Olympic View Post Acute
Inspection history, citations, penalties and survey trends for this long-term care facility in Port Angeles, Washington.
- Location
- 1116 E Lauridsen Boulevard, Port Angeles, Washington 98362
- CMS Provider Number
- 505185
- Inspections on file
- 57
- Latest survey
- March 16, 2026
- Citations (last 12 mo.)
- 16
Citation history
Health deficiencies cited at Olympic View Post Acute during CMS and state inspections, most recent first.
A resident sustained a partial-thickness abdominal burn after being served hot chocolate prepared with water drawn directly from a dispensing machine without a temperature check. A dietary aide filled a cup from the machine, added mix, applied a plastic lid, and handed it to the resident, who placed the cup in their lap while using a motorized wheelchair. The liquid spilled through the straw opening, causing a blistering burn measuring approximately 10 cm by 2.5 cm. Surveyors later measured the machine’s water at 180.1°F, and the dietary director confirmed the machine routinely produced 180°F water and described reliance on cooling carafes or adding ice when needed. The wound care nurse classified the injury as a partial-thickness burn.
Two residents who required extensive ADL assistance did not receive regular showers or thorough bed baths over an extended period, and their care plans lacked clear specifications for bathing frequency and method. One resident with back fractures reported only receiving minimal wipe-downs and feeling unclean and uncomfortable, while another resident with a recent leg amputation had only two documented bed baths and no showers. The unit manager LPN confirmed the bathing records were accurate and noted that residents had not been receiving showers or baths because floor aides were too busy, and the administrator stated residents should receive bathing at least twice weekly with preferences reflected in the care plan.
Surveyors found that the facility lacked an Infection Prevention and Control Program that included an antibiotic stewardship component. During an interview, the DON could not locate any IPCP documentation and reported being unaware of any system used to track antibiotic use. As a result, there was no structured process in place to monitor or manage antibiotic prescribing and usage, as required by WAC 388-97-1620(2)(b)(i)(ii).
Surveyors found that the facility did not have a designated, qualified Infection Preventionist (IP) overseeing the infection prevention and control program. The DON reported that an RN had been assigned the IP role but could not provide information about the program. The RN stated they were newly graduated, had no infection control experience beyond nursing school, were working full-time as a wound care nurse with more than 40 hours per week, could not devote the required 20 hours weekly to IP duties, and had not started IP certification. This resulted in a cited deficiency under F880 for infection control.
The facility failed to implement an effective IPCP when a resident with moderate cognitive impairment developed respiratory symptoms and was diagnosed with RSV. The resident was found by EMS in a soiled environment with vomit-like material on the body, bed, floor, and wall, while staff entered and exited the room without PPE or precautions, and the room remained uncleaned upon the resident’s return from the hospital. Later observations showed staff ignoring posted Contact Precautions, exiting the room without gloves, gowns, or hand hygiene, and an RN misunderstanding the reason for isolation signage. The DNS acknowledged that appropriate Droplet and Contact Precautions and thorough cleaning should have been in place, while the designated IP reported having no training or time for IP duties and the DNS did not know where IPCP information was located. Subsequently, multiple severely cognitively impaired residents tested positive for RSV and experienced respiratory decline and hospital transfers, and a regional nurse consultant attributed the RSV outbreak and its severity to the absence of a comprehensive IPCP, a trained IP, and staff infection control education.
A resident with moderate cognitive impairment was found living in a room with significant debris, stained bedding, dark yellow-brown substances on the window area and floor trim, and brownish-yellow liquid oozing from under the bed, which the housekeeping manager described as very dirty and not deep cleaned for a long time. A large disc space heater was operating on a dresser beneath a corkboard, with the plug only partially inserted into the outlet and surrounded by piles of clothes, bedding, and personal items, despite the maintenance manager acknowledging that heaters require at least three feet of clearance. The administrator reported that the resident often refused room cleaning and that staff had not reported the room’s condition or the refusals to management, even when there were concerns about infectious diseases.
The facility failed to ensure licensed nursing assessment, monitoring, and care for multiple residents, instead allowing medication and nurse technicians to perform tasks outside their scope, including wound assessment and sterile wound care. One resident with bilateral lower extremity ulcers had no care plan interventions for edema or wounds, had advanced wound care documented as completed by a med tech, and had no nursing notes for an extended period before being found unresponsive and later diagnosed in the hospital with severe sepsis related to infected leg wounds. Another resident with severe esophageal stenosis developed shortness of breath, wheezing, and cough with hemoptysis over several days; a chest x-ray ordered by a provider was never completed, no RN assessments were documented for two days, and a nurse tech, without RN involvement, ultimately called EMS, after which the resident was hospitalized with aspiration PNA. A third resident with a PICC line reported that the dressing was falling off; although orders required regular and PRN dressing changes with arm circumference and catheter length measurements, there was no documentation of a dressing change or required measurements, and the care plan lacked specific PICC care interventions or sterile technique instructions.
A resident admitted for IV antibiotic therapy for pneumonia, with a PICC line in place and cognitively intact, did not receive ordered Meropenem IV doses for an extended period because the medication was unavailable, resulting in four missed doses. Later labs showed an elevated WBC count and the resident reported feeling unwell and was sent to the hospital. A hospital social worker reported the resident was frustrated about not receiving medications and treatments as ordered and feared for their well-being, while the DNS acknowledged the PICC should have been changed as ordered and that detailed care plan instructions and interventions were lacking.
A resident with severe cognitive impairment was assaulted by a roommate, sustained injuries, was treated in the ER, and moved to a different room. The legal guardian, listed as the primary contact, was not notified of the incident, injuries, ER visit, or room change, as confirmed by interviews and record review.
A resident admitted after a ureteral stent placement experienced severe pain due to missed and delayed administration of both scheduled and PRN pain medications, including Tylenol, tramadol, lidocaine patches, and oxycodone. Staff were unaware of the resident's pain requests, and a medication technician admitted to forgetting to apply prescribed patches. The DON could not explain the delays in medication administration.
A resident with dementia, bipolar disorder, and diabetes was admitted with a DPOA-HC in place, but the designated representative was not informed of significant changes to the care plan, including medication discontinuations and new treatments. Despite repeated requests, the representative did not receive timely updates or access to the care plan, and staff interviews confirmed that required notifications were not made.
A resident with multiple diagnoses, including diabetes and bipolar disorder, was admitted with symptoms such as nausea and somnolence. The provider ordered several lab tests and IV fluids, but the facility did not collect the labs as ordered. Some tests were delayed by weeks, and one test was never collected. Staff confirmed the delays and missing results, and the DON acknowledged that timely completion of labs is expected.
Multiple facility areas, including shower rooms, a resident room, and a soiled utility room, were found in unsanitary and unsafe conditions. Observations included garbage and used supplies on floors, soiled toilets, exposed wires, improper storage of clean and dirty items, and equipment placed on dirty floors. Staff interviews confirmed that these practices did not meet required standards for safety and sanitation.
A resident with severe cognitive impairment and a cancerous wound developed a maggot infestation, but the family was not notified of this significant change in condition. Staff communicated with the family about a room change but did not discuss the infestation or treatment options, and key staff members assumed others had informed the family. This resulted in the resident's representative not being able to participate in or make informed decisions about care.
Surveyors found that appropriate care was not provided for residents regarding continence management, catheter care, and UTI prevention, indicating lapses in facility practices.
A resident with a suprapubic catheter was hospitalized for complications including obstruction, calcifications, and cellulitis, after the catheter had not been changed as ordered. Facility staff did not investigate or report the incident, and communication regarding hospital records requests was inadequate.
Several residents received opioid pain medications without documented attempts to use non-pharmacological interventions or non-opioid alternatives, and medication orders lacked clear parameters for administration. Staff did not consistently document the effectiveness of pain interventions, and monitoring for adverse effects of opioids was not evident. These actions and omissions resulted in a failure to ensure residents were free from unnecessary medications.
The facility did not maintain required documentation of staff COVID-19 vaccination screening, education, offering, and current vaccination status for a 12-month period. Despite requests, only a general statement and a Vaccine Information Statement were provided, with no individual staff records available.
The facility did not consistently obtain or accurately document informed consent for psychotropic medications. In several cases, residents with severe cognitive impairment or dementia received medications without proper consent, or the consent forms contained incorrect information about the drug class and associated risks. Staff acknowledged missing consents for medication changes and that consent was sometimes obtained from individuals not authorized to provide it.
The facility did not ensure that residents and their legal representatives were included in care conferences or discussions about person-centered care plans, including decisions about hospital transfers, end-of-life care, and significant changes in treatment. Several residents and representatives were unaware of or not involved in these decisions, and staff interviews confirmed a lack of documentation and individualized care planning.
Multiple residents were administered psychotropic medications without adequate indications, specific target behaviors, or proper monitoring. Orders for PRN medications exceeded recommended durations without provider reassessment or clinical rationale, and non-pharmacological interventions were not consistently attempted or documented. Staff were unable to clearly link behaviors to medication use, and documentation practices were found to be incomplete or insufficient.
The facility did not provide timely written bed hold notices to two residents transferred to the hospital and failed to notify the ombudsman for three residents who were hospitalized or discharged. Documentation and staff interviews confirmed that required notifications were either delayed or missing, affecting residents with varying cognitive statuses.
Surveyors found that the facility did not provide individualized, updated, or comprehensive care plans for multiple residents, resulting in generic or incomplete documentation that failed to address specific diagnoses, changes in condition, or personal preferences. Staff confirmed that care plans often lacked measurable goals, effective interventions, and resident-centered details, affecting residents with dementia, chronic pain, end-of-life needs, and other complex conditions.
