Park Rose Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Tacoma, Washington.
- Location
- 3919 South 19th Street, Tacoma, Washington 98405
- CMS Provider Number
- 505239
- Inspections on file
- 38
- Latest survey
- July 2, 2025
- Citations (last 12 mo.)
- 76
Citation history
Health deficiencies cited at Park Rose Care Center during CMS and state inspections, most recent first.
The facility did not ensure its QAPI program effectively identified and addressed deficiencies, resulting in repeated citations for issues such as ROM/mobility, nutrition/hydration, pain management, and nursing staff levels. The Administrator was unaware of several ongoing problems, and action plans were not implemented in a timely manner, leading to a pattern of uncorrected deficiencies.
Several residents with significant mobility limitations did not receive restorative nursing services or splint/brace assistance as recommended by therapy, following the discontinuation of therapy services. In each case, referrals to restorative programs were missed, care plans were not updated, and residents did not receive interventions necessary to maintain or improve range of motion, resulting in observed declines and unmet needs.
A resident with multiple health conditions experienced two unwitnessed falls, including one resulting in a fracture and surgery, without timely updates to their care plan or documentation of the first incident. Elopement precautions were lacking in one hall, as a resident was able to exit through an unalarmed door and unlocked gates, and a medication cart was left unsecured in a hallway accessible to residents and visitors.
Three residents with complex medical conditions experienced deficiencies in nutrition and fluid management due to inaccurate meal intake documentation, unclear communication of fluid restrictions between nursing and dietary staff, and lack of monitoring for residents on fluid restrictions. Staff interviews confirmed that intake records were not accurately maintained and that fluid restriction protocols were not consistently followed.
Several residents with complex medical needs received as-needed pain medications without consistent documentation of pain assessments or the use of non-pharmacological interventions (NPI) prior to medication administration. Staff interviews confirmed that NPIs were not always offered or recorded as required, and pain locations were often missing from the records, resulting in incomplete pain management documentation.
The facility did not maintain adequate nursing staff or functioning call light systems, resulting in prolonged call light response times across multiple hallways. Multiple residents reported waiting up to an hour or more for assistance, especially during night shifts, and grievance logs and Resident Council minutes documented ongoing concerns about delayed responses and unmet urgent needs.
Surveyors found that food in the kitchen was improperly cooled and stored without required logs, outside food was kept in the facility refrigerator, and dented cans were present in dry storage. In a resident refrigerator, temperatures were above recommended levels for several days without corrective action, expired food items were present, and shelving was unclean. Facility staff confirmed these practices did not meet expectations.
A resident with metabolic encephalopathy, anxiety, and depression received Buspirone and Duloxetine without documented informed consent. Review of the EHR and MAR confirmed the absence of required consents, and both the RCM/LPN and DON acknowledged the deficiency during interviews.
A resident with a history of stroke and mobility impairment experienced a fall while attempting to transfer from a wheelchair to bed. The facility did not complete the required investigation, documentation of interventions, and summary within the mandated five-day period, instead finalizing these seven days after the incident. Staff acknowledged the delay and confirmed it did not meet policy expectations.
A resident with chronic pain, diabetes, and dementia was transferred to the hospital on two occasions without being provided the required written bed hold notice. Documentation in the EHR did not show that a bed hold was offered, and staff interviews confirmed that the notification was not provided or documented as required.
A resident with paraplegia, COPD, and chronic pain was observed with a bent inward left hand and reported not receiving restorative services or help with a hand splint. Despite these issues, the resident's MDS assessment was coded as having no upper extremity impairment. Staff confirmed the MDS was coded incorrectly and acknowledged the expectation for accurate assessments.
A resident with a history of stroke-related hemiplegia and hemiparesis experienced a fall while transferring from a wheelchair to bed. Although the incident was documented, the care plan was not updated with new interventions in a timely manner. Staff interviews confirmed that the care plan should have been revised soon after the fall to address the resident's needs.
Nursing staff did not follow provider orders for medication administration and monitoring for three residents. One resident's sleep monitoring was inaccurately documented, with staff recording data before the end of shift. Another resident received blood pressure medication despite not meeting the required parameters, and a third resident had overlapping orders for lidocaine cream that were not properly managed. Staff and management confirmed these failures to adhere to provider instructions.
A resident with hemiplegia and hemiparesis following a stroke did not receive a prescribed brace/splint and offloading boot as ordered and care planned. Multiple observations and interviews confirmed the devices were not in use, and staff were unaware of the requirements until prompted. Documentation inaccurately reflected that the devices were applied, and the care plan interventions were not implemented.
A resident with multiple comorbidities developed a pressure ulcer on the heel after repeatedly having their feet pressed against a bed footboard that was too short for their height. Staff did not recognize or address the risk posed by the bed setup, and interventions to prevent further injury were delayed until after the issue was identified through observation and interviews.
