changed from baseline and that there was no evidence staff did so.
Failure to Thoroughly Investigate and Resolve Resident Grievance Regarding Incontinence Care and Staff Conduct
Penalty
Summary
The deficiency involves the facility’s failure to thoroughly investigate and resolve a grievance alleging neglect and disrespect toward a resident, as required by its grievance policy. The resident had depression, anxiety, moderate cognitive impairment, occasional urinary incontinence, and required moderate assistance with toileting, with a care plan directing staff to check the resident every two hours, ask about toileting needs, and ensure they were clean and dry. A collateral contact reported arriving to visit the resident and finding them soaking wet and agitated, with behavior that was not typical for the resident. The collateral contact documented in a written grievance that the resident’s tablet was off, the resident appeared upset, and the resident reported being told they had to wait five minutes to be changed and that staff would change their “nasty *ss” in five minutes, leading the collateral contact to believe the resident had been given a consequence of no tablet and sitting in wet clothes, which they characterized as abuse/neglect and requested immediate removal of the responsible staff and a report filed. The facility documented receipt of the grievance and created an incident report indicating the matter was reported to the state agency, and that the unit manager interviewed the collateral contact and the resident, with the resident described as confused and denying being soaking wet. The incident report stated that a different nursing assistant was assigned to assist with the brief change and that the unit manager believed the resident was not soaking wet, and that the resident and collateral contact were satisfied when they left the room. However, a CNA who actually changed the resident reported that the resident’s brief was soaked through their pants onto the wheelchair and their socks were soaked, and that the resident was timid, repeatedly saying they had to sit for five minutes, and not acting like themselves; this CNA stated they were never interviewed or asked about the grievance or the resident’s condition. The DON acknowledged not interviewing this CNA or investigating the resident’s behavior and why they were upset, and the unit manager did not recall whether the collateral contact was present during follow-up and did not believe they followed up with the collateral contact regarding the grievance. The administrator, identified as the Grievance Official, stated the facility should have thoroughly investigated the grievance and discussed findings and resolution with the collateral contact, indicating the grievance process was not fully carried out in accordance with policy and WAC 388-97-0460.
Failure to Obtain Timely Emergency Transport for Resident in Respiratory Distress
Penalty
Summary
The deficiency involves the facility’s failure to obtain timely emergency medical services for a resident experiencing new-onset respiratory distress. The resident had dementia, respiratory failure, and heart failure, with severe cognitive impairment and a need for substantial assistance with activities of daily living. On the day the resident was sent to the hospital, a collateral contact observed the resident having difficulty breathing, appearing unable to get enough air, and looking as if they were sleeping or unconscious, and reported this to staff with a request to contact the doctor. An SBAR Communication Form documented that the resident was experiencing shortness of breath that had not occurred before, with an oxygen saturation of 90%. The physician was notified and ordered the resident sent to the emergency department for treatment and evaluation, and the collateral contact was notified shortly thereafter. Progress notes later documented that, despite the order for emergency department transfer, the resident was still awaiting pickup by Olympic transportation several hours later, with no estimated time of arrival. At approximately 3:30 AM, the dispatcher informed the facility that they could not provide transportation and instructed that 911 be called; only then was 911 contacted and the resident transported to the hospital via ambulance for respiratory distress. The RN caring for the resident stated they completed the SBAR, notified the physician and family, and at the end of their shift reported to the oncoming nurse that the resident needed to be sent to the emergency department for respiratory distress and that paramedics should be contacted, then left assuming 911 would be called. The DON stated that staff are expected to contact 911 for emergent conditions such as shortness of breath or respiratory distress, and that Olympic Ambulance is used only for non-emergent transport.