The facility did not maintain proper refrigerator temperature logs or document corrective actions for repeated out-of-range temperatures in two nursing station refrigerators. Multiple temperature violations were recorded over several months, and staff did not follow the established process for addressing these issues, as confirmed by the Dietary Manager.
The facility did not adequately inform residents or their representatives about the terms and implications of binding arbitration agreements, resulting in several individuals signing without understanding they were waiving their right to litigation. Staff explanations were inconsistent with the agreement's actual terms, and there was no evidence that the agreements were explained in a manner accommodating the needs of those signing.
The facility did not provide evidence of an ongoing, effective QAPI program, including documentation of performance improvement activities or proof of the medical director's participation in QAPI meetings. The administrator was unable to produce a QAPI plan or records of current or past improvement projects, and the only meeting documentation provided was insufficient.
The facility did not ensure accurate and complete documentation of infection signs and symptoms on monthly line listings and failed to consistently apply McGeer's Criteria for antibiotic use. A resident with a history of Bullous Pemphigoid received two courses of antibiotics for cellulitis without meeting required criteria or proper documentation, and staff interviews confirmed inconsistent communication and record-keeping regarding infection assessments and antibiotic initiation.
Facility staff did not consistently administer or document medications and treatments as ordered for two residents, including late administration of IV antibiotics, missing documentation for PICC line care, and incomplete records for medication administration and monitoring of side effects. Staff acknowledged that blank documentation indicated tasks were not completed or not recorded, which did not meet professional standards.
Two residents experienced multiple days without documented bowel movements, and staff failed to administer or document bowel protocol medications as required by facility policy and physician orders. Staff interviews confirmed that interventions were not initiated or recorded, despite care plans and protocols directing such actions.
A resident with a pressure ulcer did not receive required weekly skin assessments, with a gap of over four weeks between evaluations, during which a Stage 3 ulcer developed. Additionally, recommended wound healing supplements were not implemented as ordered, with staff unable to provide documentation that the supplement was administered.
A resident receiving IV antibiotic therapy via a PICC line did not receive care and monitoring in accordance with physician orders and professional standards. Required PICC dressing changes, measurement of external catheter length, and arm circumference were not documented or performed as ordered, and staff signed off on tasks that were not completed. Additionally, physician orders lacked instructions for flushing the PICC line before and after medication administration and for changing needleless injection caps.
Nurses did not consistently co-sign medication ledgers to verify counts of schedule three and four controlled substances at shift changes on a medication cart. Review showed that required signatures were missing for nearly all shift changes over several months, and staff interviews confirmed inconsistent practices in counting and signing procedures.
The facility did not ensure that PASRR assessments accurately reflected the mental health diagnoses of two residents. One resident with severe cognitive impairment, depression, and delirium was not properly identified for a level 2 PASRR referral, despite receiving antipsychotic and antidepressant medications. Another resident with depression and anxiety disorder had these diagnoses omitted from the level 1 PASRR, leading to an invalidated level 2 referral. Staff acknowledged these errors in the assessment process.
Two residents experienced significant weight loss, but the facility did not promptly notify their physician or legal representative. In both cases, weight changes were either not entered into the EHR in a timely manner or not communicated at all, resulting in delayed awareness by family and care providers.
The facility did not properly assess or document the use of bed rails, beds against the wall, and a wander guard for four residents, including those with cognitive impairment and elopement risk. Required safety evaluations, care plans, and evidence of less restrictive alternatives were missing, and staff were unclear about assessment responsibilities. Devices such as mobility bars were found to be loose and unsafe, with no comprehensive documentation supporting their use.
A resident receiving IV antibiotics for pneumonia did not receive doses at the prescribed eight-hour intervals. Nursing staff repeatedly administered the midnight dose several hours late and did not adjust subsequent doses, resulting in prolonged gaps between some doses and shortened intervals between others. This pattern of medication administration was confirmed by facility records and staff.
Surveyors found that medications and biologicals were not stored at proper temperatures, with refrigerator logs left unchecked for months, and expired medications were not discarded as required. Staff confirmed that daily checks and timely disposal of expired drugs had not occurred, and some medications were stored in the wrong locations or beyond their recommended use period.
The facility did not follow its grievance policy for two residents, failing to log and address concerns raised by a family member about care and staff conduct, as well as a resident's report of missing personal property. Staff interviews revealed inconsistent practices and a lack of formal documentation, resulting in grievances not being formally recognized or resolved.
A resident who required a wheelchair and daily injectable medications was discharged to a non-accessible hotel room without documented assessment of their ability to self-administer medications, manage insulin, or access meals. Staff and administration did not confirm the accessibility of the discharge location or the resident's capacity for independent living tasks, resulting in the resident's hospitalization shortly after discharge.
The facility did not develop or implement baseline care plans within 48 hours of admission for several residents with complex medical needs, including those with central lines, feeding tubes, and IV medications. Essential interventions were delayed or omitted from care plans and treatment records, resulting in incomplete guidance for staff on immediate care requirements.
Two residents did not receive adequate care, resulting in hospitalization and death. One resident with a central line lacked a care plan for line maintenance, and there was no documentation of required dressing changes or flushes, leading to a suspected line infection and sepsis. Another resident with a feeding tube did not have timely care planning or consistent head-of-bed elevation to prevent aspiration, and after episodes of emesis, there was no skilled assessment or vital sign monitoring, resulting in acute respiratory failure. Staff interviews revealed inconsistent knowledge and documentation regarding both central line and enteral feeding care.
The facility did not maintain a working audible call system for multiple resident rooms, resulting in residents lacking effective means to summon staff. Manual bells were inconsistently provided or accessible, and some residents were unaware of their use. Staff reported ongoing delays and uncertainty in repairing the system, with the audible alarm remaining nonfunctional despite attempted repairs.
A resident with a history of right hip fracture was found on the floor with subsequent diagnosis of a dislocated hip. Facility documentation lacked details on how the resident was assisted back to bed and did not include staff or resident interviews to determine the cause of injury. Despite the resident's repeated statements to her POA that she was thrown, and this being reported to staff, there was no documented follow-up or thorough investigation.
A resident with a history of sexually inappropriate and aggressive behaviors did not receive adequate behavioral health care, as ongoing incidents were documented despite interventions and regular telehealth visits. Staff reported fear for their safety, and the resident expressed dissatisfaction with the brief, virtual mental health services provided. The facility did not offer in-person or community-based mental health services, and a discharge notice was issued without a discharge plan due to continued behaviors.
The facility failed to maintain a clean and homelike environment due to poorly maintained hallway carpets in three observed halls. Observations revealed numerous stains, debris, and odors, leading to a family member removing a resident. Staff interviews indicated inconsistent cleaning schedules and lack of documentation, with plans for flooring replacement not yet completed.
A facility failed to monitor and document vital signs for a resident at risk for sepsis, leading to two hospital admissions. The resident, who was medically complex with an indwelling catheter, did not have vital signs recorded on multiple days, and nursing assessments were missing. Despite being readmitted after a sepsis diagnosis, the facility continued to neglect proper documentation and monitoring. Staff interviews revealed a lack of training on sepsis prevention and recognition.
The facility failed to ensure residents were treated with dignity and respect, as evidenced by reports from two residents. One resident experienced delayed response to a call light and unkind treatment from a staff member, while another reported rough handling during care. Despite multiple grievances, there was no documentation of corrective actions or staff education to address these issues.
A resident with gangrenous toes and ankle wounds did not receive consistent wound care as ordered, with missing documentation for several days. Family members and staff observed that dressings were not changed daily, and drainage was visible during dialysis appointments. The LPN and DON acknowledged the omissions, expecting daily changes and documentation.
The facility failed to prevent and manage pressure ulcers for four residents, leading to the deterioration of existing wounds and the emergence of new ones. A resident developed avoidable pressure ulcers, which were not consistently treated, resulting in infection and hospitalization. Another resident developed a Stage 3 ulcer, with lapses in wound care and documentation. Two other residents experienced similar issues, with inadequate skin assessments and wound care. Staff reported challenges in completing wound care due to workload, and there was a lack of communication and documentation regarding the residents' wound conditions.
The facility failed to notify family members of two residents about the development of pressure wounds. One resident developed an unstageable wound and a stage 2 ulcer, while another had a stage 3 ulcer. Despite care plans and wound care orders, there was no documentation of family notification, and staff interviews confirmed this oversight.
Resident Burn from Unsafe Hot Beverage Temperature
Penalty
Summary
The facility failed to ensure hot water used for beverages was at a safe temperature and adequately supervised, resulting in a burn injury to one resident. A cognitively intact resident requested a cup of hot chocolate from the kitchen. A dietary aide filled a cup directly from the hot water dispensing machine, added hot chocolate mix, placed a plastic lid on the cup, and handed it to the resident without checking the water temperature. The resident then placed the cup in their lap while in a motorized wheelchair and went outside. The resident later reported that the hot liquid spilled through the straw hole in the lid onto their abdomen. Subsequent nursing assessment documented a burn measuring 10 cm long by 2.5 cm wide with blistering at the midline of the resident’s abdomen, and the resident reported some pain. The wound care nurse later acknowledged that the burn was consistent with a partial-thickness (Stage 2) burn. During the survey, the hot water dispensing machine was observed to produce water at 180.1°F. The dietary director stated that the machine had always produced 180°F water and described a practice of filling carafes and allowing them to cool to 140°F, or adding ice cubes if carafes were not available. The dietary aide involved stated they became busy and forgot to check the temperature of the hot cocoa before serving it and also noted that cups became warped in the dishwasher and lids did not always fit correctly.
