Orchard Park Health Care & Rehab Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Tacoma, Washington.
- Location
- 4755 South 48th, Tacoma, Washington 98409
- CMS Provider Number
- 505093
- Inspections on file
- 51
- Latest survey
- March 26, 2026
- Citations (last 12 mo.)
- 9
Citation history
Health deficiencies cited at Orchard Park Health Care & Rehab Center during CMS and state inspections, most recent first.
Two residents experienced unwitnessed falls that were documented in nursing notes and reviewed by the IDT, but the facility failed to enter these incidents into the incident reporting log and did not report them to the State Survey Agency within the required timeframe. One resident, alert and oriented after recent hip/femur surgery, fell while attempting to transfer to a chair and had subsequent hip imaging, while another bedridden resident with dementia and multiple comorbidities was found on the floor next to the bed and could not explain the fall. In both cases, staff later acknowledged the falls were recorded in the internal system but not added to the State reporting log, resulting in noncompliance with required reporting standards.
A resident with a history of stroke, contractures, and limited mobility was discharged from skilled PT with goals and recommendations to continue splinting, ROM techniques, and use of a splint and brace. The care plan later identified limited physical mobility related to contractures and included a referral to a Restorative Nurse Assistant, but staff could not locate the written restorative program or any documentation that restorative services, including right knee splinting three times per week, were provided during the period after therapy discharge. This failure to implement and document the restorative nursing program for ROM and mobility resulted in a cited deficiency.
Facility staff did not incorporate a wound care specialist’s ten documented recommendations for PI prevention and treatment into the comprehensive care plan or CNA Kardex for a resident admitted with diabetes, malnutrition, muscle weakness, existing PIs, and total dependence for turning and repositioning. Despite facility policy requiring development and revision of interdisciplinary care plans for skin integrity, the specialist’s directives—such as q2h turning, maintaining clean and dry skin, avoiding massage of bony prominences, using positioning devices, minimizing HOB elevation, keeping sheets wrinkle-free, eliminating fragranced products, and implementing aggressive offloading—were never translated into provider orders or care plan entries. The DON later verified that none of these interventions appeared in the resident’s care plan or Kardex and acknowledged that CNAs rely on the Kardex and verbal report to obtain resident care instructions.
A resident with bilateral heel wounds and dependence for repositioning did not receive adequate PI prevention and treatment. The care plan lacked a turning schedule and pressure-relief mattress, and the Kardex used by CNAs did not reflect needed interventions. A contracted wound care provider documented a worsening Stage 4 right heel PI with increasing necrotic tissue, maceration, and a large increase in wound size, and issued multiple recommendations, including aggressive offloading, but none were entered as orders or care-planned. Additional PIs, including an unstageable left 4th toe PI, a deep tissue PI on the left lateral ankle, and an unstageable sacral PI, were later identified at the hospital but were not documented or treated by facility staff prior to transfer. Facility provider notes recorded escalating foot and heel pain without documented wound examination, and no further antibiotics were ordered despite later hospital findings of calcaneal osteomyelitis and a non-salvageable right lower extremity.
Multiple residents experienced harm due to the facility's failure to provide adequate supervision and follow care plans, including incidents of elopement, falls, and injuries. Residents at risk for wandering were not properly monitored or equipped with required safety devices, and staff did not consistently follow protocols for assistance during transfers and repositioning. Care plans were not timely updated after incidents, and required safety interventions were not always implemented.
The facility did not thoroughly or promptly investigate falls and injuries for multiple residents, including those with dementia and mobility issues. Several incidents, such as repeated falls, a head injury during repositioning, and a hip dislocation during transfer, were either not documented, not investigated, or not followed by timely care plan updates. Staff confirmed that required investigations and care plan revisions were not completed as expected.
Several residents were not accurately assessed for dental conditions, respiratory care, and restraint use. Two residents with missing or broken teeth had their dental issues omitted from the MDS, while a resident on oxygen therapy for COPD was not coded for oxygen use in the MDS despite having a provider order and being observed on oxygen. Another resident was incorrectly documented as using a trunk restraint. Staff interviews confirmed these assessment errors.
Two residents received oxygen therapy at flow rates higher than ordered by their providers, as observed and confirmed by staff interviews. Documentation did not reflect the actual oxygen settings, and there was no evidence of provider notification or order clarification. The deficiency involved failure to follow physician orders and monitor oxygen settings as required.
Surveyors found that a resident's IV nutrition, infuvite vials, and infusion kit were stored in a food refrigerator instead of the medication refrigerator, and multiple expired medical supplies—including viral transport kits, peroxide test strips, cleansing towelettes, and a wound vac therapy system—were kept in the medication room. Both an LPN and the DON confirmed these practices did not meet facility expectations.
Several residents reported that their food preferences, including specific meal choices and requests for double portions, were not consistently honored. Despite filing grievances, residents continued to experience issues with not receiving their preferred foods or portions, and staff interviews revealed gaps in communication and follow-through regarding dietary changes.
The facility did not report a Covid-19 outbreak involving two residents to the local health department as required, and failed to maintain complete infection surveillance for two of three months reviewed. Additionally, a resident with an open wound and chronic kidney disease did not receive timely urine testing for infection, and their infection was not tracked on the facility's infection control line list.
Two CNAs did not receive required training in abuse prevention, dementia care, or annual competency assessments. Training records showed one CNA had no documented training, while another had only a single in-service session. The Administrator confirmed the lack of completed education and competencies for these staff members.
A resident with cerebral palsy and other medical conditions was unable to set their own shower schedule, and showers were not provided as planned despite being scheduled. Staff assigned showers based on room location, and documentation confirmed missed showers. Staff interviews indicated that resident preferences were not honored as expected.
A resident with dementia and psychotic disturbance was prescribed antipsychotic medication, but staff failed to complete or document a baseline abnormal involuntary movement (AIM) assessment as required. Despite the medication administration record indicating the need to monitor for extrapyramidal symptoms, no AIM assessment was found in the electronic health record. Both an LPN and the DON confirmed the assessment should have been completed and acknowledged the deficiency.
Two residents with mental health diagnoses did not receive required PASARR Level II referrals. One resident with dementia and depression, unable to communicate needs and receiving multiple antidepressants, had indications for serious mental illness but no Level II referral was completed. Another resident with anxiety, depression, and PTSD was admitted under a hospital exempt discharge but remained in the facility beyond 30 days without a corrected PASARR or Level II referral, contrary to facility policy.
Surveyors found that the facility did not develop or implement individualized care plans for three residents, including one receiving oxygen therapy for COPD and two with significant oral or dental issues. Staff confirmed that care plans lacked necessary details about oxygen use and dental status, despite provider orders and resident reports.
Three residents did not receive care in accordance with professional standards: a resident did not have protective boots applied as ordered and refusals were not documented; another received midodrine outside of provider-specified blood pressure parameters; and a third, dependent on a central line for nutrition, had no provider orders or care for the line. Staff interviews confirmed these lapses in following provider orders and documentation.
A resident with encephalopathy, diabetes, and dementia was admitted without an activities assessment or an activity-focused care plan. The resident was repeatedly observed sitting in a wheelchair near the nurse's station, and staff interviews revealed that no recreation assessment or activity care plan was completed due to the resident's isolation status at admission, with uncertainty about the current isolation status. The Administrator confirmed that activity care plans should be completed within 72 hours and that isolated residents should receive one-on-one or in-room activities.
The facility did not properly document or care plan for non-pressure skin injuries in two residents, including missing wound type documentation, lack of weekly assessments, and absence of treatment orders. Additionally, a resident receiving Hospice care did not have a comprehensive care plan reflecting their end-of-life needs. Staff interviews confirmed these omissions and acknowledged that expectations were not met.
A resident with diabetes, obesity, and chronic pain reported needing new glasses, as their current pair was four years old. Although the resident had previously seen an eye doctor, there was no follow-up to obtain new glasses. Staff, including an LPN and the DON, confirmed that the resident was not seen during the most recent eye doctor visit, which did not meet facility expectations.
A resident with cerebral palsy, muscle weakness, and a urinary tract infection, who was able to express their needs, was observed to have multiple broken and discolored upper front teeth and reported ongoing dental issues. The resident's health record showed no dental consultation, plan, or treatment, and staff indicated the resident could not see the facility dentist due to their temporary status. Social services could not provide information about the resident's dental appointment status.
Two residents did not receive necessary dental services or follow-up. One resident with quadriplegia and other complex conditions had missing and stained teeth but had not seen a dentist since admission, despite provider orders and documentation of dental issues. Another resident, dependent on artificial feeding, needed lower dentures, but there was no care plan or dental consult in place. Staff interviews confirmed that the process for arranging dental care was not followed.