Failure to Provide Social Service Advocacy After Abuse Allegation and Questionable Representative
Penalty
Summary
The deficiency involves the facility’s failure to provide appropriate medically-related social services and advocacy for a resident following an allegation of abuse and concerns about the resident’s representative. The resident had an anoxic brain injury, dysarthria, moderate cognitive impairment, and was dependent on staff for activities of daily living. A hospital palliative care note documented that the resident lacked decisional capacity, had no DPOA, that the legal next of kin (CC4) did not want to be part of care decisions, and that care decisions were being deferred to another contact (CC5). CC5 accompanied the resident on admission, signed admission forms, and was listed as the primary contact in the medical record profile. On a date in February, during communication therapy, the resident reported that CC5 had done something to them, pounded their hands on their chest, recalled being hit in the back of the head by an unknown person, and stated they were sometimes afraid of CC5. A social services staff member reported this allegation to the state agency but did not complete a facility incident report, did not initiate care plan changes or interventions, and took no further action. CC5 continued to be treated as the resident’s representative, and progress notes documented CC5 at the bedside on multiple dates, including an entry noting the room smelled like foreign substances and that CC5 was seen waking the resident and then asking the nurse to administer pain medications. A psychiatry note later documented concern that CC5 was providing the resident with illicit substances and stated it would be prudent for the resident to identify a POA. Subsequently, the resident was found unresponsive, transported to the hospital, and later readmitted after altered mental status and overdose, with a provider note stating that CC5 posed a significant danger to the resident and was banned from visiting. After readmission, staff attempted to contact CC4 for consent to treat but initially reached someone who stated they were not CC4. The social service director acknowledged that, beyond reporting the initial allegation, no additional interventions were implemented, that CC5 continued to be used as the resident’s representative after the allegation, and that they had not explored legal authority for decision making following the abuse allegation or concerns about substances. The social service assistant reported they did not speak with the resident about the hospital stay or CC5 and did not complete an incident report or care plan changes after the allegation. The unit manager and DON were unaware of the initial abuse allegation, and the administrator, who served as abuse coordinator, also stated they were unaware of the allegation and that an investigation should have been initiated and a representative for the resident investigated at a minimum.
Injury from Mechanical Lift Sling Detachment During Transfer
Penalty
Summary
The facility failed to ensure a safe mechanical lift transfer when a resident was being moved with a Hoyer lift and sling, resulting in a fall and injury. Facility policy for using a mechanical lifting machine required staff to securely attach sling straps to the sling bar according to manufacturer’s instructions, double-check the security of the sling attachment before lifting, examine all hooks, clips, or fasteners, check strap stability, and ensure the sling bar was securely attached and sound. Despite these requirements, during a transfer for dinner, two CNAs placed the sling under the resident, attached the loops at each corner of the sling to the lift, and raised the resident off the bed into the space between the bed and wheelchair when the bottom left corner of the sling became disengaged from the lift. The resident involved had multiple diagnoses including osteoarthritis, cervical and thoracic spondylosis, and Alzheimer’s disease, with the Minimum Data Set documenting severely impaired cognitive skills for daily decision-making. The resident’s care plan required the assistance of two staff during Hoyer lift transfers. During the transfer, the resident fell approximately four feet, landing on her buttocks, bouncing, and then falling backward and striking her head on the leg of the Hoyer lift. Hospital records documented that the resident sustained an abrasion to the back of the head, fractures of the 6th, 7th, 8th, and 10th ribs, and fractures of the 1st and 2nd lumbar vertebra. Staff interviews and observations showed that staff believed the sling loops had been securely fastened and reported hearing the loops click into place before lifting. One CNA stated that they had barely lifted the resident off the bed when the bottom left loop became disconnected and the resident fell. Another CNA reported being shocked and unable to figure out what had happened. A nurse who assessed the resident and then examined the equipment after the fall noted that one of the loops of the sling had become disengaged but stated the sling appeared to be in good condition. During a later demonstration, a CNA indicated she thought one of the round metal disks on the lift might have been a little loose. Maintenance logs for Hoyer slings and lifts for the preceding months documented no concerns with the slings or lifts, and the DON acknowledged expecting a citation due to the resident’s injury from the fall.