Failure to Provide Timely and Adequate Bathing Assistance per Resident Needs and Preferences
Penalty
Summary
Surveyors identified a failure to provide necessary assistance with personal hygiene in a timely manner and in accordance with resident preferences for two residents who required extensive help with activities of daily living. One resident, admitted after a fall at home with lower back fractures and assessed as cognitively intact and needing extensive ADL assistance, had a care plan stating they would receive a bed bath when a shower could not be tolerated, but the plan did not specify frequency or days. Bathing/Shower task forms showed this resident did not receive any showers over a several-week period and only received intermittent bed baths. In an interview, the resident reported not receiving showers or adequate bed baths since admission, describing the bed baths as limited to some wet wipes and not thorough, and stated they felt unclean and uncomfortable and had not received communication from staff about why showers were not being provided. Another resident, admitted after a recent left lower leg amputation and assessed as moderately cognitively impaired and needing extensive ADL assistance, had a care plan indicating they required one to two staff for transfers and that nails were to be cleaned and trimmed on bath day as necessary, but the plan did not specify how the resident was to be bathed or the number of bathing days per week. Bathing/Shower task forms showed this resident also did not receive showers over an extended period and only received two bed baths during that time. The unit manager LPN confirmed the task forms were accurate, that there was no additional documentation, and acknowledged noticing over the previous few weeks that residents were not receiving showers or baths, attributing this to floor aides being too busy. The administrator stated that residents should be receiving bathing services at least twice per week and that preferences should be reflected on the care plan. The deficiency was cited under WAC 388-97-1060(1)-(3).
Failure to Implement Antibiotic Stewardship Within Infection Control Program
Penalty
Summary
Surveyors determined that the facility failed to establish an Infection Prevention and Control Program (IPCP) that included an antibiotic stewardship program as required. Based on interview and record review, the facility did not have a system in place to promote appropriate use of antibiotics or to reduce unnecessary antibiotic use and the development of antibiotic resistance. During an interview on 02/04/2026 at 3:15 PM, the Director of Nursing Services (Staff B) was unable to locate any information related to the facility’s IPCP and stated they were unaware of any system being used to track antibiotic usage in the facility. The report states that this failure placed residents at risk for potential adverse outcomes associated with inappropriate or unnecessary antibiotic use. No specific residents, medical histories, or clinical conditions were identified in the report; the deficiency centers on the absence of a functional antibiotic stewardship component within the IPCP and the DON’s lack of knowledge of any antibiotic tracking system, in violation of WAC 388-97-1620(2)(b)(i)(ii).
Lack of Qualified and Dedicated Infection Preventionist
Penalty
Summary
The facility failed to ensure there was a designated and qualified Infection Preventionist (IP) responsible for the Infection Prevention and Control Program, placing residents at risk for unmet infection control issues or care needs. During an interview, the Director of Nursing Services stated that a registered nurse had been assigned the IP role since December 2025 but was unable to provide any information on the facility’s Infection Prevention and Control Program. In a separate interview, the RN reported they were assigned dual roles as Wound Care Nurse and IP, had only recently graduated from nursing school with no infection control experience beyond their schooling, were working over 40 hours per week on wound care, and were therefore unable to dedicate the required 20 hours per week to the IP role. The RN also stated they had not begun the IP certification program. No specific residents or their medical histories were identified in the report, but the deficiency was cited under F880, Infection Control, with reference to WAC 388-97-1620(2)(b)(i)(ii).
Failure to Implement Effective Infection Prevention and Control for RSV
Penalty
Summary
The deficiency involves the facility’s failure to develop and implement a comprehensive Infection Prevention and Control Program (IPCP) based on facility-specific and community-based risk assessment, and to timely prevent, identify, and respond to respiratory symptoms in a resident. Resident 1, who was moderately cognitively impaired, complained of breathing discomfort and chest pain on 02/01/2026 and was sent to the hospital, returning the same day with a diagnosis of RSV. An EMT later reported that Resident 1 had yellowish, vomit-smelling liquid all over their body, with the bed, floor, and bedside wall covered in dry yellow liquid, and that staff entering and exiting the room were not wearing PPE or using any precautions. Upon Resident 1’s return, the EMT stated the room appeared unchanged and had to be cleaned with disinfecting wipes found outside the room, while Resident 1’s roommate remained in the shared room without infection precautions in place. On 02/04/2026, a Contact Precautions sign was observed on the door to the room, but staff were seen exiting without gloves or gowns and without performing hand hygiene before proceeding to other tasks and rooms. When questioned, the RN did not know why the Contact Precautions sign was posted and incorrectly associated it with the presence of a foley catheter, further stating they did not know who was responsible for signage and that the facility did not have a good infection control program. The DNS later stated that Resident 1 should have been placed on a combination of Droplet and Contact Precautions upon return from the hospital and that the room should have been thoroughly cleaned and disinfected. The DNS reported that an RN had been designated as the Infection Preventionist in December 2025 after the previous IP left, but this RN stated they had not been trained and did not have time to perform IP duties. The DNS also did not know where any of the IPCP information was. Following Resident 1’s RSV diagnosis and subsequent death, additional residents with severe cognitive impairment (Residents 2, 3, 4, and 5) later tested positive for RSV, with documentation of respiratory distress, increased temperature, decreased oxygen saturation, and hospital transfers. The Regional Nurse Consultant stated that the lack of a comprehensive IPCP, the lack of a credentialed and trained IP, and the lack of infection control training and education for staff all contributed to the RSV outbreak and its severity.
Failure to Maintain Cleanliness and Safe Use of Space Heater in Resident Room
Penalty
Summary
The facility failed to maintain a safe, clean, comfortable, and homelike environment in a resident’s room, including ensuring treatment and supports for daily living were provided safely. The resident, who was moderately cognitively impaired per the quarterly MDS, was admitted on a specified date and occupied room 50, bed 2. During observation, the floor by the window was littered with debris such as ear cleaners, wrappers, and pill containers. The window sill, blinds, and floor trim had dark yellow-brown substances. The bed sheet contained food particles and stains of varying shapes and colors. When the Housekeeping Manager later observed the room and moved the bed with a foot, brownish-yellow liquid was seen oozing from under the bed frame legs, and the manager stated the room was very dirty and had not been deep cleaned for a long time. The Housekeeping Manager also acknowledged that cleaning rooms with potential pathogens was very important to decrease the risk of spreading infection. In addition to the unsanitary conditions, a large disc space heater was found on the dresser beneath a large corkboard. The heater was turned on, producing a bright orange glow, and its plug was only halfway inserted into the outlet. Piles of clothes, bedding, and personal items were crowded around the heater. The Maintenance Manager stated that the fire marshal allowed heaters in facilities but required at least three feet of clearance from any object and acknowledged that there were too many items close to the heater, including the corkboard, creating a fire hazard. When asked how staff would know the regulations regarding space heaters in resident rooms, the Maintenance Manager responded that they “should just know.” The Administrator later stated that the resident often refused to have the room cleaned and that staff should have reported the room’s condition and refusals to management, especially when there was concern for infectious diseases.
Failure to Provide Licensed Nursing Assessment and Oversight for Wounds, Change in Condition, and PICC Line Care
Penalty
Summary
The deficiency involves the facility’s failure to ensure residents received necessary nursing assessment, monitoring, and care, including wound management and change-in-condition evaluation, and the improper use of unlicensed staff for tasks requiring nursing judgment. For one resident with bilateral lower extremity venous and/or arterial ulcers, medication technicians documented daily edema monitoring on multiple days, even though the Director of Nursing Services (DNS) later stated that assessing and monitoring edema and performing wound care were outside their scope of practice. The resident’s care plan did not include documentation of edema, wound problems, wound interventions, signs and symptoms of infection, or which staff were responsible for wound care management. A nursing progress note later documented multiple blisters, open wounds, and drainage on both lower extremities, but wound cultures were not ordered until the resident was seen by an outside wound care team several days later. Orders for advanced wound care, including cleansing and application of sterile dressings such as calcium alginate with silver and collagen to multiple areas of both lower legs, were initiated, yet a medication technician signed off as having performed this wound care on several mornings. During this period, a provider note documented that the resident was somnolent and mumbling incoherently, with a meal tray in front of them that they were not eating, and speculated that over-sedation from oxycodone might be the cause. The medication administration record showed the resident received two doses of oxycodone that day, and the higher-dose order was discontinued that afternoon. The electronic health record contained no nursing notes for a ten-day period leading up to the resident’s transfer to the hospital. A certified nursing aide reported being concerned about the resident’s lack of responsiveness on the night shift and stated they notified the nurse twice, but the nurse only checked the resident’s pulse and did not call EMS. The resident was later found unresponsive, hypothermic, and was sent to the hospital, where emergency room documentation showed very low body temperature, infected lower extremity wounds with multiple organisms, bloodstream infection, severe thrombocytopenia, and a physician-documented diagnosis of severe sepsis with organ dysfunction and possible disseminated intravascular coagulation; the resident subsequently died at the hospital. For a second resident admitted with severe esophageal stenosis and on a full liquid diet, the care plan allowed thin liquids, and a daily skilled evaluation documented normal respiratory status and clear lung sounds on one date, but no nursing evaluations were completed for the following two days. A provider note documented that the resident was short of breath, had audible wheezing, and a non-productive cough, and a chest x-ray was ordered but never completed. A nursing note entered by a nurse technician later documented that the resident was struggling to breathe, had audible wheezing, and was coughing up blood, and that EMS was called and the resident was admitted to the hospital for aspiration pneumonia. The nurse technician later stated the resident had been coughing up blood for two days, did not know if an RN had assessed the resident during that time, and confirmed that no RN assessed the resident before EMS was called, citing that there was only one RN in the building for 83 residents and that they felt overwhelmed. The DNS stated that, given the resident’s symptoms, the chest x-ray should have been obtained as soon as possible, that the resident should have been placed on alert and closely monitored by a licensed nurse, and that it was outside the nurse technician’s scope of practice to make the judgment call to send a resident to the emergency room. For a third resident admitted for IV antibiotic therapy for pneumonia with a PICC line in the right arm, a provider note documented the resident’s concern that the PICC dressing was falling off and at risk for infection, and indicated that nursing would be notified so the dressing could be changed. The treatment administration record showed two orders for PICC dressing changes: one weekly order, which was completed on one date, and a second order to change the dressing as needed every 24 hours. There was no documentation that the dressing was changed on the date the concern was raised. Both orders required measurement of upper arm circumference and external catheter length on admission and with each dressing change, but there was no documentation of these measurements. The resident’s care plan acknowledged the presence of the PICC but did not include interventions, monitoring parameters, directions for blood draws, instructions to avoid blood pressures on the PICC arm, or instructions on the sterile technique required for dressing changes. The DNS stated that the PICC dressing should have been changed as ordered and that detailed instructions and interventions should have been added to the care plan.