Two residents who were dependent on staff for bathing did not consistently receive showers or bed baths as per their care plans and facility policy. One resident reported going up to two weeks without a bath or shower, especially on weekends when the shower aide was not available, and documentation of bathing was incomplete. Another resident with moderate cognitive impairment received only one shower in a two-week period, with staff unable to consistently locate records of care provided.
The facility failed to report and investigate neglect allegations for two residents, one of whom experienced delayed administration of pain medication post-amputation, and another who did not receive requested Tylenol for chronic pain. Both residents were alert and able to communicate their needs, yet their grievances were not logged or reported to the State Agency.
The facility failed to manage pain effectively for two residents, leading to unmanaged and increased levels of pain. A resident with a history of leg amputation experienced a delay in receiving oxycodone, despite multiple reminders to the responsible RN. Another resident with chronic pain reported not receiving Tylenol and tramadol in a timely manner during the night shift, often waiting three to four hours. The DON confirmed that pain medication should be administered promptly according to provider orders.
A facility failed to provide consistent restorative care for three residents, leading to avoidable declines in their range of motion and mobility. One resident experienced worsening contractures due to the lack of splint application, another was not placed on a restorative program despite referrals, resulting in decreased joint flexibility, and a third did not receive follow-up on referrals for a prosthetic leg and hand surgery. These deficiencies were due to the facility's failure to implement and follow through with necessary care plans and referrals.
The facility did not have a written transfer agreement with a local hospital approved for Medicare/Medicaid, as revealed during a documentation review. The Administrator confirmed the absence of such documentation, risking delayed hospital transfers for residents.
The facility, with 145 beds, failed to employ a qualified social worker as required for facilities with more than 120 beds. The Director of Social Services did not hold a bachelor's degree, and both the Director and the Administrator were aware of the requirement but confirmed non-compliance.
The facility failed to maintain a safe and homelike environment, with broken blinds compromising privacy and unsanitary conditions in resident rooms and bathrooms. Staff were aware of these issues but cited budget restrictions and lack of follow-up as barriers to resolution.
A facility failed to thoroughly investigate incidents involving three residents, including falls and alleged abuse. For one resident, staff interviews were not conducted after a fall, and interventions were not documented. Another resident's unwitnessed fall was not investigated, and required monitoring was not documented. A third resident's abuse allegation was inadequately investigated, with delayed and insufficient interviews, and the alleged staff member was not suspended. These deficiencies indicate a failure to follow proper investigation protocols.
The facility failed to ensure accurate MDS assessments for three residents, leading to potential risks for unmet care needs. A resident with foot drop had an MDS showing no impairment despite evidence of chronic ankle contractures. Another resident's MDS did not document antipsychotic medication use, and a third resident's MDS failed to reflect dental issues and nutritional concerns. The MDS Nurse acknowledged incorrect coding, and the DNS expected accurate assessments.
The facility failed to accurately complete PASRR assessments for four residents, risking unidentified mental health needs. One resident's PASRR lacked necessary documentation, while others required Level II evaluations that were not conducted. Staff acknowledged the inaccuracies, and the need for updated assessments was confirmed.
The facility failed to review and revise care plans for several residents, leading to deficiencies in care. A resident with paraplegia lacked a restorative nursing program, while another with a rash had an inaccurate care plan. Two residents did not have timely care conferences, and a resident with anxiety lacked a care plan addressing mental health needs. Staff acknowledged these deficiencies, which did not meet expectations.
The facility failed to provide necessary interventions for a resident at risk of skin breakdown, did not coordinate hospice care for two residents, and neglected bowel management for three residents. Additionally, the facility did not promptly notify a provider about a resident's change in condition.
The facility failed to provide safe dialysis care for two residents due to inaccurate documentation and poor communication with the dialysis provider. Resident 308's care plan and orders were not updated to reflect the correct dialysis schedule, and communication forms were incomplete. Resident 60's records contained incorrect information about dialysis access type and pick-up times, and there was a lack of documentation for medication administration during dialysis. Staff interviews confirmed these deficiencies.
The facility failed to provide non-pharmacological interventions before administering pain medications to several residents, as required. Residents with chronic conditions received pain medications without documented attempts of alternative interventions. Additionally, a resident received blood pressure medication outside of specified parameters, and orders for topical medications lacked specific application locations. These deficiencies risked adverse side effects and diminished quality of life.
The facility failed to properly monitor and justify the use of psychotropic medications for two residents. One resident was given quetiapine for dementia with agitation without a defined psychotic disorder, and the facility did not follow the pharmacist's recommendation for dose reduction. Another resident was prescribed Seroquel for insomnia without evaluating the cause or monitoring sleep hours, despite recommendations for dose reduction. Staff interviews confirmed the lack of necessary monitoring and dose adjustments.
The facility failed to follow the posted menu during a lunch service, serving half portions of macaroni with ham instead of the full portion specified. This was due to staff using a scoop that provided only half a cup instead of the required full cup. Resident feedback indicated concerns about menu adherence and sudden changes, which were acknowledged by the Dietary Manager and Administrator.
The facility failed to provide palatable food at appetizing temperatures, affecting several residents. Observations revealed issues with food preparation and serving, including cold, bland, and unappetizing meals. Resident council minutes indicated ongoing grievances about food quality, which were not resolved despite monthly meetings and interviews.
The facility failed to safely prepare and store food, with dented cans found in storage and improper hand hygiene observed. Additionally, resident refrigerators were not monitored correctly, with temperatures consistently above safe levels. These actions did not meet the expected standards for food safety.
The facility's QAPI program failed to self-identify and sustain corrections for deficiencies, resulting in repeated and widespread issues. The administrator admitted the QAPI process was ineffective, leading to risks for residents. Deficiencies included maintaining a safe environment, accurate assessments, and proper nutrition.
The facility failed to implement transmission-based precautions for five residents, including those with indwelling catheters and wounds, by not providing proper signage and PPE. Staff entered rooms without required PPE, citing misunderstandings of precaution requirements. Additionally, laundry staff did not sanitize washing machines between loads, despite visible soil, increasing infection risk.
A resident was administered hydroxyzine for anxiety without informed consent for three days. The facility's policy requires informed consent before administering psychotropic medications, but this was not followed. Staff acknowledged the oversight.
The facility failed to maintain privacy for residents during medication administration and personal calls. A resident expressed concerns about a lack of privacy due to a roommate's yelling, which staff reportedly dismissed. Two residents were observed receiving topical medications without adequate privacy measures, exposing their bodies to others. The DNS acknowledged these practices were unacceptable.
The facility failed to address grievances for two residents, one experiencing sleep disturbances due to a noisy roommate and another with a missing personal item. Despite complaints, no formal grievances were initiated or resolved in a timely manner, contrary to the facility's policy requiring resolution within 72 hours.
A facility failed to provide written notification of a hospital transfer to a resident or their responsible party. The resident, diagnosed with multiple sclerosis, heart failure, and diabetes, was hospitalized and readmitted without documented transfer notice. Interviews with staff confirmed the lack of required documentation.
A facility failed to provide a written bed hold notice for a resident hospitalized with multiple sclerosis, heart failure, and diabetes. The resident's EHR showed hospitalization and readmission, but lacked bed hold documentation. Interviews with staff confirmed the absence of the required notice, which was expected to be documented and scanned into the EHR.
The facility failed to develop baseline care plans within 48 hours for two residents admitted with dementia and hospice needs. One resident had multiple diagnoses, including Alzheimer's, and required monitoring and medication for dementia, but lacked a care plan focus. Another resident, receiving hospice care, also lacked a care plan for hospice services. Staff interviews confirmed delays and omissions in care plan development.
A resident with multiple health issues was subject to unprofessional documentation by a registered nurse, who described them as 'annoying' and 'difficult' in progress notes. Interviews with staff confirmed that such subjective documentation was inappropriate and did not meet professional standards.
The facility failed to provide adequate pressure ulcer care for two residents, leading to deficiencies. One resident had an undocumented and untreated wound on the ischium, despite being at high risk for pressure injuries. Another resident experienced multiple pressure injuries, with improper positioning and an outdated care plan. The DON acknowledged the failure to follow care plans and prevention measures.