Two residents received oxygen therapy without proper provider orders or at rates inconsistent with provider orders. One resident was administered oxygen without any provider order, while another received oxygen at a higher rate than ordered, with documentation showing fluctuating oxygen levels. Staff and nursing leadership confirmed these discrepancies and acknowledged the lack of compliance with required protocols.
Lispro insulin was found with an open date and Lantus insulin was found without an open date in a medication cart. An LPN confirmed insulins are to be stored for 28 days after opening, and the DON acknowledged the storage did not meet expectations. This reflects a failure to ensure proper labeling and storage of insulin.
The facility did not consistently post daily nurse staffing information that included actual hours worked, instead displaying only scheduled hours. Staff responsible for staffing coordination and administration were unaware of the requirement to post both scheduled and actual hours.
A facility failed to provide adequate pharmaceutical services by incorrectly transcribing medication orders with stop dates for a resident with multiple diagnoses, leading to potential inadequate treatment. Additionally, the facility failed to reconcile controlled medications correctly for another resident, resulting in unaccounted Lorazepam tablets. These deficiencies placed residents at risk for inadequate treatment and potential medication diversion.
The facility failed to perform scheduled central line dressing changes for two residents, leading to a deficiency in care. One resident's dressing was not changed as required, and another's dressing was found to be outdated. Staff interviews revealed inconsistencies in following protocols for dressing changes.
The facility failed to ensure staff adhered to CDC guidelines for PPE use and hand hygiene when caring for COVID-19 positive residents. Staff members did not properly discard N95 respirators or perform hand hygiene, compromising infection control. The Infection Preventionist confirmed non-compliance with CDC protocols.
A resident with severe cognitive impairment was seen by medical providers without notifying their POA, despite the POA's request to be present. The facility did not document attempts to contact the POA before or after visits, nor include them in discussions about medication changes or treatment decisions, placing the resident at risk of uninformed healthcare decisions.
Two residents did not consistently receive their prescribed restorative care programs, which included splint applications and ROM exercises. One resident with stroke and dementia had sporadic application of hand and ankle splints and inconsistent ROM exercises. Another resident with complex medical diagnoses received their hand/wrist splint and strengthening program irregularly. The oversight RN confirmed the inconsistency in the restorative programs.
A facility failed to act on a pharmacist's recommendations for a resident with heart disease, stroke, and dementia. The pharmacist suggested a fasting lipid panel and a change in famotidine dosage, both accepted by the medical provider pending consent from the resident's POA and granddaughter. However, there was no documentation of consent being sought or actions taken, and the medication was administered incorrectly.
A resident with severe cognitive impairment and on a pain medication regimen did not receive their Fentanyl patch according to physician orders. The patch was not administered every 72 hours as required, and the presence of two nurses during application was not consistently documented. The Director of Nursing confirmed this as a medication error.
The facility failed to manage enteral nutrition properly for four residents, leading to repeated hospital visits for one resident due to a clogged J-tube. Staff did not follow provider's orders for checking tube placement or administering PRN medications. Observations showed inadequate flushing of tubes and failure to meet nutritional goals for another resident. The DON expected staff to check tube placement and implement interventions as ordered.
The facility failed to investigate allegations of abuse and neglect for three residents. A resident with a tracheostomy was not interviewed after reports of neglect and aggressive staff behavior. Another resident reported an argument with a roommate, but the facility did not conduct interviews to find the cause. A third resident alleged physical abuse, but the investigation lacked staff and resident interviews, leaving the perpetrator unidentified.
The facility failed to provide consistent catheter care for three residents, leading to improper management and lack of documentation. One resident had discrepancies in catheter type and improper drainage, another had unsecured catheter tubing and improper urine sample documentation, and the third had no current orders or documentation for catheter care.
A resident with multiple missing teeth and dental issues did not receive necessary follow-up care after dental consultations recommended x-rays, extractions, and denture evaluation. Despite being assessed by an outside dental provider, the facility failed to implement a care plan or provide the required dental services, as confirmed by interviews with the Resident Care Manager and DON.
The facility failed to implement proper infection control measures for several residents, including those on contact and enhanced barrier precautions. Staff did not adhere to protocols such as wearing isolation gowns, performing hand hygiene, and changing gloves between tasks, leading to increased risk of infection. These deficiencies were observed during care for residents with multi-drug resistant organisms, wounds, and urinary catheters.
The facility failed to maintain mechanical lifts safely across three halls, as observed during a survey. The lifts lacked safety clips on sling hooks, contrary to the facility's Mechanical Lift Checklist. Both the Maintenance Director and Administrator confirmed that the absence of safety clips did not meet the facility's expectations and posed a potential safety risk.
A facility failed to provide written notification of the reason for hospital transfer to a resident or their responsible party. The resident, with chronic respiratory failure and asthma, was hospitalized and readmitted without documented transfer notice. The DON stated that residents should receive written documentation and a completed transfer form.