Failure to Provide Timely IV Antibiotic Therapy and PICC Care
Penalty
Summary
The deficiency involves the facility’s failure to ensure timely pharmaceutical services and a system to obtain ordered antibiotics, resulting in missed doses for a resident admitted for IV antibiotic therapy. Resident 3 was admitted for treatment of pneumonia and had a PICC line in the right arm. The 5-day admission MDS indicated the resident was cognitively intact and required substantial assistance with ADLs. An order for Meropenem-Sodium Chloride 1 gram IV every 8 hours was written on 12/13/2025, with the first dose due at 11:00 PM that night. However, the medication was not administered until 7:00 AM on 12/15/2025 because it was unavailable, resulting in four missed doses. Subsequent provider documentation on 12/19/2025 noted that lab results showed an increased white blood cell count and that the resident reported not feeling well, after which the resident was sent to the hospital. A hospital social worker reported that the resident expressed frustration about not receiving medications and treatments as ordered and stated fear for their well-being at the facility, with no intention of returning. Additionally, the DNS stated that the PICC should have been changed as ordered and that detailed instructions and interventions should have been added to the care plan.
Failure to Notify Legal Guardian of Significant Change and Injury
Penalty
Summary
The facility failed to notify the legal guardian of a resident with dementia, who was severely cognitively impaired, about significant events affecting the resident. The resident was admitted with a diagnosis of dementia and had a legal guardian listed as the primary contact for any changes. On a specified date, the resident was assaulted by a roommate, resulting in skin injuries to the left elbow and left pointer finger, and was subsequently seen in the emergency room. The resident was returned to the facility the same day and moved to a different room. Despite these significant events, the legal guardian was not informed of the altercation, the injuries, the emergency room visit, or the room change, as confirmed by both the legal guardian and facility staff during interviews and record review.
Failure to Provide Timely Pain Management
Penalty
Summary
The facility failed to provide timely and appropriate pain management for a resident who was admitted following a left ureteral stent placement. The resident, who was cognitively intact and experiencing pain that interfered with activities of daily living, reported severe pain and stated that they had not received their scheduled noon dose of Tylenol and had been waiting over two hours for PRN pain medication. The resident also indicated that they had repeatedly asked staff for pain relief and had not received adequate pain management since admission. Observation confirmed the absence of prescribed lidocaine patches, and the resident reported not having any patches applied. Review of the resident's medication orders and administration records revealed multiple missed or delayed doses of both scheduled and PRN pain medications, including Tylenol, tramadol, lidocaine patches, and oxycodone. Staff interviews indicated a lack of awareness regarding the resident's pain and requests for medication, and a medication technician admitted to forgetting to apply the lidocaine patches. The Director of Nursing was unable to explain the significant delays in administering pain medications and acknowledged that medications should be given consistently and in a timely manner.
Failure to Involve Resident Representative in Care Planning and Notification of Changes
Penalty
Summary
The facility failed to involve a resident's designated representative in the development and ongoing review of the resident's person-centered plan of care. The resident, who had diagnoses of dementia, bipolar disorder, and diabetes, was admitted with moderate cognitive impairment and a Durable Power of Attorney for Health Care (DPOA-HC) in place. Despite the DPOA-HC being documented in the electronic medical record, the representative (CC1) was not informed of significant changes to the resident's care, including the discontinuation of medications for diabetes and bipolar disorder, and the initiation of IV fluids and lab orders following the resident's episodes of nausea, vomiting, and somnolence. CC1 reported not being notified about the discontinuation of critical medications or changes in the resident's condition, and expressed concern that these changes led to instability in the resident's health, which affected discharge planning. Multiple emails from CC1 to facility staff show repeated requests for the care plan, medication lists, and updates on the resident's condition, which were not adequately addressed. Progress notes and staff interviews confirmed that there was no documentation of timely notification to CC1 regarding medication changes or care plan updates, and that the first substantial care conference with CC1 occurred weeks after admission. Staff interviews revealed that the responsibility for notifying representatives of changes in care was not consistently followed, and facility leadership acknowledged that the representative should have been involved from admission and kept informed of all significant changes. The lack of communication and collaboration with the resident's representative resulted in ongoing frustration and unanswered questions regarding the resident's care and discharge planning.
Failure to Timely Obtain and Monitor Ordered Laboratory Tests
Penalty
Summary
The facility failed to obtain and monitor laboratory tests in a timely manner as ordered by the physician for one resident. The resident was admitted with diagnoses including dementia, bipolar disorder, and diabetes, and upon admission, exhibited symptoms such as nausea, vomiting, somnolence, and poor intake. The medical provider identified possible medication or metabolic causes for these symptoms and ordered a series of laboratory tests (CMP, CBC, TSH, Hgb A1C, and valproic acid level) along with IV fluids for hydration. Despite these orders, the laboratory tests were not completed promptly. Provider notes indicated that, nearly two weeks after the initial order, the laboratory results were still pending, and medication was held pending lab results. Review of the resident's records showed that the CMP, CBC, and TSH were not collected until over two weeks after the order, the valproic acid level was not completed until almost a month later, and the Hgb A1C was never collected. Staff confirmed the delays and missing results during interviews and record reviews. The Director of Nursing acknowledged that providers expect labs to be completed in a timely manner when ordered.
Unsafe and Unsanitary Conditions in Shower, Utility, and Equipment Storage Areas
Penalty
Summary
Surveyors observed multiple areas of the facility that were not maintained in a safe or sanitary condition. In the shower room on the [NAME] wing, the floor was found littered with garbage such as used gloves, paper towels, and wipes. Personal hygiene items were open and scattered, the toilet was visibly soiled, the shower drain was uncovered, and the exhaust fan had exposed wires. In a resident room, equipment including beds, wheelchairs, air mattresses, and mechanical lift devices were stored, with an air mattress placed on a dirty floor with dead insects. Garbage containers with used incontinence products and a laundry container with dirty clothes were also present in this room, with the garbage container lids left ajar. The soiled utility room on the East wing contained garbage on the floor, including oxygen masks and gloves, and isolation carts with clean supplies were stored there inappropriately. The hopper was empty of water and had dark brown rings inside. Another shower room on the North wing had an uncovered outlet with visible wires. During interviews, the Housekeeping Supervisor confirmed that garbage and soiled linen containers should not be stored in the resident room and that isolation carts with clean supplies should not be in the dirty utility room. The Administrator acknowledged that the observed rooms were not in safe or sanitary conditions and agreed that proper storage procedures were not followed.
Failure to Inform Resident Representative of Significant Change in Condition
Penalty
Summary
The facility failed to ensure that a resident's representative was adequately informed and involved in healthcare decisions, as required by policy. A resident with severe cognitive impairment and a history of skin cancer was receiving wound care for a cancerous lesion. Staff discovered maggots in the resident's wound during a dressing change, but the family was not notified of this significant change in the resident's condition. Documentation showed that while staff communicated with the family about moving the resident to a private room, there was no mention of the maggot infestation or discussion of treatment options, including possible hospitalization. Interviews with facility staff revealed that the LPN who discovered the maggots did not notify the family, and the DON also did not inform the family, assuming another nurse had done so. The physician assistant involved in the resident's care did not speak to the family directly, believing the DON had already communicated with them. As a result, the resident's representative was not given the opportunity to participate in or make informed decisions regarding the resident's care and treatment during a critical event.
Deficient Continence and Catheter Care Practices
Penalty
Summary
The report identifies a deficiency related to the provision of care for residents who are continent or incontinent of bowel and bladder, as well as the management of catheter care and the prevention of urinary tract infections (UTIs). Surveyors found that appropriate care was not provided in these areas, indicating lapses in the facility's practices for maintaining continence care, catheter hygiene, and UTI prevention. Specific details regarding the actions or inactions of staff, or the condition of affected residents at the time of the deficiency, are not provided in the report.
Failure to Report and Investigate Catheter-Related Hospitalization
Penalty
Summary
The facility failed to report and investigate an incident of potential neglect involving a resident who was hospitalized due to a preventable complication related to a suprapubic catheter. The resident, who was cognitively intact and required minimal assistance with activities of daily living, had a history of obstructive uropathy and an indwelling urethral catheter, which was later replaced with a suprapubic catheter. Hospital documentation revealed that the resident was admitted with an obstructed suprapubic catheter, calcifications at the insertion site, a hardened catheter balloon, and cellulitis caused by leaking urine. The resident required surgical and intravenous interventions for these complications. Facility records indicated that the suprapubic catheter had not been changed since 11/12/2024, despite clinical orders specifying monthly changes. When questioned, the Director of Nursing (DNS) acknowledged that no investigation had been completed regarding the hospitalization, and was unaware of the hospital's request for documentation about the last catheter change. Communication between staff members regarding the records request was not effectively addressed, and the administrator confirmed that the incident should have been investigated and reported to the appropriate agencies.