Failure to Revise Care Plans to Reflect Resident Needs and Preferences
Penalty
Summary
The deficiency involves the facility’s failure to revise and individualize comprehensive care plans to reflect residents’ current needs and preferences, as required by its own care planning policy. For one resident with hemiplegia, hemiparesis following cerebrovascular disease, and mononeuropathy of the upper limb, the admission MDS showed intact cognition and upper extremity impairment. This resident reported having bilateral shoulder surgery and an inability to tolerate blood pressure measurements on the upper arms due to pain, and stated a preference for BP measurements on the forearms. The resident reported having informed multiple nursing staff of this preference, but staff continued to place the cuff on the upper arms. Review of the resident’s care plan and Kardex showed no interventions or instructions regarding forearm BP cuff placement. A NAC confirmed they were unaware of the preference until the resident told them directly and that this instruction was not documented in the Kardex. The RN/Unit Manager, who stated they were responsible for revising and reviewing care plans when there were changes, also confirmed they were not aware of the resident’s preference and that it should have been updated in the care plan. Another resident, readmitted with hemiplegia and hemiparesis following a nontraumatic subarachnoid hemorrhage, contracture of the left hand, and weakness, was cognitively intact and required maximum assistance for bed mobility per a quarterly MDS. This resident stated they were supposed to get out of bed for two hours every day, but some NACs were not aware of this care requirement. Review of the resident’s March 2026 MAR/TAR showed an order to document the time the resident got up and the time they returned to bed daily. The report states that, overall, the facility failed to revise care plans accurately to reflect residents’ needs for three of four residents reviewed for care plan revision, placing them at risk for unidentified and unmet care needs and a diminished quality of life.
Failure to Implement Restorative Nursing and Splint/Brace Programs After Therapy Discharge
Penalty
Summary
The deficiency involves the facility’s failure to provide restorative nursing services, including range of motion (ROM) exercises and splint/brace assistance, to maintain or prevent decline in mobility and contractures for two residents with significant motor impairments. The facility’s undated Restorative Nursing Services policy stated that residents would receive restorative care as needed to achieve and maintain optimal functioning and that residents may initiate a restorative program upon discharge from rehabilitative care. Despite this, surveyors found that residents with documented hemiplegia, hemiparesis, weakness, and contractures were not placed on restorative programs and had no restorative interventions documented in their electronic health records (EHRs). Resident 1 was admitted with hemiplegia and hemiparesis following cerebrovascular disease, a left lower leg fracture, and weakness, and the admission MDS showed intact cognition, moderate assistance needs for bed mobility and transfers, and one-sided upper and lower extremity impairment. During observation, the resident was seen lying in bed with a bent inward left forearm and hand and reported no longer receiving therapy or nursing-assisted exercises. The care plan initiated in January showed no restorative services, and the care plan history and EHR contained no restorative nursing interventions. However, the PT discharge summary from February documented that restorative ROM and transfer programs had been established and trained, including PROM to the left upper and lower extremities and stand-by assist with transfers, and the OT discharge summary recommended a splint/brace to prevent contracture. The OT stated that the splint/brace was not tried due to lack of time before insurance was discontinued, and both the Director of Rehab and the MDS coordinator confirmed there was no restorative referral in the EHR and they were unaware of the recommendations. Resident 2 was readmitted with hemiplegia and hemiparesis following a nontraumatic subarachnoid hemorrhage, a left-hand contracture, and weakness, and the quarterly MDS showed intact cognition, maximum assistance needs for bed mobility, total assistance for transfers, bilateral upper and lower extremity impairment, and no therapy or restorative programs. The resident reported that therapy had been discontinued months earlier and that no restorative staff were assisting with exercises. The care plan and EHR showed no restorative services. OT evaluation documented left upper extremity ROM impairment, a left-hand contracture, and prior use of a left orthotic to manage flexion tone, and the OT discharge summary recommended restorative care and assistance with donning/doffing the orthotic. The PT discharge summary recommended restorative programs if Medicaid Part B services did not continue. The Director of Rehab confirmed therapy was discontinued and that restorative nursing programs were recommended, but both the Director of Rehab and the MDS coordinator stated there were no restorative referrals in the EHR after readmission, and the MDS coordinator confirmed the resident had no restorative programs since readmission.