Three residents were inaccurately assessed in their MDS, leading to discrepancies in diagnoses and care needs. One resident was wrongly coded with dementia, another was documented as not receiving oxygen despite evidence to the contrary, and a third had incorrect wound assessments. Staff acknowledged these errors, citing communication issues and new personnel as contributing factors.
Two residents did not receive scheduled showers and personal hygiene care as per their care plans. One resident, dependent on staff for all ADLs, received only three showers and one bed bath over 30 days due to the absence of the assigned shower aide. Another resident, needing assistance with personal care, reported going eight days without a shower and wore the same clothing for multiple days. The facility's records confirmed only one documented shower in the past 30 days, despite a twice-weekly schedule.
The facility failed to provide adequate care for bowel, diabetic, and edema management for three residents. One resident with diarrhea did not receive prescribed medication, while another with diabetes did not have their blood glucose monitored or receive necessary medication due to unavailability. Additionally, a resident with edema had no interventions offered, and the condition was not monitored or documented. These deficiencies were confirmed through staff interviews and record reviews.
A resident with multiple pressure ulcers did not receive adequate care, as documented follow-up assessments were missing, and wound care procedures were not properly followed. An LPN failed to apply wound cleanser to a new ear ulcer and did not offload the ear, while the sacral wound dressing was insufficient, leading to uncovered skin redness. Nursing leadership acknowledged the care did not meet expectations.
A resident with a tracheostomy and ventilator dependency experienced inadequate care when CNAs turned the resident without waiting for the RT, causing fluid to enter the tracheostomy. Observations showed ongoing issues with fluid management, and staff interviews revealed a failure to notify the RT for necessary care.
The facility failed to implement gradual dose reductions and monitor adverse side effects for psychotropic medications for two residents, leading to unnecessary medication use and potential risks. One resident did not receive a recommended dose reduction of Seroquel due to miscommunication, while another resident, who experienced a fall, was not monitored with an AIMS test or orthostatic blood pressure checks after being prescribed quetiapine.
A medication error occurred when a nurse administered baclofen and tizanidine to a resident at 9:12 AM instead of the prescribed 8:00 AM. The Director of Nursing acknowledged that this did not meet the facility's expectations for medication administration timing.
The facility failed to properly store and label medications, risking expired and ineffective treatments. Observations showed open vials of Tubersol without dates, expired Timolol eye drops, and insulin pens past their usage period. Missing nurse signatures on narcotic records were also noted. Staff confirmed that medications should be dated and narcotics double signed, which was not done.
A resident who consented to receive a pneumococcal vaccine did not receive it due to the facility's lack of a process for screening and administering vaccines. The resident, admitted with diabetes and surgical amputation, had no documentation of receiving the vaccine despite consenting. The infection preventionist/LPN and DON acknowledged the oversight and the absence of a proper vaccination process.
The facility did not post the actual nursing staffing hours daily, failing to account for staff absences and not reconciling actual hours worked. The Staffing Coordinator was unaware of this requirement, while the Administrator expected compliance. This resulted in a deficiency in transparency regarding nursing staff availability.
A facility failed to document and update a resident's CPR directives, leading to a risk of not honoring the resident's wishes. The resident's EHR showed a DNR status, but after a request to change to CPR, the POLST form was not updated in the EHR, and the form was lost. The DNS noted that the admitting nurse should have updated the EHR with the new code status.
A resident with severe cognitive impairment and dependency on staff was found with bilateral shoulder subluxation, but the LTC facility failed to investigate the injury for potential abuse or neglect. The incident was not logged, and the care plan was not updated. Staff were unaware of the injury until informed by external sources, indicating a breach in communication and protocol adherence.
A facility failed to provide written notification of transfer/discharge reasons and appeal information for a resident with malignant neoplasm of the brain, who was dependent on staff for care. The resident was discharged to the hospital with an anticipated return, but the facility denied readmission citing the resident's code status and complex medical needs. The facility did not document notifying the hospital or family about the decision, nor was there a bed hold notice.
A facility failed to implement post-op diet orders and coordinate specialty appointments for a resident with a laryngectomy. The resident did not receive the prescribed liquid diet for nearly a month due to miscommunication, and missed several critical medical appointments due to staffing and coordination issues.
The facility failed to provide a written decision for a grievance when requested by a resident's representative. The grievances included issues related to staff neglecting to wear PPE, delays in informing about quarantine protocols, inaccurate information in the resident's medical record, and missing medication patches. Despite the representative's request, the facility did not comply with providing a written decision.
The facility failed to follow physician orders for a resident with chronic pain by not properly applying and removing a Lidoderm Patch as scheduled. An observation revealed the patch was not changed as required, and the Medication Administration Record inaccurately documented the patch's removal and reapplication. The DON confirmed the expected procedure was not followed.
The facility failed to follow infection control standards, including the use of PPE and hand hygiene practices. Staff did not adhere to protocols for Enhanced Barrier Precautions (EBP) and failed to clean equipment between resident uses, placing residents at risk for healthcare-associated infections.