Failure to Ensure Residents Are Free from Unnecessary Medications Due to Inadequate Pain Management Practices
Penalty
Summary
The facility failed to ensure that residents were free from unnecessary medications by not providing or documenting non-pharmacological interventions (NPIs) for pain management, not establishing clear parameters for medication administration, and not consistently offering non-opioid medications prior to opioid use. For one resident with chronic pain and muscle spasms, morphine was administered multiple times without documented attempts to use NPIs or offer non-opioid alternatives such as ibuprofen, despite care plans indicating NPIs should be used. Staff interviews confirmed that NPIs and non-opioid medications were not consistently offered or documented, and medication orders lacked specific parameters for administration. For two other residents, physician orders required assessment for pain and the use of NPIs with documentation of their effectiveness. However, the medication administration records showed that NPIs were documented as used daily, even when no pain was reported, and there was no documentation of the effectiveness of these interventions. Progress notes did not specify which NPIs were used or their outcomes, and staff acknowledged that documentation was incomplete and often copied from previous entries. Another resident with significant cognitive impairment and end-of-life care needs had morphine orders that were not linked to NPI instructions, and staff did not document attempts to use NPIs prior to administering morphine. The morphine orders also lacked specific pain scale parameters, and there was no evidence that the facility was monitoring for adverse side effects of opioid administration. Staff interviews confirmed that these documentation and monitoring practices were not being followed as required.
Failure to Document Staff COVID-19 Vaccination Status and Education
Penalty
Summary
The facility failed to maintain a system for documenting staff screening, education, offering, and current COVID-19 vaccination status for a 12-month period. During interviews and record reviews, the Administrator and Infection Preventionist acknowledged that they did not have documentation for the current year, stating that all staff had refused the COVID-19 vaccine and only last year's records were available. When requested, the facility provided a general statement and a Vaccine Information Statement but did not supply individual staff records of screening, education, offering, or vaccination status as required.
Failure to Obtain and Document Accurate Informed Consent for Psychotropic Medications
Penalty
Summary
The facility failed to ensure that informed consent was properly obtained and documented prior to administering psychotropic medications for three residents. In one case, a resident with severe cognitive impairment and delirium was prescribed aripiprazole, but the informed consent form incorrectly identified the medication as an antidepressant rather than an antipsychotic. As a result, the resident or their representative was educated about the risks and benefits of antidepressants instead of antipsychotics, and staff confirmed that the resident could not have made an informed decision based on inaccurate information. For another resident with severe cognitive impairment, there was no documented consent for an increased dose of quetiapine or for the administration of lorazepam, both psychotropic medications. Staff acknowledged that consents should have been obtained with these medication changes but were not. In a third case, a resident with dementia was found to have provided consent for psychotropic medications despite being unable to do so, and the resident's son, who was not the active power of attorney, was present at the time. Additionally, there was no consent found for trazodone, another psychotropic medication. These findings indicate that the facility did not consistently ensure that informed consent was obtained from the appropriate party and that the consent process accurately reflected the medications and their associated risks.
Failure to Involve Residents and Representatives in Person-Centered Care Planning
Penalty
Summary
The facility failed to ensure that residents were included in the development and implementation of their person-centered plans of care, as evidenced by multiple instances where residents or their representatives were not involved in care conferences or discussions regarding significant care decisions. For several residents who were cognitively intact or had decision-making capacity, there was no documentation that they were consulted or gave consent for hospital transfers, changes in code status, or the initiation of end-of-life (EOL) or comfort care services. In one case, a resident with a POLST indicating comfort-focused treatment was sent to the hospital multiple times without documented consent or re-evaluation of their preferences, and the resident later expressed a desire for more active treatment if it would save their life. Other residents with significant changes in condition, such as weight loss or the initiation of palliative care, were not included in discussions about their care plans. For example, a resident with depression and malnutrition was not informed about the discontinuation of weights or involved in decisions regarding EOL care and anti-anxiety medication, despite expressing a desire to be weighed and to have their preferences considered. Documentation was lacking to show that residents or their legal representatives were notified or involved in these decisions, and staff interviews confirmed that such conversations either did not occur or were not documented as required. Additionally, residents with severe cognitive impairment and their legal representatives were not included in care planning or notified about significant changes such as the initiation of comfort care or discontinuation of weights. In several cases, representatives reported not being aware of the resident's care status or the meaning of comfort care, and there was no evidence of care conferences or individualized care planning. The lack of resident and representative involvement was further confirmed by staff who acknowledged the absence of required documentation and individualized care plans.
Failure to Prevent Unnecessary Psychotropic Medication Use and Chemical Restraints
Penalty
Summary
The facility failed to ensure that residents were free from unnecessary psychotropic medications and chemical restraints, as evidenced by the care of five residents reviewed for unnecessary medications or pain. For these residents, psychotropic medications were administered without adequate indications for use, and resident-specific target behaviors (TBs) were not properly identified or monitored. In several cases, gradual dose reductions (GDRs) were not performed, and non-drug interventions were not attempted or documented prior to the administration of as-needed (PRN) psychotropic medications. Additionally, PRN psychotropic medication orders exceeded 14 days without documented clinical rationale or provider reassessment. One resident with diagnoses of depression, anxiety, and bipolar disorder was prescribed buspirone and duloxetine, but the TBs listed in the care plan were simply restatements of diagnoses rather than specific behaviors, making it impossible to assess medication effectiveness. Another resident with severe cognitive impairment and a history of delirium and depression was prescribed two antipsychotics and an antidepressant, but the care plan failed to identify goals or TBs for these medications. The antipsychotics were continued after the resolution of delirium, with no clear indication for ongoing use, and no documentation of GDRs or rationale for continuation. Other residents were prescribed PRN lorazepam for anxiety or agitation, but orders were written for extended periods (up to six months) without provider reassessment every 14 days or documentation of clinical rationale for ongoing use. Non-pharmacological interventions were not individualized or documented prior to medication administration, and staff were unable to specify or monitor TBs linked to each medication. In some cases, medication orders lacked end dates, and staff interviews confirmed that documentation and monitoring practices did not meet expectations, with missing or inadequate records of behaviors and interventions.
Failure to Provide Timely Bed Hold Notices and Ombudsman Notifications During Resident Transfers
Penalty
Summary
The facility failed to provide required written bed hold notices at the time of hospital transfer for two residents and did not notify the ombudsman for three residents who were hospitalized. For one resident with moderate cognitive impairment, the bed hold notice was not signed or provided within 24 hours of transfer, and the resident was not included in the facility's list of those leaving the building. Documentation showed the bed hold notice was signed several weeks after the transfer. Additionally, the ombudsman was not notified of this resident's transfer as required. Another resident, who was cognitively intact, left the facility against medical advice, but the facility was unable to provide documentation that the ombudsman had been notified of the discharge. For a third resident, who was transferred to acute care with a return anticipated, there was no documentation that a bed hold was offered or that the ombudsman was notified of the transfer. These failures were confirmed through staff interviews and record reviews, with staff acknowledging the lack of timely notifications and documentation.
Failure to Provide Individualized and Comprehensive Care Plans
Penalty
Summary
The facility failed to develop and implement comprehensive, individualized, and person-centered care plans for 11 of 18 sampled residents. Surveyors found that care plans were often generic, not updated, and lacked specific interventions or measurable goals tailored to each resident's unique needs and diagnoses. For example, one resident with dementia and depression had a care plan that did not address meal refusals or provide alternatives, and another resident's care plan listed an incorrect diagnosis for anti-anxiety medication. Staff interviews confirmed that care plans were not individualized and did not reflect current conditions or effective interventions. Several residents with complex medical histories, such as malnutrition, chronic pain, kidney disease, and end-of-life care needs, had care plans that were either missing critical information or were not updated to reflect significant changes in their health status. For instance, a resident with chronic pain did not have a care plan specifying pain goals, effective medications, or non-pharmacological interventions, and another resident with significant weight loss did not have this issue addressed in their care plan. Additionally, residents receiving palliative or end-of-life care had care plans that were described as 'cookie cutter,' lacking any individualized preferences, goals, or interventions. Other deficiencies included the absence of care plans for specific conditions observed during the survey, such as senile purpura, constipation, and the use of safety devices like bed placement against the wall. Staff acknowledged that these omissions meant care plans did not guide staff on how to address residents' specific needs or preferences. The lack of individualized, updated, and comprehensive care plans placed residents at risk of unidentified and unmet care needs.
Failure to Document Corrective Actions for Out-of-Range Refrigerator Temperatures
Penalty
Summary
The facility failed to store food in accordance with professional standards by not maintaining proper refrigerator temperature logs and not documenting corrective actions for out-of-range temperatures in two nursing station refrigerators. Multiple instances were recorded where refrigerator temperatures exceeded the recommended maximum of 40 degrees Fahrenheit, with some readings as high as 49 degrees Fahrenheit. These out-of-range temperatures were documented repeatedly over several months, including both AM and PM shifts, without any evidence of corrective action being taken or documented by staff. During interviews, the Dietary Manager confirmed that the expected process for out-of-range temperatures was to ensure the refrigerator door was closed, recheck the temperature after an hour, and, if the issue persisted, contact maintenance and the Administrator. However, review of the logs showed that this process was not followed, as there was no documentation of any corrective actions taken for the numerous temperature violations. The lack of adherence to proper food storage protocols was observed and confirmed through record review and staff interviews.