Failure to Report Unwitnessed Falls to State Agency and Incident Log
Penalty
Summary
The deficiency involves the facility’s failure to report unwitnessed falls to the State Survey Agency within 24 hours and to enter these incidents into the facility’s incident reporting log for two residents. One resident, admitted for nursing care and rehabilitation after a fall requiring hip and femur surgery, was alert, oriented, and able to make their needs known. This resident reported attempting to transfer into a chair at night, falling to the floor, and being unable to reach the call light, then crawling to the door to yell for help. A nurse’s progress note documented hearing the resident calling for help, finding the resident on the floor, and noting that the wheelchair and walker were far from the fall position, consistent with the resident’s report of having pulled themself to the door. The resident was assisted back to bed, had a hip x-ray, and the fall was documented by the provider and reviewed by the interdisciplinary team, but there was no corresponding entry in the facility’s incident reporting log and no report submitted to the State Survey Agency for this unwitnessed fall. The second resident, admitted with dementia, chronic kidney disease, and pressure ulcers for respite nursing and palliative care, was cognitively impaired but able to make needs known and required staff assistance with ADLs. A collateral contact stated the resident was bedridden, questioned how the resident could have fallen out of bed, and expressed concern that staff could not say how long the resident had been on the floor. A nursing note documented that the resident was found on the floor next to the bed, was unable to verbalize how the fall occurred, and was returned to bed via Hoyer lift with two-person assist, with no injuries identified. The provider and family were notified, and the fall was reviewed by the interdisciplinary team with care plan updates, but the incident was not entered into the facility’s incident reporting log and was not reported to the State Survey Agency. Staff later stated that both residents’ falls had been reported in the internal system but were not added to the State reporting log, resulting in the failure to meet the reporting requirements under WAC 388-97-0640(7)(a)(b)(i).
Failure to Implement Restorative Nursing Program for ROM and Mobility
Penalty
Summary
The deficiency involves the facility’s failure to initiate and provide a restorative nursing program for a resident with limited range of motion (ROM) and mobility needs after discharge from skilled therapy. The resident was admitted with diagnoses including stroke, aphasia, malnutrition, and depression, and the admission MDS documented that the resident did not walk, required partial to maximal assistance with ADLs, and was always incontinent of bowel and bladder. An observation showed the resident in bed with the right leg demonstrating full ROM while the left leg, hand, and arm appeared contracted. The PT discharge summary, dated mid-January, indicated that the resident was discharged from skilled PT services and had goals to improve active/passive ROM of the left hip and knee using splinting and ROM techniques, and to tolerate right knee splinting with functional ROM carryover. The PT discharge recommendations included continuing the resident’s splint and brace. The care plan, dated late February, identified the resident as having limited physical mobility related to contractures and documented a referral to a Restorative Nurse Assistant. However, during interviews, the COTA stated that although a restorative nursing program had been written for the resident, it could not be located. The DNS reported that there was a restorative nursing program referral for right knee splinting three times per week, but the facility was unable to locate the referral or any documentation showing that a restorative nursing program was implemented for the resident between the PT discharge date in mid-January and the early March observation. This lack of implementation and documentation of the restorative nursing program led to the cited deficiency for failure to provide appropriate care to maintain or improve ROM and mobility.
Failure to Integrate Wound Specialist PI Interventions Into Resident Care Plan
Penalty
Summary
Facility staff failed to develop and implement an individualized comprehensive care plan incorporating wound care specialist recommendations for a resident at risk for pressure injuries (PIs). The facility’s Skin Integrity Management policy, dated 05/26/2025, directed staff to develop comprehensive, interdisciplinary plans of care for prevention and wound treatments, including offloading devices, turning and repositioning, special wound care techniques, and appropriate support surfaces, and to review and revise care plans as indicated. The resident was admitted with diagnoses including diabetes, malnutrition, and muscle weakness, was identified on the admission MDS as being at risk for PIs, admitted with existing PIs, and totally dependent on staff for turning and repositioning in bed. A wound care specialist documented progress notes on 10/08/2025 listing nine specific recommended interventions and preventive measures related to the resident’s PIs, including turning every two hours, keeping skin clean and dry, avoiding massage of bony prominences, using positioning devices, keeping the head of bed as low as possible to reduce shearing, keeping sheets dry and wrinkle-free, and removing all fragranced products in favor of chemical-free, fragrance-free disposable washcloths. On 10/22/2025, the wound care specialist added a tenth recommendation for aggressive offloading. Review of the resident’s care plans and Kardex on 11/19/2025 showed that none of these ten recommendations had been added to the care plan or Kardex. On 12/17/2025, the DON confirmed that there were no provider orders for the recommended interventions, none of the ten recommendations were care planned or present on the Kardex, and stated that CNAs rely on the Kardex and verbal shift report to know resident care needs.
Failure to Implement Wound Care Recommendations and Prevent Worsening Pressure Injuries
Penalty
Summary
The deficiency involves the facility’s failure to provide adequate pressure injury (PI) prevention and treatment for a dependent resident with multiple existing wounds and high risk for skin breakdown. On admission, the resident had bilateral heel wounds and wounds to the right lower extremity and required substantial/maximal assistance for bed mobility and was totally dependent on staff for turning and repositioning. The MDS documented the resident was not on a turning/repositioning program, and the care plan, while noting bilateral heel pressure ulcers and wounds to the right lower extremity with a goal for healing, did not include a turning schedule or pressure-relieving mattress. Staff interviews confirmed the resident could not turn without assistance, that CNAs relied on the Kardex for care instructions, and that there was no order or care plan for a pressure-relief mattress. The facility used a contracted wound care and treatment company (WCTC) to manage the resident’s PIs. WCTC progress notes documented a right heel/foot Stage 4 PI that initially measured 15.75 cm² pre-debridement and 19.11 cm² post-debridement, with 100% necrotic tissue. Subsequent weekly assessments showed fluctuating but generally worsening wound characteristics, including increasing necrotic tissue, maceration, erythema, and a significant increase in wound size to 48 cm². WCTC notes over several visits identified peri-wound maceration and erythema and recommended multiple PI-related interventions, including aggressive offloading. However, review of the resident’s EHR, orders, care plans, and Kardex showed no documentation that any of the ten WCTC-recommended interventions were implemented. The resident completed an initial course of antibiotics shortly after admission, and no further antibiotics were ordered prior to hospital transfer, despite ongoing wound issues and later-confirmed osteomyelitis. Additional wounds were not identified or documented by facility staff prior to the resident’s transfer to the hospital. WCTC documentation showed a left 4th toe wound first described as a non-pressure chronic ulcer with 100% necrotic tissue and fragile peri-wound skin with mild erythema and maceration, later reclassified as an unstageable PI with persistent 100% necrotic tissue and progression to severe erythema and severe maceration. The facility’s EHR contained no documentation that this left 4th toe PI was present on admission or that it was identified or treated by the facility before transfer. Hospital records documented, at the time of admission, an unstageable right heel PI, a deep tissue PI to the left lateral ankle, and an unstageable sacral PI, all present on admission, yet the facility’s EHR contained no documentation that the left lateral ankle PI or sacral PI had been identified or treated. Hospital podiatry and provider notes later confirmed right calcaneal osteomyelitis with a non-salvageable right lower extremity and concern for osteomyelitis in the left calcaneus. Facility nursing and management staff acknowledged that WCTC recommendations had not been entered as orders or care-planned and that direct care staff relied on the Kardex, which did not reflect these interventions. Provider follow-up notes from the facility documented the resident’s reports of stabbing pain in both feet, heels, and sometimes up to the knees, and a decrease in effectiveness of gabapentin, with discussion of increasing the dose. These notes did not include any documented physical examination of the resident’s feet or foot wounds. A nurse’s progress note later recorded the resident’s transfer to the hospital for a non-pressure injury/pain-related care need. At the hospital, wound nurse and podiatry consults documented multiple PIs, including those not previously documented by the facility, and confirmed severe infection and osteomyelitis. Throughout this period, the facility’s failure to implement WCTC recommendations, to provide documented offloading and pressure-relief measures, to identify and document new or worsening PIs (left 4th toe, left lateral ankle, sacral area), and to conduct and document appropriate wound assessments and follow-up contributed to the identified deficiency in providing pressure ulcer care and preventing new ulcers from developing.
Failure to Prevent Accidents, Elopement, and Falls Due to Inadequate Supervision and Care Plan Implementation
Penalty
Summary
The facility failed to ensure that residents were free from accident hazards and did not provide adequate supervision to prevent accidents, resulting in multiple incidents of harm. One resident with severe cognitive impairment and a history of wandering was able to elope from the facility without staff knowledge. The front desk staff observed the resident leaving but did not intervene or follow elopement protocols, and there was a delay in calling 911 due to confusion about staff responsibilities. The resident was later found by a member of the public after experiencing a fall. Another resident at risk for elopement did not consistently have a Wander Guard device in place, as required, with documentation showing multiple missed opportunities to ensure the device was present and functioning. The facility also failed to provide the required level of assistance during care, resulting in avoidable injuries. One resident, who was totally dependent on staff for repositioning and required two staff members for bed mobility, was assisted by only one staff member, leading to a fall and a laceration near the eye that required hospital treatment. Despite care plan requirements, staff continued to provide care with only one person. Another resident with recent hip surgery and specific hip precautions experienced a dislocation and severe pain during a transfer when staff failed to follow the required precautions. The care plan and provider orders for hip precautions were not properly implemented or communicated. Additionally, the facility did not consistently assess the effectiveness of interventions or revise care plans in a timely manner following falls. One resident experienced three falls within a short period, resulting in injuries including a head laceration and hematoma, but the care plan was not updated with new interventions after the first two falls. Another resident, at high risk for falls and with a history of impulsivity, was left unattended after expressing intent to get out of bed, leading to a fall. In several cases, required safety equipment such as reacher tools and call lights were not kept within reach, and staff did not remain with residents at risk until help arrived.