Failure to Sustain Effective QAPI Program and Address Repeated Deficiencies
Penalty
Summary
The facility failed to ensure 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 cited deficiencies. Despite having a policy stating that QAPI would oversee the identification and correction of quality issues, the facility did not consistently recognize or address ongoing problems. During interviews, the Administrator was unaware of several issues found during the survey, including deficiencies in the restorative nursing program, nutrition management related to fluid restrictions and inaccurate documentation, and pain management practices involving non-pharmacological interventions. The Administrator acknowledged awareness of staffing issues related to long call light wait times but only initiated a Performance Improvement Plan after several months of related grievances, indicating a delay in addressing known concerns. Repeated citations were noted for areas such as range of motion/mobility, nutrition/hydration status, and sufficient nursing staff, with deficiencies recurring over multiple years. Review of QAPI documentation showed that while meetings were held, the facility did not self-identify deficiencies, recognize failures to sustain previous corrections, or make timely revisions to action plans. This lack of effective QAPI oversight led to a pattern of deficiencies that were not adequately addressed or corrected, as evidenced by repeated citations in the same areas.
Failure to Provide Restorative Services and Splint/Brace Assistance
Penalty
Summary
The facility failed to ensure that residents consistently received restorative services and/or splint brace assistance to maintain or prevent declines in mobility and range of motion (ROM) for multiple residents. For one resident with a history of stroke and left-sided weakness, therapy services were discontinued without a referral to a restorative nursing program, despite recommendations for home ROM exercises. Staff interviews confirmed that the referral process was missed, and the resident was not followed up for restorative care after therapy ended, leaving them dependent on staff for mobility and dressing. Another resident with paraplegia and chronic pain was observed with a contracted left hand and reported no longer receiving restorative services or assistance with their hand splint. Care plan reviews showed that restorative services had been discontinued, despite prior therapy discharge recommendations for a restorative program and splint use. Staff interviews revealed that the resident was not referred to restorative nursing as recommended, and the resident experienced a decline in functional mobility, with staff unable to locate the necessary splint. A third resident with muscle wasting and a tracheostomy was observed with upper extremity contractures and reported that the restorative program was not being provided, despite wanting to participate. Therapy discharge summaries recommended a restorative ROM program with splint/brace, but there was no order or care plan for such a program. Staff confirmed that the referral for restorative services was missing, and the resident's needs were not met according to expectations.
Failure to Prevent Accident Hazards and Ensure Resident Safety
Penalty
Summary
The facility failed to implement new interventions to reduce fall incidents for a resident with chronic pain, diabetes, and dementia. After an unwitnessed fall resulting in a left femur fracture and subsequent surgery, there was no documentation of the incident in the March incident log, and the resident's care plan was not updated with new interventions following the fall. The care plan was only revised after a second unwitnessed fall in April, when an intervention to encourage the resident to use the call light for assistance was added. Additionally, the facility did not ensure elopement precautions were in place for one hall. A resident exited the facility through a gym door to a patio area, which had an unlocked gate leading to the parking lot and another to a city street. The door alarm was not functioning, and staff confirmed that the gates were not locked, allowing residents to leave the property. Furthermore, a medication cart was observed unsecured in a hallway with residents nearby, making medications accessible to residents and visitors. Staff acknowledged that the cart should have been secured.
Failure to Accurately Monitor Nutrition and Fluid Restrictions
Penalty
Summary
The facility failed to accurately monitor and manage the nutritional status and fluid intake of three residents, resulting in deficiencies related to nutrition and hydration. For one resident with COPD, diabetes, and dementia, multiple observations showed the resident was unable to self-feed effectively, consuming minimal portions of meals, yet meal intake records inaccurately reflected higher consumption. Staff interviews confirmed that meal intake documentation included fluids and did not accurately represent food intake, which did not meet facility expectations. Another resident with COPD, diabetes, and atrial fibrillation was on a fluid restriction, but there was a lack of clear communication between nursing and dietary staff regarding the specific amount of fluids to be provided by dietary. The dietary manager was unaware of the exact fluid allocation and only provided a small amount of juice, while the medication administration record did not account for fluids provided by dietary. Staff acknowledged that the fluid restriction was not properly communicated or documented. A third resident with end stage renal disease, diabetes, and atrial fibrillation was also on a fluid restriction, but was observed with unrestricted fluids at bedside and managed their own intake, contrary to provider orders. The dietary manager was unaware of the fluid restriction, and staff confirmed that the resident's fluid intake was not monitored if they had access to fluids independently. The care plan specified fluid limits, but the resident did not comply, and monitoring was not enforced.