Failure to Properly Inform Residents and Representatives of Binding Arbitration Agreements
Penalty
Summary
The facility failed to ensure that binding arbitration agreements were properly reviewed and explained to residents or their representatives, resulting in a lack of understanding about the agreements' terms and implications. For three residents, either the resident or their representative signed the arbitration agreement without being explicitly informed that they were waiving their right to litigation in a court proceeding. Interviews revealed that these individuals did not recall being told about their right to refuse or withdraw from the agreement, nor did they understand the arbitration process or the legal consequences of signing. One resident, who had recently been hospitalized for sepsis and was recovering from a urinary tract infection with a history of hallucinations, expressed uncertainty about their mental acuity at the time of signing. Another resident's POA and a responsible party for a third resident both stated they did not understand what they had signed, with one indicating they were in a distressed state due to a family member's critical illness. Staff interviews indicated that the business office manager provided explanations that were inconsistent with the actual terms of the arbitration agreement, suggesting that residents could still go to court after arbitration, which was inaccurate. The administrator acknowledged that the expectation was for staff to explain the agreements in an understandable way, but admitted that this was not achieved, as evidenced by the residents' and representatives' lack of understanding. There was no documentation or evidence that the agreements were explained in a manner accommodating the needs of the residents or their representatives, nor that their consent was fully informed.
Lack of Documentation and Participation in QAPI Program
Penalty
Summary
The facility failed to provide evidence of an ongoing, effective, and comprehensive Quality Assurance and Performance Improvement (QAPI) program as required. During interviews and record reviews, it was found that the facility did not have documentation demonstrating the development, implementation, or evaluation of a performance improvement activity for the one sampled Process Improvement Project (PIP) reviewed. The facility also could not provide sign-in sheets or proof that the medical director participated in QAPI meetings at least quarterly, as required by policy. The administrator was unable to produce a QAPI plan or evidence of any current or past performance improvement activities when asked. Additionally, the only document provided in response to requests for QAPI documentation was a sparse meeting record that did not contain the relevant information needed to demonstrate compliance. No PIP documentation or sign-in sheets from QAPI meetings were provided, and the administrator acknowledged the lack of these records. The facility's policy requires a data-driven, proactive approach involving all levels of staff, but there was no evidence that these processes were being followed or documented.
Failure to Implement and Document Antibiotic Stewardship Program
Penalty
Summary
The facility failed to implement an effective Antibiotic Stewardship Program as required by its own policy and infection control standards. Specifically, the program did not ensure that accurate and complete information regarding signs and symptoms of infection was collected, monitored, and documented on monthly infection line listings for two of three months reviewed. The February and April infection line listings were missing critical documentation of signs and symptoms for multiple entries, including cases of cholecystitis, urinary tract infections, wound infections, osteomyelitis, cellulitis, and sepsis. In several instances, only the diagnosis or hospitalization was recorded without any supporting clinical details, such as the onset date or specific symptoms, and in one case, an antibiotic was started without any documentation of symptoms or diagnosis. For one resident with a history of Bullous Pemphigoid, the facility did not follow McGeer's Criteria, a tool used to determine if antibiotic treatment is indicated. This resident was prescribed two courses of doxycycline for cellulitis, but the documentation showed only new redness and serosanguinous drainage, without other required symptoms or evidence that McGeer's Criteria were met. There was no documentation of fever, pus, or other qualifying symptoms, and vital signs were not recorded to rule out fever. Additionally, the second course of antibiotics for this resident was not entered on the April infection control line listing, further indicating a lack of proper tracking and oversight. Interviews with facility staff, including the Administrator/Infection Preventionist and the DON, revealed that while McGeer's Criteria was the stated tool for infection assessment, there was no consistent process for documenting its use or for communicating with providers when criteria were not met. Staff could not recall specific discussions or documentation regarding the initiation of antibiotics for the resident in question, and the last completed infection screening evaluation in the EHR was from 2022. This lack of documentation and oversight resulted in incomplete tracking of antibiotic use and infection assessments.
Failure to Administer and Document Medications and Treatments per Professional Standards
Penalty
Summary
Facility staff failed to provide services in accordance with professional standards of practice for two residents. For one resident, who was admitted with pneumonia and sepsis and required IV antibiotics via a PICC line, staff did not consistently administer IV cefazolin at the ordered times, with several doses given between 3 to 6.5 hours late. Additionally, staff did not document required measurements of the PICC line external length and arm circumference upon admission or with scheduled dressing changes, despite signing off that these tasks were completed. There were also missed or undocumented tasks related to monitoring the IV site for infection, administering and documenting oxygen therapy, and changing IV tubing as ordered. For another resident with diagnoses including depression and atrial fibrillation, there were multiple instances where staff left blank documentation boxes on the MAR and TAR for ordered medications, supplements, and required monitoring. These included missed documentation for administration of high calorie/protein supplements, Eliquis, and monitoring for side effects of antidepressant and antipsychotic medications, as well as documentation of target behaviors related to insomnia and major depressive disorder. Staff confirmed that blank boxes indicated the task was either not done or not documented, and that all medications and treatments should be documented upon administration. Interviews with facility staff, including the Resident Care Manager and Director of Nursing, confirmed that the expectation was for nurses to administer medications and perform treatments as ordered, and to only sign for tasks that were actually completed. The lack of documentation and inconsistent administration of medications and treatments were acknowledged by staff as not meeting professional standards of practice.
Failure to Implement and Document Bowel Management Protocol
Penalty
Summary
The facility failed to implement and document its bowel management protocol for two residents who were at risk for constipation and unnecessary medication use. For one resident, there was a six-day period with no documented bowel movements, and no bowel medications were administered during that time, despite physician orders and facility policy requiring intervention. Staff interviews confirmed that there was no documentation of bowel medications being given or of staff verifying the resident's self-reported bowel movement, even though the resident was dependent on staff for care. For another resident, there were three separate periods ranging from four to five days without a documented bowel movement, and again, no bowel medications were administered or documented as required by the facility's protocol. The resident's care plan specified the goal of a normal bowel movement at least every third day and directed staff to follow the facility's bowel management protocol, which was not done. Staff confirmed that the necessary interventions were either not started or not documented during these periods.
Failure to Complete Weekly Skin Assessments and Implement Wound Healing Supplements
Penalty
Summary
The facility failed to consistently perform weekly skin assessments and did not implement recommended nutritional supplements for wound healing for a resident with a pressure ulcer. According to facility policy, weekly Total Body Skin Evaluations were required, but documentation showed that these assessments were not completed weekly for the resident. There was a gap of over four weeks between assessments, during which time a Stage 3 pressure ulcer developed. Staff interviews confirmed that the required weekly assessments were not being performed as expected, and that earlier detection of skin issues could have potentially prevented the development of the pressure ulcer. Additionally, the facility did not follow through on a wound care nurse practitioner's recommendation to provide a specific nutritional supplement, Arginaid, to promote wound healing. Although the recommendation was communicated to the facility's registered dietician and noted in the resident's record, there was no evidence that the supplement was ordered or administered as intended. Staff interviews revealed confusion regarding the administration of the supplement due to the resident's need for honey thick fluids, and no documentation was found to confirm that the supplement was provided as recommended.
Failure to Provide Proper PICC Line Care and Documentation
Penalty
Summary
The facility failed to provide intravenous (IV) services in accordance with professional standards of practice for a resident who was cognitively impaired, had a diagnosis of pneumonia, and was receiving IV antibiotic therapy via a peripherally inserted central catheter (PICC). Physician orders required regular PICC dressing changes every 72 hours, measurement of external catheter length and arm circumference with each dressing change, and monitoring of the IV site for infection. However, there was no documentation that these tasks were completed as ordered, and staff signed off on tasks that were not performed. Additionally, the physician orders did not include instructions to flush the PICC line before and after medication administration or to change the needleless injection caps with dressing changes, after blood draws, or as needed. Observation revealed that the PICC dressing was not changed as scheduled, despite staff documentation indicating otherwise. There was also no evidence in the electronic health record that the required measurements of external catheter length and arm circumference were performed. The Resident Care Manager confirmed the lack of documentation and acknowledged that staff had erroneously signed for incomplete tasks on multiple occasions. These failures were identified during review of the resident's records, direct observation, and staff interviews.
Failure to Reconcile and Co-Sign Controlled Medication Counts at Shift Change
Penalty
Summary
The facility failed to maintain a system for periodic reconciliation and accounting of all controlled medications on the East B medication cart. Specifically, nurses were required to count all schedule two, three, and four medications at each shift change and co-sign the medication ledgers to confirm the accuracy of the counts. However, review of the schedule three and four medication ledger revealed that nurses rarely signed to validate the counts, with only one of 62 shift changes in January, none in February, and one of 62 in March having the required signatures. Interviews with staff confirmed that the expected process of dual verification and signing was not consistently followed. Staff interviews indicated inconsistency in practice, with some nurses signing the ledger and others not, and some believing that a single signature sufficed for both schedule two and schedule three/four ledgers. The Resident Care Manager confirmed that the required process of both oncoming and offgoing nurses signing the ledger for schedule three and four medications was not being followed for the East B cart. No specific residents were identified as being directly affected in the report.
Failure to Accurately Complete PASRR Assessments for Mental Health Diagnoses
Penalty
Summary
The facility failed to ensure that Pre-Admission Screening and Resident Review (PASRR) assessments accurately reflected the mental health diagnoses of two residents. For one resident, the admission Minimum Data Set (MDS) indicated severe cognitive impairment, a diagnosis of depression, and symptoms of delirium, with orders for both antipsychotic and antidepressant medications. However, the level 1 PASRR assessment did not identify any indicators of serious mental illness and did not trigger a level 2 PASRR referral, despite the resident's documented mental health conditions. Staff later acknowledged that the PASRR was inaccurately completed and should have included the resident's diagnoses, necessitating a level 2 referral. For another resident, the significant change MDS documented diagnoses of depression and anxiety disorder, but the level 1 PASRR assessment did not include these diagnoses. A subsequent level 2 PASRR assessment, which relied on the inaccurate level 1 PASRR, failed to identify the resident's underlying mental health conditions, resulting in an invalidated referral. Facility staff confirmed that the omission of these diagnoses in the PASRR assessments was an error and should have been identified and corrected.