Failure to Implement Effective Fall and Toileting Interventions for High-Risk Resident
Penalty
Summary
The deficiency involves the facility’s failure to provide adequate supervision, identify fall trends, and implement progressive, resident-centered interventions for a resident with multiple falls and declining strength. The facility’s own Falls and Fall Risk Management policy required staff to identify interventions related to residents’ specific risks and causes to prevent falls and minimize complications. The resident’s Care Area Assessment identified cancer-related risks for pain, falls, and ADL decline, and stated that falls and urinary incontinence would be addressed in the care plan with an objective of improvement and risk minimization. However, the comprehensive care plan did not include a urinary or ADL care plan and contained no toileting plan, despite the resident’s identified risks and prior fall history. Over a series of falls, the resident repeatedly fell while attempting to toilet or move toward the bathroom, yet the facility did not recognize or address this pattern in its investigations or care planning. The resident had multiple unwitnessed falls: next to the bed while getting up to use the restroom, in the bathroom while standing to use the toilet, and near or in the bathroom on several occasions. Incident investigations and post-fall assessments documented environmental factors such as clutter, items on the floor, water on the floor, and issues with footwear, as well as the resident’s increasing weakness, impulsivity, poor safety awareness, and poor insight into limitations. Interventions documented in investigations and risk reviews included encouraging use of the front-wheeled walker, keeping the wheelchair and walker accessible, ensuring proper footwear and non-skid socks, and providing resident education on safe transfers, ambulation, and assistive device use. However, several of these planned interventions, including placement of the wheelchair and frequent rounding/toileting assistance, were not added to or reflected in the care plan as stated. Staff interviews further showed that the resident frequently fell while trying to go to the bathroom and that staff relied on verbal education and reminders to use the call light, even though the resident often did not use it. Staff acknowledged the resident’s impulsivity and tendency to get up independently despite instructions, and one staff member stated that nursing assistants were verbally instructed to offer bathroom assistance, but this intervention was not documented in the care plan. The resident’s bed remained the one furthest from the bathroom throughout the stay, and none of the facility’s investigations identified the trend of bathroom-related falls or addressed toileting options in the care plan. Ultimately, the resident sustained a left ankle fracture after another bathroom-related fall, requiring transfer to the emergency department for evaluation and treatment, and later records documented additional fractures and a decline in condition. The surveyors concluded that the facility’s failures placed residents at risk of repeated falls and injuries.