Failure to Consistently Document Pain Assessments and Non-Pharmacological Interventions
Penalty
Summary
The facility failed to consistently monitor and document pain management interventions, including the use of non-pharmacological interventions (NPI), for four residents with significant medical conditions such as respiratory failure, stroke, quadriplegia, metabolic encephalopathy, anxiety, and depression. For these residents, the medication administration records (MAR) showed missing or incomplete documentation of pain assessments, pain locations, and the use of NPIs prior to administering as-needed pain medications such as acetaminophen, oxycodone, and tramadol. In several instances, pain was recorded using numerical scales, but the corresponding pain site or NPI attempts were not documented as required by facility policy and provider orders. Staff interviews confirmed that the expected practice was to offer and document NPIs before administering as-needed pain medications, but this was not consistently done. Specific examples included multiple occasions where residents received pain medications without any record of NPIs being offered or documented, and staff acknowledged these omissions during interviews. The lack of proper documentation and inconsistent monitoring of pain and NPIs did not meet the facility's expectations and requirements for safe and appropriate pain management.
Failure to Provide Sufficient Staff for Timely Call Light Response
Penalty
Summary
The facility failed to provide sufficient nursing staff to ensure timely responses to resident call lights across three hallways (100, 300, and 400). Observations revealed that call lights were illuminated in multiple rooms without any audible alert at the nurses' station, and staff interviews confirmed that the 400 hall call lights were not audible. Multiple residents reported excessive wait times for call light responses, with some stating they waited up to an hour or more, particularly during night shifts. Resident Council meeting minutes over several months consistently documented ongoing concerns about delayed call light responses, including instances where staff turned off call lights without returning and prolonged waits when residents were in the bathroom or required urgent assistance, such as for oxygen needs. The facility's grievance logs from January through May 2025 showed a recurring pattern of complaints related to call light wait times, with the number of grievances increasing over time. Staff interviews acknowledged awareness of the staffing issues and the impact on call light response times. The combination of insufficient staffing, non-functioning audible call light systems, and repeated resident and family complaints contributed to the deficiency, placing residents at risk for accidents, injuries, and diminished quality of life.
Deficient Sanitary Food Storage and Handling Practices
Penalty
Summary
Surveyors observed multiple failures in the facility's food storage and handling practices. In the kitchen, a freestanding refrigerator contained uncovered trays of eggs, sliced ham, and cooked bacon, with staff unable to specify when the items were placed in the fridge or produce a cooling log. Additionally, two large containers of beef and chicken, prepared at home for a staff potluck, were found stored in the kitchen refrigerator, which staff acknowledged should not have occurred. Dented cans of pineapple and cream of mushroom soup were also found on dry storage shelves, contrary to facility expectations. The Dietary Manager confirmed that food cooling procedures were not properly followed, outside food was improperly stored, and dented cans were not removed as required. In the 400 Hall resident refrigerator, the temperature was recorded at 44°F, with logs showing five days above 40°F and no corrective action taken, despite instructions to report such temperatures. Expired food items, including a strawberry fruit drink and buttermilk ranch dressing, were found, and shelving was observed to be dirty with dried food residue. Both the Dietary Manager and Administrator confirmed that the refrigerator was not maintained according to expectations for temperature, cleanliness, and removal of expired foods.
Failure to Obtain Informed Consent for Mood-Altering Medications
Penalty
Summary
The facility failed to obtain signed informed consent prior to administering mood-altering medications to a resident. The resident, who was admitted with diagnoses including metabolic encephalopathy, anxiety, and depression, was able to communicate their needs. Review of the electronic health record (EHR) and medication administration record (MAR) showed that the resident was prescribed and received Buspirone and Duloxetine, both mood-altering medications, without any documented consents for their use. During interviews, both the Resident Care Manager/LPN and the Director of Nursing Services confirmed that the required consents were not present in the EHR and acknowledged that this did not meet facility expectations.
Untimely Completion of Fall Investigation
Penalty
Summary
The facility failed to complete a timely investigation following a fall incident involving a resident with a history of respiratory failure, hemiplegia, and hemiparesis after a stroke. The resident, who was able to communicate needs, reported falling out of their wheelchair while attempting to return to bed. The incident occurred on 06/19/2025, but the documentation of interventions, investigation summary, and conclusion were not completed until 06/26/2025, which was seven days after the fall. Interviews with facility staff, including the Resident Care Manager and the Director of Nursing Services, confirmed that the investigation should have been completed within five days, as per facility policy and regulatory guidelines. Both staff members acknowledged that the investigation did not meet the expected timeline. The delay in completing the investigation was attributed to factors such as weekends, but it was recognized that the process exceeded the required timeframe.
Failure to Provide Bed Hold Notice During Hospital Transfers
Penalty
Summary
The facility failed to provide written bed hold notices to a resident at the time of transfer to the hospital on two separate occasions. Record review showed that the resident, who had chronic pain, diabetes, and dementia and was able to make their needs known, was hospitalized twice and subsequently readmitted to the facility. There was no documentation in the electronic health record indicating that a bed hold was offered or that the required written notification was provided during either hospitalization. Interviews with the Business Office Manager and the Administrator confirmed that the bed hold notice was not offered or documented as required by facility policy and regulatory standards.