Failure to Notify Physician and Representative of Significant Weight Loss
Penalty
Summary
The facility failed to immediately notify the physician and resident representative of significant changes in physical condition for two residents reviewed for nutrition. In the first case, a resident with severe cognitive impairment experienced a significant weight loss, dropping from 111.6 lbs to 85.8 lbs over several months, representing a loss of over 23%. The resident's Durable Power of Attorney (DPOA) was not informed of this weight loss, and both the provider and Registered Dietitian (RD) were also not notified, as confirmed by staff review of the electronic health record (EHR). The DPOA only became aware of the weight loss after noticing physical changes and was concerned about the lack of communication from the facility. In the second case, another resident with dementia experienced a weight loss of over 6% in one month and nearly 8% in three months. The resident's family member noticed the weight loss and expressed concern. The resident's weight was recorded in a weight binder but was not entered into the EHR in a timely manner, which delayed notification to the power of attorney and provider. Staff confirmed that the expectation was for weights to be entered into the EHR on the same shift and for notifications to be made, but this did not occur for this resident.
Failure to Assess and Document Use of Physical Restraint-Related Devices
Penalty
Summary
The facility failed to comprehensively assess and document the use of physical restraint-related devices for four residents, including bed rails/mobility bars, beds placed against the wall, and a wander guard. For one resident with moderate cognitive impairment and a history of psychosis, a wander guard was ordered and used daily, but there was no documented safety evaluation or care plan addressing its use. Staff interviews confirmed that required assessments and documentation were missing. Another resident, who was cognitively intact, had a physician's order for their bed to be placed against the wall as a safety device. However, there was no evidence of a Physical Therapy evaluation or documentation of less restrictive alternatives being attempted prior to this intervention. The Director of Nursing acknowledged that such documentation and evaluation should have been completed before implementing the intervention. For a resident with severe cognitive impairment, mobility bars were ordered for safe mobility, but both bars were found to be loose and unstable during inspection. Staff confirmed that the bars should have been solid and stationary, and recognized the risk of injury or entrapment. There was no documentation of a comprehensive assessment for the use of these mobility bars, nor evidence that less restrictive alternatives were considered. Similarly, another resident with severe cognitive impairment had their bed placed against the wall without an order, assessment, or care plan, and no documentation of less restrictive alternatives. Staff interviews revealed confusion about responsibility for assessments and a lack of required documentation in the electronic health record.
Failure to Administer IV Antibiotics at Prescribed Intervals
Penalty
Summary
Facility staff failed to administer intravenous (IV) antibiotics at the prescribed times and intervals for a resident who was cognitively intact and being treated for bilateral lower lobe pneumonia. The resident had a physician's order for IV cefazolin to be given every eight hours at 8:00 AM, 4:00 PM, and midnight, with each dose to be infused over one hour via a peripherally inserted central catheter. Review of the medication administration record revealed a pattern where the midnight dose was consistently administered four to six and a half hours late, resulting in a 13-14 hour gap between the 4:00 PM and midnight doses, and a 2-3 hour interval between the midnight and 8:00 AM doses, instead of the ordered eight-hour intervals. Staff confirmed that nurses did not administer the IV cefazolin at the prescribed times and failed to adjust subsequent doses to maintain the correct intervals. This deviation from the ordered schedule was observed on multiple occasions, as documented in the electronic health record and confirmed by the Resident Care Manager. The failure to follow the prescribed medication schedule constituted a significant medication error for the resident receiving IV therapy.
Improper Medication Storage and Expired Drugs Found
Penalty
Summary
Surveyors identified that the facility failed to ensure proper storage and management of medications and biologicals in two medication rooms and one medication cart. In the East Medication Room, the medication refrigerator contained intravenous cefazolin, unopened insulin pens, and an opened multi-use vial of Tuberculin PPD, all of which require refrigeration within specific temperature ranges. However, the refrigerator temperature log had not been checked or recorded since October 2024, a lapse of over six months. Staff confirmed that daily temperature checks and recordings were required but had not been performed. In the West Medication Room, a multi-use vial of Tuberculin PPD was found stored in the freezer instead of the refrigerator and had been open for 56 days, exceeding the 30-day discard requirement. On the East A Medication Cart, two medication cards—benzonatate 100 mg and mirtazapine 7.5 mg—were found to be expired. Staff acknowledged that these medications were expired and should have been discarded. These findings demonstrate failures in medication storage, labeling, and timely disposal of expired drugs.
Failure to Initiate and Document Resident Grievances
Penalty
Summary
The facility failed to initiate and document resident grievances for two of five sampled residents, despite having a policy requiring all concerns to be logged and addressed within five days. For one resident, who was cognitively intact and required significant assistance with activities of daily living due to COPD, the family member reported concerns about the resident's unresponsiveness and staff's dismissive behavior when they sought help. The family member attempted to file a grievance regarding both the care provided and the staff's conduct but found no formal process in place. The administrator and director of nursing acknowledged the incident but did not document it as a grievance or log it, as required by facility policy. Another resident, also cognitively intact and medically complex, reported the loss of personal property (reading glasses) to a nursing assistant shortly after admission. The item was not replaced, and the resident was unfamiliar with the grievance process. Staff interviews revealed inconsistent practices regarding the documentation and handling of missing items, with some staff indicating that grievances should be logged and others stating that missing items were tracked separately. The administrator confirmed that the missing glasses were not logged and that no formal grievance process was initiated for this concern. The facility's failure to follow its own grievance policy resulted in concerns and complaints from residents and their representatives not being formally recognized, tracked, or resolved through the established process. This lack of documentation and follow-through denied residents and their families the opportunity for timely resolution of their grievances, as required by facility policy and regulatory standards.
Failure to Ensure Safe and Comprehensive Discharge Planning
Penalty
Summary
The facility failed to ensure comprehensive discharge planning for a resident who was being discharged, resulting in unmet care needs. The resident, who was cognitively intact, required a wheelchair for mobility, and needed daily medication via injections, was given a 30-day eviction notice. Despite the ongoing discharge planning, the care plan indicated the resident would remain in the facility until placement was found, but the resident was ultimately discharged to a local hotel that was not handicap accessible. The discharge notice cited that the resident no longer required skilled nursing services and exhibited behaviors that threatened the safety of others. Upon discharge, the resident's family member reported that the hotel room was not wheelchair accessible, lacked safety bars in the bathroom, and required navigating stairs, which the resident could not do. The resident was sent with medications, including insulin, but there was no documented assessment of the resident's ability to self-administer medications or manage insulin injections. Shortly after arrival at the hotel, the family member called 911 due to concerns about the resident's blood sugar, and the resident was subsequently admitted to the hospital. Interviews with facility staff revealed that no formal self-medication management assessment was completed, and there was no documentation of a physical therapy assessment or evaluation of the resident's ability to prepare meals or access prepared food. The administrator who arranged the hotel stay was unaware of the accessibility needs, and staff assumed the resident could manage independently without documented evidence. The discharge planning process did not ensure the resident's needs and preferences were met, nor did it prepare the resident for a safe transition.
Failure to Develop and Implement Timely Baseline Care Plans on Admission
Penalty
Summary
The facility failed to develop and implement baseline care plans within 48 hours of admission for four sampled residents, as required by facility policy. For one resident with a central line, the care plan did not include any focus, goals, or interventions related to the central line access. Another resident with a feeding tube did not have a care plan focus for tube feedings added until 11 days after admission. A third resident receiving IV medications had a care plan that only addressed activities of daily living, with no interventions for the resident's PICC line until 11 days post-admission. The fourth resident, also receiving IV medications, had a care plan that included infection prevention interventions for a PICC line, but the treatment administration record did not show implementation of PICC line dressing changes until 10 days after admission. Staff interviews revealed that nursing assistants and nurses relied on the care plan, Kardex, and medication/treatment administration records to identify necessary interventions for residents with specialized needs such as feeding tubes and IV access. However, the lack of timely and complete baseline care plans meant that essential interventions were not consistently documented or implemented in the initial days following admission. This failure to promptly establish and communicate care needs resulted in a lack of direction for staff in providing immediate and appropriate care for newly admitted residents.
Failure to Provide Central Line and Enteral Feeding Care Resulting in Hospitalizations
Penalty
Summary
The facility failed to provide adequate care and services to prevent hospitalization for two residents. For one resident with a central venous catheter (CVC), the care plan did not include focus, goals, or interventions related to the central line. There was no documentation of routine dressing changes or flushes on the Medication and Treatment Administration Records, and staff interviews revealed uncertainty about maintenance orders and expectations. The resident developed confusion, was found to have an elevated temperature and blood glucose, and was hospitalized for bacteremia. Hospital records indicated a suspected central line infection, leading to the decision for comfort measures and the resident's subsequent death. For another resident receiving nutrition via a feeding tube, the care plan for tube feedings was not initiated until 11 days after admission and did not include the intervention to keep the head of the bed elevated to reduce aspiration risk. After episodes of emesis, there was no skilled nursing assessment note, and vital signs were not documented in the days following the incident. The resident was later found to have low oxygen saturation, was lethargic, and requested hospital transfer, where they were admitted for acute respiratory failure with hypoxia and subsequently died. Family members reported concerns about ongoing vomiting, lack of intervention, and improper bed positioning, which were corroborated by staff interviews indicating inconsistent knowledge and practice regarding head-of-bed elevation. Staff interviews revealed gaps in knowledge and practice regarding both central line maintenance and enteral feeding management. Staff were unclear about the frequency and responsibility for central line care, and there was a lack of clear documentation and care planning for both residents. The absence of appropriate interventions and monitoring contributed to the residents' deteriorating conditions and hospitalizations.