Failure to Timely Investigate and Address Falls and Injuries
Penalty
Summary
The facility failed to thoroughly and timely investigate falls and injuries, and did not implement interventions to prevent repeat falls for several residents. For one resident with dementia and multiple comorbidities, there were repeated falls over several months, with delayed or incomplete investigations and unclear or delayed care plan interventions. Incident reports for some falls were completed days after the events, and some investigations were not completed at all. Another resident, also with dementia and mobility issues, experienced multiple falls, including one resulting in a head laceration and another in an occipital hematoma. The facility did not update the care plan with new interventions after one of the falls, and the incident report was completed several days late. Staff interviews confirmed that care plans were not revised and interventions were not implemented in a timely manner following these incidents. Additional deficiencies included a resident who sustained a head injury requiring sutures after falling from bed during repositioning, with the incident not recorded in the facility's logs and the investigation completed late. Another resident suffered a hip dislocation during a transfer, with no documentation of the incident in facility logs and no investigation completed. Staff interviews confirmed that these incidents were not reported or investigated as required.
Inaccurate Resident Assessments in Dental, Respiratory, and Restraint Care
Penalty
Summary
The facility failed to ensure accurate assessments for several residents in key areas, including dental conditions, respiratory care, and the use of restraints. For two residents with dental issues, staff observations and interviews revealed missing, broken, and discolored teeth, yet the Minimum Data Set (MDS) assessments did not accurately reflect these conditions. In one case, a resident with quadriplegia and malnutrition had multiple missing and stained teeth, which were noted in progress notes and the initial nursing evaluation, but the MDS incorrectly indicated no dental issues. Another resident with broken and discolored teeth was also inaccurately assessed in the MDS, which failed to document their dental problems. A resident receiving oxygen therapy for chronic obstructive pulmonary disease (COPD) was not properly coded for oxygen use in the modified quarterly MDS, despite having a provider order and being observed on oxygen during multiple visits. Staff interviews confirmed that the resident was receiving oxygen therapy and that the MDS should have indicated this, but it was marked incorrectly. Additionally, a resident was incorrectly documented as using a partial trunk restraint in the quarterly MDS, although staff later confirmed this was an error and the resident did not use such restraints. These inaccuracies in resident assessments were confirmed through interviews with staff, including the MDS nurse and the Director of Nursing Services, who acknowledged the errors and stated that the MDS should have accurately reflected the residents' conditions. The failures in assessment were identified through a combination of record review, direct observation, and staff interviews, and were not known to some staff members responsible for coordinating care, such as the social worker.
Failure to Follow Physician Orders for Oxygen Therapy
Penalty
Summary
The facility failed to provide respiratory care consistent with physician orders for oxygen therapy for two residents. For one resident with heart failure, COPD, and asthma, observations showed oxygen was administered at five and six liters per minute via nasal cannula, while the provider order specified three liters per minute continuously. Documentation in the treatment administration record indicated the order was being followed, but interviews with staff confirmed the resident was receiving a higher oxygen flow than ordered, and there was no documentation of a provider order change or notification. For another resident with encephalopathy, diabetes, and dementia, observations on multiple occasions showed oxygen was set at three liters per minute via nasal cannula, while the care plan required one liter continuously. Staff interviews confirmed the oxygen was set higher than ordered, and the expectation was that staff follow provider orders and monitor oxygen settings every shift. These failures resulted in oxygen being administered at rates inconsistent with physician orders for both residents.
Improper Storage of Medications and Expired Supplies in Medication Room
Penalty
Summary
Surveyors observed that medication and medical supplies were not stored according to accepted professional standards in the East medication room. Specifically, a large plastic bag labeled with a resident's name containing an IV solution of liquid nutrition, two vials of infuvite, and an infusion kit was found stored in the resident's food refrigerator instead of the designated medication refrigerator. Additionally, multiple expired medical supplies and equipment were found in cabinets, including universal viral transport kits, ECOLAB peroxide test strips, cleansing towelettes, and a gel/wound vac therapy system package, with expiration dates ranging from November 2022 to March 2025. During interviews, both an LPN and the Director of Nursing Services confirmed that medications should not be stored in the food refrigerator and that expired supplies should not be kept in the medication room. Both staff members acknowledged that these practices did not meet facility expectations. The findings were based on direct observation, staff interviews, and record review, and were cited as not being in compliance with regulations regarding the proper storage and labeling of drugs and biologicals.
Failure to Honor Resident Food Preferences and Grievance Resolution
Penalty
Summary
The facility failed to provide food services that met the stated preferences of five out of eight sampled residents. Multiple residents reported that their menu selections and food preferences, such as specific meal choices and requests for double portions, were not honored. For example, one resident did not receive their ordered cheeseburger and had to request it directly from the kitchen, while another reported not receiving their requested hamburger, juice, and tea for lunch. Several residents filed grievances regarding not receiving double portions or specific meal items, but continued to experience the same issues despite the grievances being marked as resolved in the facility's log. Observations and record reviews confirmed that residents did not consistently receive the foods or portions indicated on their meal cards, such as double portions, condiments, or additional beverages. Interviews with dietary staff and the registered dietician revealed a lack of communication regarding residents' grievances and food preference changes, with the dietician unaware of several residents' requests for double portions. The administrator acknowledged that food preferences should be honored and that the ongoing issues did not meet facility expectations.
Failure to Report Covid-19 Outbreak and Inadequate Infection Surveillance
Penalty
Summary
The facility failed to report a Covid-19 outbreak to the local health department as required by its own policy. After one resident was diagnosed with Covid-19 at the hospital, testing was conducted for all residents and staff on the affected hall, resulting in a second resident, who was the roommate of the first, also testing positive. Despite this, the local health department was not notified of the outbreak. Interviews with facility staff, including the Infection Preventionist and Director of Nursing Services, confirmed that the required notification did not occur. Additionally, the facility did not maintain adequate infection surveillance and tracking for two of three months reviewed. There was no infection control data available for one month, and incomplete tracking and lack of a monthly summary for another. In one case, a resident with an open abdominal wound and chronic kidney disease had multiple provider orders for urine testing to check for infection, but the tests were not completed in a timely manner. When the test was eventually performed, an infection was found and treated, but this infection was not included in the facility's infection control line list or tracked on the infection map. Staff interviews confirmed these lapses in infection tracking and timely testing.
Failure to Provide Required Abuse and Dementia Training for CNAs
Penalty
Summary
The facility failed to ensure that each staff member received required training related to resident abuse prevention, dementia management, and annual continuing competencies for certified nurse aides. Review of training records revealed that one CNA had a blank training record, and another CNA had only one in-service training completed within the past year. During an interview, the Administrator confirmed that these staff members did not have the necessary training and that this did not meet the facility's expectations for staff education and competencies prior to working with residents.
Failure to Honor Resident Bathing Preferences
Penalty
Summary
The facility failed to honor and facilitate a resident's choice regarding their bathing schedule. A resident with cerebral palsy, urinary tract infection, and muscle weakness, who was able to communicate their needs, reported that they could not set their own shower time and that showers were only scheduled twice a week at specific times, which were not consistently followed. Observations and interviews revealed that showers were assigned based on room and bed location, and although the resident was scheduled for a shower on certain days, the showers were not provided as planned. Documentation review confirmed that showers were not given on the scheduled days. Staff interviews indicated that while the expectation was to ask for and honor resident preferences, this did not occur for the resident in question. The deficiency was identified through observation, resident and staff interviews, and review of shower documentation, showing a failure to support resident self-determination and choice as required.
Failure to Complete Baseline AIM Assessment for Resident on Antipsychotic Medication
Penalty
Summary
The facility failed to conduct or document an initial or baseline abnormal involuntary movement (AIM) assessment for a resident who was prescribed an antipsychotic medication. The resident, who had diagnoses including dementia with psychotic disturbance and cognitive and communication deficits, was readmitted to the facility and received both antidepressant and antipsychotic medications on a routine basis. Despite the medication administration record indicating the need to monitor for extrapyramidal symptoms such as tardive dyskinesia, tremors, gait issues, and involuntary movements, there was no evidence in the electronic health record of a completed AIM assessment at admission or readmission. Observations showed the resident exhibiting various movements, such as moving legs and feet, and manipulating their gown, but staff were unable to locate any AIM assessment documentation. Interviews with both an LPN and the Director of Nursing confirmed that an AIM scale assessment should have been completed and documented for residents on antipsychotic medications, but this was not done for this resident. Both staff members acknowledged that this failure did not meet facility expectations.