Inaccurate MDS Assessment for Resident with Upper Extremity Impairment
Penalty
Summary
The facility failed to ensure the accuracy of the Minimum Data Set (MDS) assessment for one resident. The resident, who had diagnoses including paraplegia, chronic obstructive pulmonary disease, and chronic pain, was observed in a wheelchair with a bent inward left hand and reported no longer receiving restorative services or assistance with a hand splint. Despite these impairments, the resident's quarterly MDS assessment indicated 'No Impairment' in the Upper Extremity section. Staff interviews confirmed that the MDS was coded incorrectly and that the expectation was for assessments to be accurate.
Failure to Timely Update Care Plan After Resident Fall
Penalty
Summary
The facility failed to ensure that a care plan was reviewed and revised in a timely manner following a fall incident involving a resident. The resident, who had a history of respiratory failure, hemiplegia, and hemiparesis following a stroke, experienced a fall in their room after attempting to transfer from their wheelchair to bed. The incident was documented in the facility's incident report log, and the resident was able to communicate their needs. Despite the fall being reported, a review of the resident's care plan showed that no new interventions were created or initiated after the incident. Interviews with facility staff, including the Resident Care Manager and the Director of Nursing Services, confirmed that the care plan was not updated within the expected timeframe following the fall. Both staff members acknowledged that interventions should have been added to the care plan shortly after the incident to address the resident's needs and prevent further falls.
Failure to Follow Provider Orders and Professional Standards in Medication Administration and Monitoring
Penalty
Summary
Nursing staff failed to follow provider orders and professional standards of quality in the care of three residents. For one resident with severe cognitive impairment and multiple diagnoses, staff did not accurately monitor and document sleep patterns as ordered. Observations showed the resident sleeping during the day, but the medication administration record (MAR) reflected inaccurate or incomplete documentation of sleep hours, with staff admitting to recording sleep data before the end of their shift rather than at the required time. Interviews with nursing staff and management confirmed that documentation was not being completed according to expectations or provider orders. For another resident with quadriplegia and ventilator dependence, staff administered midodrine for low blood pressure even when the resident's systolic blood pressure was above the threshold specified in the provider's order, both in the current and previous months. Additionally, a third resident with metabolic encephalopathy and mood disorders had overlapping orders for two different concentrations of lidocaine cream, and staff failed to discontinue the previous order as required when the new order was received. In each case, staff and management acknowledged that provider orders were not followed, resulting in medication administration and monitoring errors.
Failure to Apply Ordered Brace and Offloading Boot
Penalty
Summary
The facility failed to apply a brace/splint and an offloading boot to a resident as ordered by the provider and outlined in the resident's care plan. The resident, who had a history of respiratory failure, hemiplegia, and hemiparesis following a stroke, was observed on multiple occasions without the prescribed brace/splint or offloading boot in place. Interviews with the resident confirmed that they had not worn the devices recently and could not recall the last time they were used. The devices were not visible in the resident's room, and staff were initially unaware of the requirement for their use, only locating the brace after being prompted. The offloading boot could not be found during the survey period. Review of the resident's treatment administration record (TAR) showed that staff documented the devices as being applied per provider orders, despite observations and interviews indicating otherwise. The care plan and Kardex both specified the need for the brace and offloading boot, with interventions for their use when in bed or in a wheelchair. Staff interviews revealed a lack of awareness of the orders and care plan requirements, and the Director of Nursing Services confirmed that provider orders and care plans were not followed, and refusals were not documented as required.
Failure to Prevent Pressure Ulcer Due to Inadequate Bed Accommodation
Penalty
Summary
A deficiency was identified when the facility failed to provide an environment conducive to the healing of a pressure ulcer for one resident. The resident, who had chronic kidney disease, diabetes, and depression, was readmitted to the facility and was able to communicate their needs. Multiple observations showed the resident's feet consistently pressed against the footboard of the bed due to their height, with a gap between the mattress and the footboard filled by a rolled-up blanket. The resident reported that their feet always touched the footboard, and staff confirmed the bed was not long enough for the resident's height. Provider orders required staff to ensure proper mattress function and body positioning, but these were not adequately followed. Interviews with facility staff revealed that the risk of pressure ulcer development from the resident's feet pressing against the footboard was not recognized or addressed in a timely manner. The Resident Care Manager and the Director of Nursing Services both acknowledged that this factor should have been considered in the investigation and incident report regarding the pressure ulcer. Interventions to prevent the resident's foot from pressing against the footboard were not implemented until after the issue was observed and brought to staff attention.