Failure to Maintain Functional Resident Call System in Multiple Halls
Penalty
Summary
The facility failed to ensure that the resident audible call system was functioning properly and repaired in a timely manner for two of four resident halls reviewed. The call light system for rooms 1-17 was not working, and manual bells were distributed to residents as a temporary measure. Multiple observations revealed that the call lights in several rooms did not produce an audible alarm, and in some cases, residents did not have manual bells within reach or were unaware of their purpose. One resident was observed calling for help without a bell within reach, and another had the call light out of reach and the manual bell placed on the sink, expressing no knowledge of its use. Additionally, a resident was given their roommate's bell due to the absence of their own. Staff interviews confirmed ongoing issues with the repair process, including delays in receiving necessary parts and uncertainty about whether facility maintenance or an outside company was responsible for repairs. Even after the part was reportedly replaced, the audible alarm remained too quiet, and further adjustments were pending. Throughout the period of observation, the audible call system for rooms 1-17 remained nonfunctional, as confirmed by repeated testing and staff acknowledgment.
Failure to Investigate Resident Injury and Alleged Abuse
Penalty
Summary
The facility failed to thoroughly investigate an injury involving a resident who was admitted with a right hip fracture and required extensive assistance for bed mobility and transfers. On the date of the incident, the resident was found on the floor next to her bed, reported right hip pain, and was later diagnosed with a dislocated right hip requiring surgical intervention. Documentation of the incident did not include details on how the resident was assisted back to bed, and there was no evidence of a comprehensive investigation, such as staff or resident interviews or statements, to determine how the injury occurred. Additionally, the resident's Power of Attorney reported that the resident repeatedly stated she had not fallen but had been thrown into the bed, and this allegation was communicated to staff without documented follow-up. The facility's investigation records lacked interviews with staff or the resident and did not address the resident's account of the incident. Staff interviews confirmed that standard investigative procedures, including interviews, were not followed in this case.
Failure to Provide Necessary Behavioral Health Services
Penalty
Summary
The facility failed to provide necessary behavioral health care and services to a resident with a history of sexually inappropriate and aggressive behaviors. The resident, who was cognitively intact and medically complex, exhibited ongoing verbal and physical behaviors that interfered with activities, social interactions, and the privacy of others. The care plan identified risks for sexually inappropriate comments and physical actions, with interventions such as calm approaches, documentation, and reinforcement of acceptable behavior. Despite these interventions and regular telehealth behavioral health visits, the resident continued to display inappropriate behaviors, including making sexual comments, attempting to touch staff and residents, and engaging in physical altercations that resulted in staff injury and law enforcement involvement. Multiple staff and social services notes documented repeated incidents of inappropriate sexual and aggressive behavior, including attempts to grab and kiss staff, following other residents, and blocking doorways. Staff interviews revealed that the resident's behavioral health needs were not being met, with staff expressing fear for their own and other residents' safety. The behavioral health provider was aware of the ongoing behaviors but made no changes to the treatment plan, and interventions remained unchanged despite continued incidents. The resident received only brief telehealth visits every two weeks, with no in-person mental health services or referrals to community providers, and expressed dissatisfaction with the adequacy of these services. The facility's response included monitoring the resident's location and issuing a discharge notice due to ongoing behaviors that threatened the safety and health of others. However, there was no discharge plan available at the time of the notice. Staff and the resident both reported that behavioral health needs were not being adequately addressed, and the lack of in-person or community-based mental health services contributed to the deficiency in care.
Facility Fails to Maintain Clean and Homelike Environment
Penalty
Summary
The facility failed to maintain a safe, clean, and comfortable environment, as evidenced by the poor condition of the hallway carpets in three observed halls: East, Mid, and [NAME] B. Observations revealed numerous stains, debris, and unpleasant odors, which were reported by a family member who removed a resident due to the facility's uncleanliness. Specific observations included various colored stains, smeared matter, and scattered debris across the halls, indicating a lack of regular and effective cleaning. Interviews with staff members, including housekeeping staff and the Director of Nursing Services, revealed inconsistencies in carpet cleaning schedules and a lack of documentation. Housekeeping staff acknowledged the carpets did not represent a clean, home-like environment and mentioned plans for flooring replacement, which had not been completed. The facility administrator confirmed the absence of a specific cleaning schedule and documentation, further highlighting the deficiency in maintaining a clean environment.
Failure to Monitor and Document Vital Signs for Resident at Risk for Sepsis
Penalty
Summary
The facility failed to meet professional standards of practice for a resident who was newly admitted and receiving skilled services. The staff did not assess, monitor, or document the resident's responses to interventions on a daily basis. Additionally, the facility did not obtain and document vital signs for the resident, who was at risk for sepsis, a life-threatening condition. This lack of documentation and monitoring placed the resident at risk for rehospitalization and health complications. The resident, who was cognitively intact and medically complex with an indwelling catheter, was admitted to the facility. However, there were multiple days where no vital signs were recorded, and nursing assessment notes were missing. The resident was eventually transferred to the hospital with symptoms of sepsis, including uncontrollable shaking and purulent matter in the catheter, and was readmitted to the facility after treatment. Despite the resident's readmission, the facility continued to fail in documenting vital signs and nursing assessments. Identical daily skilled notes were found on different days, indicating a lack of proper documentation. Staff interviews revealed that vital signs should have been obtained every shift, and there was an expectation for daily skilled assessments, especially for a resident at risk for sepsis. However, staff reported a lack of training on sepsis prevention and recognition.
Failure to Promote Resident Dignity and Respect
Penalty
Summary
The facility failed to provide care that promoted respect and dignity for two residents, leading to unmet needs and episodes of disrespect. Resident 2, who was cognitively intact, reported that her call light was ignored for over 35 minutes, and when she approached the nurses' station, she was told by a staff member that they would assist her after finishing their apple. Additionally, Resident 2 experienced a situation where a staff member, identified as Staff F, was unkind and suggested reusing a bag for ice, which was reported to another staff member who acknowledged multiple concerns about Staff F. Resident 3, also cognitively intact, reported rough treatment during care, where a staff member moved her leg roughly and dismissed her complaint of pain by suggesting she should have moved faster. The grievance log indicated that the staff member involved would no longer be assigned to care for Resident 3. Despite multiple grievances regarding Staff F's behavior, there was no documentation of staff education or corrective actions taken to address these concerns, and staff members were unaware of the frequency and specifics of the grievances.
Inconsistent Wound Care for Resident with Gangrenous Toes
Penalty
Summary
The facility failed to consistently provide care and services as ordered for a resident with non-pressure wounds, specifically gangrenous toes and ankle wounds. The resident, who was cognitively intact and medically complex, had physician orders for specific wound care treatments, including daily dressing changes for the toes and every three days for the ankle wounds. However, documentation revealed that these treatments were not consistently performed on multiple occasions, as evidenced by missing entries in the Treatment Administration Record for specific dates in October and November. Family members and staff observations further confirmed the inconsistency in wound care. Family members reported that dressings were not changed daily, and drainage was often visible, especially during the resident's dialysis appointments. Staff members, including a Licensed Practical Nurse and the Director of Nursing, acknowledged the omissions and expressed expectations that the dressings should be changed and documented daily as per the orders. Despite these expectations, the facility's failure to adhere to the prescribed wound care regimen placed the resident at risk for worsening conditions.
Failure to Prevent and Manage Pressure Ulcers
Penalty
Summary
The facility failed to prevent the development of pressure ulcers and perform regular skin assessments for four residents, leading to the deterioration of existing wounds and the emergence of new ones. Resident 1, who had moderate cognitive impairment and was always incontinent, developed an unstageable wound on the right lateral buttock and a Stage 2 pressure ulcer on the coccyx, both identified as avoidable. The facility did not consistently perform wound care as ordered, and there were instances where the wound was left uncovered, leading to infection and the resident being hospitalized for sepsis and osteomyelitis. Resident 2, with severe cognitive impairment and complete dependence on staff, developed a Stage 3 pressure ulcer that was not present on admission. The facility failed to perform wound care on multiple occasions and did not document weekly skin assessments. Staff reported being unable to complete wound care due to time constraints, and there was no documentation of wound care being provided by the oncoming shift. Residents 3 and 4 also experienced similar issues, with Resident 3 developing a Stage 4 pressure ulcer and Resident 4 having an unstageable pressure injury. Both residents did not receive regular skin assessments, and there were lapses in wound care documentation. The facility's staff reported challenges in completing wound care due to workload, and there was a lack of communication and documentation regarding the condition and care of the residents' wounds.
Failure to Notify Family of Pressure Wounds
Penalty
Summary
The facility failed to notify resident representatives of changes in condition for two residents, specifically regarding the development of pressure wounds. For Resident 1, who had moderate cognitive impairment and was at risk for pressure injuries, the facility did not inform the family member about the development of a new unstageable wound and a stage 2 pressure ulcer. The wounds were documented by the wound provider but were not communicated to the family, as evidenced by the lack of documentation in the electronic health record. The family only became aware of the wounds when they noticed the resident's condition and called emergency services. Similarly, for Resident 2, who had severe cognitive impairment and was dependent on staff for all activities of daily living, the facility did not notify the family about a stage 3 pressure ulcer that developed. Despite having a care plan and physician's orders for wound care, there was no documentation of family notification in the electronic health record. Staff interviews confirmed that the expectation was to notify families of new wounds, but this was not done in these cases.
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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