Failure to Complete Required PASARR Assessments for Residents with Mental Health Diagnoses
Penalty
Summary
The facility failed to ensure that Pre-admission Screening and Resident Review (PASARR) assessments were accurately completed for two residents. For one resident with diagnoses including dementia, depression, and impaired memory, the record showed the resident was unable to make their needs known and was prescribed and administered multiple antidepressant medications. Despite indications for serious mental illness on the Level I PASARR, no Level II referral was completed. Staff interviews confirmed that the PASARR process was missed for this resident, and the lack of a Level II referral did not meet facility expectations. For another resident with multiple health conditions, including anxiety, depression, and PTSD, the Level I PASARR was marked as an exempted hospital discharge, allowing admission without a Level II review. However, the resident remained in the facility longer than 30 days, which should have triggered a correction of the PASARR and a Level II referral. Staff interviews confirmed that this step was not taken. The facility's policy required that all admissions have the appropriate PASARR completed and that state-specific guidelines be followed, but these procedures were not adhered to in these cases.
Failure to Individualize Care Plans for Oxygen Therapy and Oral/Dental Needs
Penalty
Summary
The facility failed to develop and implement individualized, comprehensive care plans for three residents regarding oxygen therapy and oral/dental status. For one resident with chronic obstructive pulmonary disease (COPD) and an order for supplemental oxygen, observations confirmed the resident was receiving oxygen therapy, but there was no corresponding care plan addressing this intervention. Both a Licensed Practical Nurse and the Director of Nursing Services acknowledged the absence of a care plan for oxygen use, despite the resident's ongoing therapy and provider orders. Another resident with cerebral palsy and multiple broken, discolored upper front teeth reported significant dental problems, but the care plan only included general oral care instructions and did not address the broken teeth or potential for oral pain. A third resident, dependent on artificial feeding and with a history of malnutrition and gastrointestinal hemorrhage, stated a need for lower dentures, but the care plan did not include any information or instructions regarding missing lower teeth. The Director of Nursing Services confirmed that care plans should have included details about broken or missing teeth.
Failure to Follow Provider Orders and Professional Standards of Care
Penalty
Summary
The facility failed to ensure that services provided to three residents met professional standards of quality. For one resident with diabetes, stiff joints, muscle weakness, and heart failure, there was a provider order for protective boots to be placed on both heels every shift. However, the resident was observed in a wheelchair without the boots, and both the resident and staff confirmed the boots were only worn in bed. There was no documentation of the resident's refusal to wear the boots while up, and staff did not notify the provider or clarify the order as required. Another resident with dementia, COPD, hypotension, and depression had a provider order for midodrine to be held if systolic blood pressure exceeded 120. Despite this, the medication was administered on two occasions when the resident's blood pressure was above the specified parameter. Additionally, a third resident dependent on artificial feeding via a central line had no provider order in place for the care of the central line, including monitoring for infection or dressing changes. Staff confirmed that care for the central line was not provided as expected.
Failure to Develop and Implement Individualized Activity Plan for Resident
Penalty
Summary
The facility failed to develop and implement an individualized activity plan for a resident who was admitted with diagnoses including encephalopathy, diabetes, and dementia. Observations over several days showed the resident sitting in a wheelchair near the nurse's station, and review of the electronic health record revealed that no activities assessment was completed upon admission and the care plan lacked an activities focus area. During interviews, the Recreation Director stated that no recreation assessment or activity care plan was completed because the resident was on isolation precautions at admission and was unaware of the resident's current isolation status. The Administrator confirmed that activity care plans are expected to be completed within 72 hours of admission and that residents on isolation should be offered one-on-one or in-room activities.
Failure to Document and Care Plan for Skin Injuries and Hospice Services
Penalty
Summary
The facility failed to provide necessary care and services for non-pressure skin injuries for two residents. One resident had a provider order for wound care to the left buttock, but the type of wound was not documented in the electronic health record (EHR), and the care plan did not specify the wound or include weekly assessments as required. Staff interviews confirmed the absence of documentation regarding the wound type and status, and the care plan lacked details about the wound and related pain management interventions. Another resident developed a skin tear and hematoma on the right-hand middle finger, which was observed and reported by the resident and staff. Although the injury was cleaned and bandaged, there was no provider order for treatment, and the care plan did not reflect the actual skin impairment. Staff acknowledged that treatment orders and care plan updates were missing and that this did not meet expectations. Additionally, the facility failed to develop a comprehensive, collaborative care plan involving Hospice services for a resident receiving end-of-life care. The resident's care plan did not include any information about Hospice, despite documentation in the EHR and Minimum Data Set (MDS) assessments indicating Hospice care. Staff interviews confirmed the omission of Hospice care planning and recognized that the care plan should have been updated to reflect the resident's current needs.
Failure to Assist Resident in Obtaining New Glasses
Penalty
Summary
Resident 63, who was admitted with diagnoses including diabetes, obesity, and chronic pain, reported that their glasses were four years old and that they needed new glasses. Although the resident was able to communicate their needs and had been seen by an eye doctor previously, there was no follow-up to obtain new glasses. The annual minimum data set assessment indicated the resident's vision was adequate with glasses. Staff interviews revealed that residents with vision needs were supposed to be seen yearly for eye exams, but Resident 63 was not seen during the most recent visit by the eye doctor, and staff acknowledged that this did not meet expectations.
Failure to Provide Routine Dental Care for a Resident
Penalty
Summary
The facility failed to provide routine dental care for one resident who was admitted with diagnoses including cerebral palsy, urinary tract infection, and muscle weakness, and who was able to communicate their needs. Observation revealed that the resident had multiple broken and discolored upper front teeth and reported ongoing dental issues. Review of the electronic health record showed no evidence of dental consultation, plan, or treatment for this resident. The resident stated that staff informed them they could not see the dentist in the facility due to their temporary resident status. Social services staff confirmed they were responsible for scheduling routine dental appointments and referring emergent cases out of the facility but could not provide information regarding the resident's dental appointment status.
Failure to Provide and Follow Up on Dental Services for Two Residents
Penalty
Summary
The facility failed to provide assistance and follow-up for dental care services for two residents. One resident, who had quadriplegia, malnutrition, muscle weakness, and depression, was observed to have multiple missing lower teeth and remaining teeth that were deeply stained. This resident reported not having seen a dentist since admission, despite a provider's order for a dental consult and documentation of missing or broken teeth in both the progress note and initial nursing assessment. The initial MDS did not indicate obvious cavities or broken teeth, and staff interviews revealed that the process for scheduling dental appointments was not followed, as the resident had been re-approved for Medicaid and should have been seen for dental needs. Another resident, admitted with malnutrition, gastrointestinal hemorrhage, chronic pain, and dependence on artificial feeding, reported having upper dentures but needing lower dentures. The care plan did not address the missing lower teeth, and there was no evidence in the electronic health record of a dental consultation or plan for lower teeth. Staff interviews confirmed that routine dental appointments were scheduled by social services, and emergent needs should have been referred out, but this was not done for the resident.
Failure to Provide Consistent Bathing and ADL Care
Penalty
Summary
The facility failed to provide necessary activities of daily living (ADL) care and services, specifically bathing, for two of three sampled residents. One resident, who had no cognitive impairment and was dependent on staff for bathing and transfers, reported only receiving bed baths and stated that showers were missed, particularly on weekends when the designated shower aide was not present. Documentation confirmed that this resident received only sporadic bed baths and showers over a four-week period, with gaps in care and incomplete records. Staff interviews revealed that the shower aide worked only weekdays, and floor staff were expected to provide showers on weekends, but it was unclear if this occurred. Paper documentation of bathing was inconsistent and not always entered into the electronic record. Another resident, with moderate cognitive impairment and dependent on staff for bathing, also experienced missed showers, with records showing only one shower during a two-week period after admission. Staff were unable to consistently locate documentation of bathing for this resident, and additional records were only found after further searching. The facility's policy was for residents to receive one to two showers or baths per week according to their preference, but this was not consistently provided or documented for the residents reviewed.
Failure to Report and Investigate Allegations of Neglect
Penalty
Summary
The facility failed to identify, report, and investigate allegations of neglect for two residents, which placed them at risk for ongoing neglect and unmet needs. Resident 1, who was admitted after a leg amputation and had complications requiring rehospitalization, reported that a registered nurse delayed administering prescribed pain medication, oxycodone, by two to three hours after it was requested. Despite Resident 1 being alert and oriented, and able to make their needs known, the facility did not log or report this complaint as an allegation of neglect to the State Agency. Similarly, Resident 4, who was admitted with chronic pain and polyneuropathy, reported not receiving requested Tylenol on several occasions during the night shift. This resident also was alert and oriented, and able to communicate their needs. The facility did not log or report this complaint as an allegation of neglect either. Interviews with the Director of Nursing Services and the Administrator confirmed that these grievances should have been interpreted as allegations of neglect and reported to the State Agency, as per regulatory requirements.