Failure to Ensure Proper Provider Orders and Administration of Oxygen
Penalty
Summary
The facility failed to ensure that proper provider orders were in place and that residents received the correct amount of oxygen as prescribed. For one resident, who had a history of chronic pain, diabetes, and dementia, observations showed that oxygen was being administered via nasal cannula at two liters per minute, but there was no provider order for oxygen in the electronic health record. Staff confirmed that the order was missing and acknowledged it was overlooked when the resident returned from the hospital. The Director of Nursing Services also confirmed that a provider's order was required for oxygen use. For another resident with diagnoses including acute and chronic respiratory failure, COPD, and heart failure, observations and interviews revealed that oxygen was being administered at six liters per minute, while the provider's order specified two liters per minute. The treatment administration record showed oxygen was used at varying rates from two to eight liters per minute. Staff confirmed that the resident was receiving six liters per minute and that the order needed clarification. The Director of Nursing Services stated that the oxygen order did not meet expectations.
Improper Labeling and Storage of Insulin in Medication Cart
Penalty
Summary
During an observation of a medication cart, Lispro insulin was found with an open date of 05/15/2025, and Lantus insulin was present without any open date. Staff Q, an LPN, confirmed that insulins are to remain in the cart for 28 days after opening, after which they are considered expired. The Director of Nursing Services acknowledged that the insulin storage did not meet facility expectations. These findings indicate that the facility failed to ensure proper labeling and storage of insulin as required.
Failure to Post Actual Nurse Staffing Hours
Penalty
Summary
The facility failed to consistently post daily nurse staffing information that included the actual nursing staff hours worked, as required. Observations on multiple dates showed that the Daily Nurse Staffing Form posted near the entrance only documented the total scheduled hours, not the actual hours worked. During interviews, the staffing coordinator stated they were unaware that both scheduled and actual hours needed to be posted, and the administrator confirmed they had just learned that actual hours were not being posted daily, which did not meet expectations. No information was provided regarding specific residents or their medical conditions in relation to this deficiency.
Pharmaceutical Services and Medication Storage Deficiencies
Penalty
Summary
The facility failed to provide adequate pharmaceutical services by incorrectly transcribing medication orders with stop dates for medications that should be ongoing for a resident with multiple diagnoses, including Diabetes Mellitus II, Epilepsy, and Hemiplegia following a stroke. The resident's electronic Medication Administration Record (eMAR) showed that medications such as Cyclobenzaprine, Insulin Glargine, Isosorbide Dinitrate, Keppra, and Prevacid were incorrectly set to end after 30 days, despite the need for continuous administration. This error occurred because the Licensed Practical Nurse (LPN) responsible for inputting orders included stop dates from hospital discharge orders, which are typically intended for patients being discharged home, not for those being admitted to a facility. Additionally, the facility failed to consistently reconcile controlled medications correctly for another resident with chronic pain syndrome. The resident's eMAR showed an active order for Lorazepam, but discrepancies were found in the narcotic book, where a blister pack with 7 remaining tablets was unaccounted for until discovered missing during a narcotic count. The investigation revealed that the off-going nurse was not thoroughly checking the narcotic book page by page, leading to the oversight. These deficiencies in pharmaceutical services and medication storage placed residents at risk for inadequate treatment of their medical conditions and potential misappropriation or diversion of controlled medications. The facility's policies for new orders and shift verification of controlled substances were not adequately followed, contributing to these issues.
Failure to Perform Scheduled Central Line Dressing Changes
Penalty
Summary
The facility failed to adhere to physician orders and perform scheduled central line dressing changes for two residents, leading to a deficiency in care. Resident 1, who was readmitted with severe sepsis and other conditions, had a physician's order for a central venous catheter dressing change on admission and weekly thereafter. However, the electronic Medication Administration Record (eMAR) indicated that the dressing change due on 10/15/2024 was signed as refused, and upon transfer to another facility, the dressing was found to be dated 09/25/2024, suggesting it was never changed as required. Resident 2, who was readmitted with MRSA pneumonia and had severely impaired cognition, also had orders for weekly dressing changes. The eMAR documented a dressing change on 11/05/2024, but an observation on 11/07/2024 revealed a dressing dated 10/29/2024, indicating it was not changed as scheduled. Interviews with staff revealed a lack of adherence to protocols, with discrepancies in understanding and executing the dressing change schedule, leading to missed changes and potential risks for the residents.