Failure to Monitor Urinary Retention After Foley Removal Leading to Prolonged Pain
Penalty
Summary
The deficiency involves the facility’s failure to adequately assess and monitor a resident for complications associated with an indwelling urinary catheter and urinary retention, particularly after catheter removal. The resident had a history of acute kidney injury due to urinary retention, which improved after Foley catheter placement in the hospital. Hospital discharge documentation indicated the catheter was placed for acute urinary retention, was deemed permanent, and included instructions that, given the resident’s significant retention and acute renal failure, staff at the skilled nursing facility should not attempt Foley removal. The facility’s catheter care plan directed staff to empty the catheter as needed and record output in milliliters, but review of the last 30 days of documentation showed continence was not rated due to the indwelling catheter and there was no documented urinary output in milliliters on the treatment administration records. The resident had a scheduled urology appointment at which the urinary catheter was discontinued. Upon return from this appointment, nursing documentation initially indicated no new orders, and an alert note later stated the catheter was discontinued and staff were monitoring for retention or pain. However, there was no documented bladder assessment or urinary output following catheter removal. Nursing assistant documentation showed that the resident did not void on the evening shift that same day. Despite the catheter having been removed, the treatment administration record showed staff continued to document provision of catheter care on subsequent shifts when no catheter was in place. Over the next day, the resident experienced vomiting, decreased oral intake, and an altered level of consciousness, with vital signs showing tachycardia and low blood pressure, and staff documented decreased urine output. A bladder scan performed later revealed more than 2000–2500 milliliters of urine in the bladder, and an indwelling catheter was reinserted, initially draining a large volume of urine. The provider note indicated the resident had not eaten since the prior night, was unable to hold down fluids, and staff were unsure whether the resident had urinated in incontinence briefs, with no wet briefs reported since the resident’s return from the hospital after catheter removal. The provider expressed concern that the documented early-morning wet brief might not be accurate given the large bladder volume on scan and stated this should require further investigation. Subsequent notes described the resident moaning and complaining of pain, with limited urine output in the catheter bag and staff flushing and then replacing the catheter due to continued complaints. Interviews with the resident, the roommate, and staff indicated the resident was crying out and moaning in pain, the roommate repeatedly alerted staff that the resident was not urinating and that the catheter was not draining, and staff had to seek assistance to replace the catheter. Facility leadership and clinical staff later acknowledged that typical practice after catheter removal would include contacting the provider, placing the resident on alert, performing post-void residuals with bladder scans, and documenting monitoring, which was not done in this case.
Medication Administration Delays, Documentation Errors, and Use of Expired Insulin
Penalty
Summary
The deficiency involves the facility’s failure to ensure sufficient nursing staff with appropriate competencies and skill sets to administer medications according to professional standards of practice, facility policy, and prescriber orders. The facility’s medication administration policy required medications to be given as prescribed, in accordance with manufacturers’ specifications and good nursing principles, with no expired medications used, and doses administered within 60 minutes of the scheduled time and documented immediately after administration. Multiple residents reported that agency nurses often gave medications late, did not read full instructions, or were slow in bringing medications, and that routinely scheduled medications were not consistently provided without residents having to ask. Surveyors observed several specific medication administration failures. For a resident with diabetes, an LPN drew up and administered Humalog/Lispro insulin from a multi-dose vial that had been opened and dated “02/16” with no year, making it expired per policy, and administered the dose nearly 1 hour and 45 minutes after it was due. Another resident with care plan instructions to receive medications as ordered had multiple scheduled medications (Gabapentin, Oxybutynin, Baclofen, and Tizanidine) that were ordered at specific times throughout the day; the LPN was observed administering all four together and acknowledged that at least one (Tizanidine) was late, while the resident reported that receiving them together at that time was typical and not at their request. For another diabetic resident, an RN checked blood sugar and prepared sliding scale Humalog/Lispro insulin almost two hours after the scheduled time; the resident refused the insulin, stating they had already finished lunch. Additional deficiencies were identified with other residents’ pain and scheduled medications. One resident with a pain care plan and an order for Methocarbamol four times daily at set times approached the cart requesting Methocarbamol and Tylenol; the RN initially stated the Methocarbamol had already been given, but then administered it two hours after it was due when the resident pointed out the scheduled timing. For another resident with a risk for pain care plan and Tramadol ordered three times daily at specific times, an LPN retrieved a PRN pain medication while the electronic record showed no 8:00 AM medications documented; the LPN stated they had given them but had not yet documented. Later, an RN prepared the 2:00 PM Tramadol dose, and review of the narcotic count showed a discrepancy between the number of pills documented and the number remaining in the card. The RN stated they had given the 8:00 AM Tramadol but had not signed it out, then signed out both the 8:00 AM and 2:00 PM doses at that time. Residents interviewed consistently reported that medications were sometimes or frequently late, that agency nurses did not always follow instructions, and that they often had to request medications that were routinely scheduled.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release May 27, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