Failure in Timely Pain Management for Residents
Penalty
Summary
The facility failed to manage pain effectively for two residents, leading to unmanaged and increased levels of pain. Resident 1, who had a history of leg amputation, fibromyalgia, depression, and anxiety, was prescribed oxycodone every six hours as needed for pain. On the day of observation, Resident 1 requested their pain medication at 10:55 AM but did not receive it until 12:20 PM, despite multiple reminders to the responsible nurse, Staff E, RN, by the resident and other staff members. This delay in administering the medication resulted in Resident 1 experiencing increased pain levels. Similarly, Resident 4, who suffered from chronic pain and polyneuropathy, reported not receiving their prescribed Tylenol and tramadol in a timely manner during the night shift. The resident expressed that they often had to wait until other scheduled medications were due, sometimes waiting three to four hours for their pain medication. The Director of Nursing Services confirmed that pain medication should be administered according to provider orders and as soon as possible after a resident's request, indicating a failure in adhering to these standards.
Failure to Provide Restorative Care Leads to Decline in Resident Mobility
Penalty
Summary
The facility failed to provide consistent restorative care to maintain or improve the range of motion (ROM) and mobility for three residents, leading to avoidable declines in their conditions. Resident 7, who had been admitted with diagnoses including right and left foot drop, experienced a decline in ROM due to the facility's failure to implement a restorative program. Despite being referred to physical therapy and showing some improvement, the resident's care plan was not followed, and the necessary splints were not applied, resulting in further contractures and potential skin breakdown. Resident 10, diagnosed with paraplegia and other conditions affecting mobility, was not placed on a restorative nursing program despite being referred for one. The resident expressed a desire to participate in such a program, but the facility did not provide the necessary passive ROM exercises. This oversight led to a significant decline in the resident's ROM, as evidenced by the comparison of measurements taken in 2020 and 2024, showing decreased flexibility in multiple joints. Resident 85, who was admitted with an absence of the right leg above the knee and muscle weakness, did not receive follow-up on referrals for a prosthetic leg and hand surgery. The facility failed to act on these referrals, leaving the resident without necessary interventions to address their mobility and contracture issues. This lack of action was attributed to the facility's failure to review hospital documentation and communicate the need for referrals, which did not meet the expected standards of care.
Lack of Hospital Transfer Agreement
Penalty
Summary
The facility failed to maintain a written transfer agreement with at least one local hospital that is approved for participation in Medicare/Medicaid programs. This deficiency was identified during a review of facility documentation on September 9, 2024, which revealed no evidence of a transfer agreement or attempts to establish one. During an interview on the same day, the Administrator, referred to as Staff A, confirmed the absence of any documentation related to hospital transfer agreements. This lack of a formal agreement placed residents at risk for delayed transfers and timely admissions to the hospital when medically necessary.
Facility Lacks Qualified Social Worker
Penalty
Summary
The facility failed to employ a qualified social worker, which is a requirement for facilities with more than 120 beds. The facility had 145 available beds as per the daily census report. During interviews, both the Director of Social Services and the Administrator acknowledged the requirement and confirmed that the facility did not employ a qualified social worker. The Director of Social Services admitted to not holding a bachelor's degree, which is necessary for the position, and was aware of the requirement. The Administrator also confirmed the facility's non-compliance with the requirement, acknowledging that the lack of a qualified social worker did not meet expectations.
Deficiencies in Environmental Maintenance and Cleanliness
Penalty
Summary
The facility failed to maintain a safe and homelike environment in two of its halls, East B and [NAME] B, as observed between 08/23/2024 and 08/27/2024. Multiple resident rooms were found with broken or missing blind slats, compromising privacy, particularly for rooms facing public areas like parking lots. Resident 29 reported the issue weeks prior, and a family member had to improvise a privacy solution. The Maintenance Director acknowledged awareness of the issue but cited budget restrictions as a barrier to repairs. Additionally, several rooms had unsanitary conditions, with dried matter and stains on bedside tables, which residents and staff noted as not meeting expectations. Further deficiencies were noted in the cleanliness and maintenance of resident bathrooms. Resident 10's bathroom had brown stains in the tub, missing faucet handles, and a dead spider, with the Housekeeping/Laundry Manager admitting the situation was unacceptable and had been reported to maintenance months prior. Resident 60 also experienced broken blinds, and Suite 66's bathroom had a malfunctioning paper towel dispenser, with makeshift solutions that did not meet standards. Staff interviews confirmed awareness of these issues, but there was a lack of follow-up and resolution, as acknowledged by the facility's Administrator.
Inadequate Investigation of Incidents and Falls
Penalty
Summary
The facility failed to conduct thorough investigations into alleged incidents of abuse, neglect, and falls for three residents. For Resident 93, the facility did not interview staff present during a fall incident to determine the root cause, and interventions such as frequent checks and physical therapy were not documented or completed. This resident had a history of falls and was sent to the hospital after two additional falls, indicating a lack of effective intervention. Resident 83 experienced an unwitnessed fall resulting in a bruise on the forehead, but the incident was not investigated as required. The resident's care plan included monitoring for orthostatic blood pressure, but there was no documentation of this being done. The facility's incident investigation log did not include this fall, and staff were unaware of the incident until days later, showing a breakdown in communication and investigation processes. Resident 62 alleged verbal abuse by a staff member, but the investigation was incomplete, lacking a statement from the resident and comprehensive interviews with witnesses. The alleged staff member was not suspended during the investigation, and interviews with other residents and staff were delayed or insufficient. These deficiencies highlight the facility's failure to adhere to guidelines for investigating and addressing incidents of abuse and neglect.
Inaccurate MDS Assessments for Three Residents
Penalty
Summary
The facility failed to ensure the accuracy of the Minimum Data Set (MDS) assessments for three residents, leading to potential risks for unmet care needs and diminished quality of life. Resident 7, who was admitted with diagnoses including right and left foot drop, had an MDS assessment that inaccurately reflected no impairment in lower extremity range of motion, despite a physical therapy evaluation indicating chronic ankle contractures. Staff J, the MDS Nurse, believed their assessment was correct, but the Director of Nursing Services (DNS) expected accurate MDS coding. Resident 25's MDS assessment failed to document the use of antipsychotic medication, despite the resident receiving Seroquel daily for insomnia. Staff J acknowledged the incorrect coding, and the DNS reiterated the expectation for accurate MDS assessments. Resident 67's MDS assessment did not reflect dental issues or nutritional concerns, despite documentation of decayed teeth and dietary supplements for weight stability. The DNS noted that the MDS did not meet expectations for accuracy in these areas.
Inaccurate PASRR Assessments for Residents
Penalty
Summary
The facility failed to ensure that Pre-Admission Screening and Resident Review (PASRR) assessments were accurately completed for four residents, placing them at risk for unidentified mental health care needs. Resident 83's Level I PASRR was incomplete, lacking a signature, completion date, and documentation of mental health diagnoses, despite the resident having conditions such as anxiety, depression, and bipolar disorder. Staff H, the Social Work Designee, acknowledged the inaccuracies, and the Administrator expected corrections to be made promptly after readmission. For Resident 60, the Level I PASRR indicated serious mental illness (SMI) indicators for depressive and anxiety disorders, but a Level II evaluation was not initiated, contrary to new regulations. Similarly, Resident 93's PASRR showed SMI indicators for mood disorders, yet no Level II evaluation was conducted. Resident 20's PASRR, dated from 2019, was outdated and inaccurately reflected the resident's current mental health status, necessitating a Level II PASRR. Staff H confirmed the need for an updated assessment to meet current standards.
Deficiencies in Care Plan Management and Timely Care Conferences
Penalty
Summary
The facility failed to ensure that care plans were reviewed and revised to accurately reflect the care needs of residents, leading to deficiencies in care for several residents. Resident 10, who was readmitted with paraplegia and other conditions, did not have a care plan for a restorative nursing program to maintain upper body strength and range of motion. The resident expressed interest in participating in such a program, but staff were unsure if any interventions were in place. The Director of Nursing Services acknowledged that the care plan was inadequate and did not meet expectations. Resident 78, who was readmitted with heart failure and diabetes, had a rash under the right breast that was being treated with a prescribed cream. However, the care plan inaccurately documented the rash's location and lacked measurable goals. Staff acknowledged the inaccuracies and the need for revision. Additionally, Resident 25 and Resident 68 did not have timely care conferences, with Resident 68 being overdue for a care conference since May, despite the expectation of holding them every three months. Resident 62, admitted with anxiety and depression, had incidents that were investigated but lacked a care plan addressing mental health needs. The care plan did not specify triggers or interventions for anxiety, leading to inadequate guidance for CNAs. Staff interviews revealed that the care plan and Kardex were not updated to include mental health needs, and the Director of Nursing Services confirmed that the care plan did not meet expectations by failing to include known triggers for anxiety.
Deficiencies in Care Coordination and Documentation
Penalty
Summary
The facility failed to ensure necessary interventions were in place for Resident 35, who was at risk for skin breakdown due to decreased mobility. Despite a provider's order for a low air loss (LAL) mattress to prevent further skin issues, the mattress was not provided, and staff inaccurately documented its use. This oversight was confirmed during interviews with staff, who acknowledged the absence of the LAL mattress and the improper documentation in the treatment administration record. For Residents 68 and 458, the facility did not adequately coordinate hospice care services. Resident 68, who was receiving hospice care for end-of-life needs, did not have a hospice care plan integrated into the facility's care plan, resulting in unmet personal care needs such as bathing and shaving. Similarly, Resident 458 experienced pain from a pressure wound, with no documentation or physician's orders related to the wound in their electronic health record. Despite communication from hospice staff about the wound, the facility failed to implement necessary treatments. The facility also neglected to monitor and document bowel movements for Residents 93, 358, and 25, failing to implement the bowel protocol as needed. Resident 93 experienced constipation without receiving appropriate medications, and Resident 358 had no documented bowel movements for several days. Resident 25 reported issues with constipation and diarrhea, yet the facility did not follow the bowel protocol. Additionally, Resident 108 experienced a significant change in condition with low blood pressure and unresponsiveness, but the facility did not notify the provider or resident representative in a timely manner, as required by their policy.
Deficiencies in Dialysis Care Documentation and Communication
Penalty
Summary
The facility failed to maintain a safe dialysis program for two residents, Resident 308 and Resident 60, who required dialysis services. For Resident 308, there was a lack of accurate documentation and communication regarding dialysis schedules and care. The resident's care plan and provider's orders were not updated to reflect the correct dialysis days and times, leading to discrepancies in the records. Additionally, the dialysis communication forms were incomplete, with missing information from both the facility staff and the dialysis provider. Resident 60's care was similarly compromised by inaccurate and incomplete documentation. The provider orders contained incorrect information regarding the resident's dialysis access type, as they specified an AV shunt when the resident had a perma cath. The care plan also had an incorrect pick-up time for dialysis, which did not match the provider's orders. Furthermore, the dialysis communication forms were often incomplete, and there was a lack of documentation for the administration of prescribed medications during dialysis sessions. Interviews with facility staff, including the Resident Care Manager and the Director of Nursing Services, revealed that the documentation and communication processes did not meet expectations. Staff acknowledged the discrepancies and incomplete records, indicating a failure to ensure accurate and consistent communication between the facility and the dialysis provider, which is essential for the safe and effective management of dialysis care for residents.
Failure to Provide Non-Pharmacological Interventions and Medication Management
Penalty
Summary
The facility failed to offer non-pharmacological interventions (NPI) before administering pain medications to four out of five sampled residents, which is a requirement to ensure that drug regimens are free from unnecessary medications. Resident 458, who was admitted with peripheral vascular disease and receiving hospice services, had an order for oxycodone every three hours as needed for pain. Despite the order for nurses to document NPI starting from a specific date, there were no documented attempts of NPI for Resident 458 during the review period. Staff interviews revealed that the expectation was to try two NPI before administering narcotics, but this was not consistently followed. Resident 83, who had a history of heart and lung disease, anxiety, depression, and bipolar disorder, was also not provided with NPI before receiving pain medications. The resident's care plan included interventions such as repositioning and the use of heat, but the medication administration record lacked documentation of these interventions throughout the month. Similarly, Resident 308, admitted with pneumonia and chronic pain, received PRN pain medications without any documented NPI, despite having an order for such interventions. Staff interviews confirmed that the orders for NPI were not properly linked to the PRN pain medication orders, leading to a lack of compliance with the facility's expectations. Resident 20, who had chronic kidney disease and chronic pain, also did not receive documented NPI before the administration of pain medications. Additionally, the facility failed to follow parameters for blood pressure medications, as Resident 20 received lisinopril despite having a heart rate below the specified threshold. Furthermore, orders for topical medications like lidocaine patches and diclofenac gel did not specify the application location, which was acknowledged as a requirement by the staff. These deficiencies placed residents at risk for adverse side effects and diminished quality of life.
Deficiencies in Psychotropic Medication Management
Penalty
Summary
The facility failed to ensure proper monitoring and justification for the use of psychotropic medications for two residents. Resident 460 was administered quetiapine, an antipsychotic medication, for dementia with agitation without a defined psychotic disorder. The pharmacist recommended a gradual dose reduction and cessation of the medication due to recent treatment for a urinary tract infection, but the provider did not act on this recommendation. Additionally, the facility did not monitor orthostatic blood pressures as ordered, which was necessary to assess potential side effects of the medication. Resident 25 was prescribed Seroquel for insomnia without proper documentation or evaluation of the cause of insomnia. The pharmacy consultation recommended a dose reduction and discontinuation, but the medication was continued without monitoring the resident's hours of sleep. Staff interviews confirmed that the necessary monitoring for effectiveness and gradual dose reduction was not conducted, leading to deficiencies in medication management for these residents.
Failure to Follow Menu Leads to Nutritional Deficiency
Penalty
Summary
The facility failed to adhere to the posted menu during a lunch service, as observed during a tray line inspection. Specifically, the menu indicated that one cup of macaroni with ham should be served, but staff used a grey-handled scoop, which was only half a cup, resulting in residents receiving a half portion of the main course. This discrepancy was confirmed by the Dietary Manager, who acknowledged that the server should have provided two scoops to meet the menu requirements. Resident feedback further highlighted issues with the menu not being followed and sudden changes to the menu, as noted in the resident council minutes. One resident expressed concern about not receiving half of the items listed on the menu. The facility's Dietary Manager and Administrator both emphasized the importance of following the dietician-developed menus to ensure adequate nutritional intake for residents, acknowledging that the failure to do so did not meet the facility's expectations.
Deficiency in Food Quality and Temperature
Penalty
Summary
The facility failed to provide palatable food served at appetizing temperatures for several residents, as observed during a survey. Multiple residents reported that the food was often cold, bland, and unappetizing. Resident 68 mentioned that the food was usually cold, while Resident 7 stated that the food was bland and often arrived cold, leading them to rely on their daughter for meals. Resident 93 reported receiving lunch as late as 3:00 PM, and Resident 20 expressed dissatisfaction with the smell, taste, and texture of the food, opting to eat only sandwiches. Resident 10 described the food as bland and processed, and Resident 62 criticized the food quality, noting that issues raised in food council meetings had not been addressed for two years. Observations during meal service revealed several issues with food preparation and serving. On one occasion, the lunch meal consisted of macaroni with ham, spinach, and a roll, with alternate options of chicken breast or pork chop. The rolls were flat and unappealing, the spinach was flaccid and soggy, and the macaroni was congealed. The tray line ran out of spinach, and staff resorted to microwaving a bag of spinach, which also turned out soggy. The meal service was prolonged, with the last resident tray being served over an hour and a half after service began. A test tray showed that the food was lukewarm and unappetizing, with macaroni at 115°F, chicken breast at 115°F, and spinach at 110°F. The resident council minutes from June, July, and August 2024 indicated ongoing grievances about food quality, including overcooked food and watered-down juice. Despite monthly food council meetings and resident interviews, the facility did not resolve these concerns. Staff R, the Dietary Manager, acknowledged that improper storage and handling of food trays could affect food temperatures. Staff A, the Administrator, admitted that residents should not receive food two hours after preparation and that the resident council's concerns should have been addressed.
Food Safety and Storage Deficiencies
Penalty
Summary
The facility failed to ensure the safe preparation and storage of food, as observed during a kitchen inspection. Two cans of food, specifically butterscotch pudding and cut sweet potato, were found with dents, which could potentially lead to contamination. Additionally, during a meal service, staff ran out of spinach and resorted to microwaving a bag of spinach in water, which was not a standard practice. Furthermore, a dietary aide was observed performing hand hygiene incorrectly by turning off the faucet with bare hands after washing, which does not meet the expected hygiene standards. The facility also failed to properly monitor the temperatures of resident food refrigerators. The East Hall refrigerator consistently recorded temperatures above 40°F for 28 consecutive days, and the [NAME] Hall refrigerator exceeded 40°F on 5 days and had a freezer temperature above 0°F on 11 days. The temperature logs used were not appropriate for food storage, as food should be kept between 33°F and 40°F. Staff interviews revealed that the monitoring process did not meet expectations, and the facility's adherence to the Food Code was questioned.
Ineffective QAPI Program Leads to Repeated Deficiencies
Penalty
Summary
The facility failed to ensure that its Quality Assessment and Performance Improvement (QAPI) program effectively self-identified deficiencies and developed or implemented effective plans of action to sustain corrections for previously identified deficiencies. This failure resulted in repeated deficiencies, a pattern of deficiencies, widespread deficiencies, and a pattern of actual harm that placed residents at risk for unmet needs. During an interview, the facility's administrator acknowledged that the QAPI process was not currently effective and needed to be reevaluated for its effectiveness. The report lists several deficiencies that were either not identified, not addressed, or had ineffective plans of correction, leading to repeated issues. These deficiencies included maintaining a safe, clean, and comfortable environment, investigating and preventing alleged violations, ensuring the accuracy of assessments, and maintaining nutrition and hydration status, among others. The deficiencies were noted to have occurred repeatedly over several years, indicating a systemic issue with the facility's QAPI program in sustaining corrections and preventing recurrence.
Failure to Implement Transmission-Based Precautions and Sanitize Laundry Equipment
Penalty
Summary
The facility failed to implement transmission-based precautions for five residents, which increased their risk of infection. Resident 6, who had an indwelling catheter and an open area, did not have a sign for Enhanced Barrier Precautions (EBP) or an isolation cart with personal protective equipment (PPE) outside their door. Similarly, Resident 458, with multiple wounds, and Resident 358, with pressure injury wounds, also lacked proper signage and PPE availability. Resident 466, diagnosed with a urinary tract infection and requiring contact precautions, had a sign posted, but staff failed to adhere to the PPE requirements. Staff Y entered the room without wearing a gown and gloves, claiming ignorance of the contact precautions. Resident 93, also on contact precautions for a UTI with ESBL, had a sign posted, but Staff X entered the room without PPE, misunderstanding the requirements for contact precautions. Additionally, the facility did not ensure proper cleaning and disinfecting of washing machines used for soiled isolation gowns. Observations showed that the laundry aide, Staff W, did not sanitize the front of the machines or the rubber gaskets between loads, despite visible soil. Staff V, the LPN and infection preventionist, acknowledged the issue and stated that education had been provided to the laundry staff. The Director of Nursing Services, Staff B, confirmed the expectation for proper implementation of isolation precautions and machine sanitization according to guidelines.
Failure to Obtain Informed Consent for Psychotropic Medication
Penalty
Summary
The facility failed to obtain informed consent for the administration of an antianxiety medication for one of the residents reviewed for unnecessary medication use. The resident, who was diagnosed with anxiety disorder and depression, was readmitted to the facility and was able to communicate their needs. Despite this, the resident was administered hydroxyzine, a psychotropic medication, for three days before an informed consent was signed. This oversight placed the resident at risk of not being fully informed about their treatment options and the potential risks and benefits of the medication. The facility's policy on psychotropic medication use, dated July 2022, mandates that residents, families, or their representatives be involved in the medication management process, which includes obtaining informed consent prior to medication administration. The policy also emphasizes the right of residents or their representatives to decline treatment after being informed of the risks and alternatives. Interviews with facility staff confirmed that the informed consent process was not followed as expected, with the Director of Nursing Services acknowledging that the consent should have been obtained before the medication was administered.
Privacy Violations During Medication Administration and Personal Calls
Penalty
Summary
The facility failed to ensure resident privacy during the administration of topical medications for two residents and did not provide a private location for personal phone calls and conversations for another resident. Resident 25, who was admitted with diagnoses including urine retention, depression, and heart failure, expressed concerns about the lack of privacy in their room due to a roommate's frequent yelling. Despite raising these concerns, staff reportedly laughed about the situation, and the roommate's yelling was observed during an interview. Resident 465, admitted with chronic respiratory failure, malnutrition, and anemia, was observed receiving topical medication with the door and privacy curtain open while the roommate had a visitor. The LPN applied patches to the resident's shoulder and back, exposing the resident's body without ensuring privacy. Similarly, Resident 62, with diagnoses of depression, anxiety, and adult failure to thrive, was observed applying a pain patch with the blinds open and lights on, exposing their body without any attempt to provide privacy. The DNS acknowledged that this was not acceptable practice.
Failure to Address Resident Grievances
Penalty
Summary
The facility failed to properly initiate and process grievances for two residents, leading to unmet needs and unresolved issues. Resident 7, who required extensive assistance with activities of daily living, reported sleep disturbances due to a noisy roommate. Despite multiple complaints to staff, including a CNA and an LPN, no formal grievance was initiated, and the issue was not addressed until social services were informed days later. The facility's policy required grievances to be investigated and resolved within 72 hours, but this was not adhered to in Resident 7's case. Resident 67, who was cognitively intact, reported a missing pair of black pants and filed a grievance that remained unresolved for several months. The grievance log confirmed the unresolved status, and interviews with staff, including the Social Services Director and Laundry Services, revealed a lack of follow-up and communication. The Administrator acknowledged that the grievance, filed months earlier, was not resolved until the day of the interview, which did not meet the facility's expectations.
Failure to Provide Transfer Notification
Penalty
Summary
The facility failed to provide written notification of the reason for transfer to the hospital to Resident 358 or their responsible party. This deficiency was identified during a review of the electronic health record (EHR) and interviews with facility staff. Resident 358, who was admitted to the facility with diagnoses including multiple sclerosis, heart failure, and diabetes, experienced a hospitalization and subsequent readmission. However, there was no documentation of a transfer notice in the EHR. Interviews with the Resident Care Manager/Licensed Practical Nurse and the Director of Nursing Services confirmed the absence of the required transfer notification documentation.
Failure to Provide Bed Hold Notice for Hospitalized Resident
Penalty
Summary
The facility failed to provide a written bed hold notice at the time of transfer to the hospital for one of the two sampled residents reviewed for hospitalization. This deficiency involved Resident 358, who was admitted to the facility with diagnoses including multiple sclerosis, heart failure, and diabetes, and was capable of making their needs known. The electronic health record (EHR) indicated that Resident 358 was hospitalized and subsequently readmitted to the facility, but there was no documentation of a bed hold notice. During interviews, both the Resident Care Manager/Licensed Practical Nurse and the Director of Nursing Services confirmed the absence of the required bed hold documentation, which was expected to be documented and scanned into the EHR.
Failure to Develop Baseline Care Plans for New Admissions
Penalty
Summary
The facility failed to develop a baseline care plan within 48 hours of admission for two residents, Resident 460 and Resident 68, which is a requirement to ensure that immediate needs are met. Resident 460 was admitted with multiple diagnoses, including heart disease, diabetes, Alzheimer's, and dementia, and had moderately impaired cognitive skills. Despite having provider orders for dementia treatment, including monitoring agitation and administering Seroquel, the facility did not create a focus area for dementia in the care plan. Interviews with staff revealed that the baseline care plan was a group effort, but there was a delay in generating it for Resident 460. Resident 68 was admitted with diagnoses of dementia and adult failure to thrive and was receiving hospice care for end-of-life services. However, no care plan for hospice services was found in the medical record. The Director of Nursing Services acknowledged that it was expected for the facility to collaborate and initiate a care plan for hospice services upon admission, which did not occur for Resident 68. This oversight placed the residents at risk for unmet needs and a diminished quality of life.
Unprofessional Documentation in Resident Records
Penalty
Summary
The facility failed to maintain professional standards of quality in documentation for one of the residents, identified as Resident 67. The resident was admitted with several diagnoses, including reduced mobility, chronic obstructive pulmonary disease, cognitive communication deficit, chronic pain, and anxiety, and was able to communicate needs. A review of the electronic health record revealed that a registered nurse, Staff F, documented subjective and unprofessional comments about Resident 67, describing them as 'annoying' and 'difficult' in progress notes. Interviews with Staff F, the Resident Care Manager, and the Director of Nursing Services confirmed that such subjective documentation was not professional and should not have been included in the resident's records.
Deficiencies in Pressure Ulcer Care for Two Residents
Penalty
Summary
The facility failed to provide necessary treatment and services for pressure ulcers for two residents, leading to deficiencies in care. Resident 458, who was at high risk for pressure injuries due to congestive heart failure, had a pressure ulcer on the tailbone documented in the care plan but lacked documentation and treatment orders for a painful wound on the ischium. Despite the hospice nurse identifying and communicating the new wound to facility staff, no incident investigation or treatment orders were initiated, as confirmed by the Director of Nursing Services. Resident 358, diagnosed with multiple sclerosis, heart failure, and diabetes, experienced multiple pressure injuries, including sores on the sacrum, left heel, right buttock, and a new open area on the left buttock. The care plan did not reflect the actual skin condition, and observations showed the resident was not repositioned as required, with heels touching the mattress due to improper placement of a wedge cushion. The Certified Nursing Assistant confirmed the incorrect positioning, and the Director of Nursing Services acknowledged the failure to follow the care plan and skin prevention plan.
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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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