Inadequate PPE Use and Hand Hygiene in COVID-19 Care
Penalty
Summary
The facility failed to ensure that staff members adhered to CDC guidelines for the use of personal protective equipment (PPE) when caring for residents with confirmed COVID-19 infections. Staff B, a Certified Nursing Assistant (CNA), was observed entering a COVID-19 positive resident's room wearing appropriate PPE but failed to discard the N95 respirator after exiting the room. Instead, Staff B continued to wear the same respirator while assisting another resident not on aerosol contact precautions, indicating a breach in infection control protocols. Similarly, Staff C, another CNA, entered a COVID-19 positive resident's room without wearing a gown, gloves, or face shield, and did not change the N95 respirator after exiting. Staff C then interacted with other residents and handled items such as lunch trays without adhering to proper PPE protocols. This behavior was consistent with Staff C's understanding that changing the N95 respirator was not necessary, highlighting a lack of proper training or adherence to infection control measures. Staff D, a Licensed Practical Nurse (LPN), also failed to remove the N95 respirator and face shield after exiting a COVID-19 positive resident's room, engaging with other residents while still wearing the same PPE. Additionally, Staff E, a CNA, did not perform hand hygiene or change gloves after providing incontinent care to a resident, further compromising infection control. The facility's Infection Preventionist confirmed that the staff did not follow CDC guidelines, which require the removal of all PPE, including the N95 respirator, after caring for COVID-19 positive residents.
Failure to Inform POA of Medical Changes
Penalty
Summary
The facility failed to inform the resident's representative in advance of physician visits and changes to the plan of care for a resident with severe cognitive impairment. The resident, who was non-verbal and had a Power of Attorney (POA) designated for healthcare decisions, was seen by medical providers on multiple occasions without the POA being notified or present, despite the POA's explicit request to be involved in all medical visits and decisions. The facility did not document any attempts to contact the POA before or after these visits, nor did they include the POA in discussions regarding medication changes, lab results, or treatment decisions. The resident's medical records showed several instances where the POA was not informed about significant changes, such as the initiation of new medications, adjustments in tube feeding, and recommendations from pharmacists. The Director of Nursing confirmed that there was no documentation of communication with the POA regarding these changes, acknowledging that the facility should have coordinated with the POA to ensure their presence during medical evaluations and discussions. This lack of communication placed the resident at risk of not having their healthcare decisions made with full knowledge and consent from their designated representative.
Inconsistent Restorative Care for Residents
Penalty
Summary
The facility failed to ensure that residents consistently received restorative care to maintain or prevent declines in mobility for two residents. Resident 1, who was admitted with diagnoses including stroke and dementia, was on a restorative program to decrease the risks of contractures. The care plan included applying a resting hand splint and an ankle splint, as well as performing passive range of motion (ROM) exercises on the resident's upper and lower extremities. However, documentation showed that the resident's restorative program was not consistently followed, with the ankle splint applied only four times over several months and the hand splint and ROM exercises performed inconsistently. Resident 5, with medically complex diagnoses, also had a restorative care plan that included a hand/wrist splint and a strengthening program for the right upper extremity. The documentation revealed that the resident received the hand/wrist splint only 14 out of 30 days in September and three out of 14 days in October. Additionally, the strengthening program was not provided during a specific week in September. Staff G, the Restorative Program Oversight Registered Nurse, acknowledged that the restorative programs for these residents were not completed consistently.
Failure to Act on Pharmacist's Recommendations
Penalty
Summary
The facility failed to act on the consultant pharmacist's drug regimen review recommendations for a resident with heart disease, stroke, and dementia. The pharmacist recommended a fasting lipid panel to evaluate medication therapy, which the medical provider accepted, noting that consent was needed from the resident's power of attorney (POA). However, there was no documentation in the resident's electronic medical record indicating that the POA was contacted or that the lipid panel was conducted. Additionally, the pharmacist recommended reducing the resident's famotidine dosage from twice per day to once at night, which the medical provider accepted, pending consent from the resident's granddaughter. Despite this, the medication administration record showed that famotidine continued to be administered twice per day, and there was no documentation that the granddaughter was contacted. The Director of Nursing confirmed that the staff should have contacted the POA and documented the actions taken, but no such documentation was found.
Failure to Administer Fentanyl Patch as Ordered
Penalty
Summary
The facility failed to administer a Fentanyl patch in accordance with physician orders for a resident who was admitted with diagnoses including stroke and dementia. The resident was severely cognitively impaired and on a pain medication regimen. The physician's order required the Fentanyl patch to be applied every 72 hours with the presence of two nurses. However, the Medication Administration Record (MAR) showed discrepancies in the administration times and the presence of two nurses during the application. On two occasions, the Fentanyl patch was not administered according to the 72-hour schedule, and the requirement for two nurses to be present was not consistently followed. Specifically, the MAR indicated that the patch was administered 27 hours after the previous application on one occasion and 50 hours later on another. The Director of Nursing acknowledged that the licensed nurses did not follow the physician's order, constituting a medication error.
Deficiencies in Enteral Nutrition Management
Penalty
Summary
The facility failed to manage enteral nutrition in accordance with provider's orders and professional standards of practice for four residents. Resident 33 experienced harm due to repeated clogging of a jejunostomy tube, which led to multiple hospital visits. The facility did not evaluate whether staff administered as-needed medication to prevent clogging or if additional interventions were necessary. Observations showed that staff did not check the placement of the J-tube before administering medications, and there was no documentation of interventions to unclog the tube prior to hospital transport. Resident 7, who was dependent on staff for care and required a gastric tube for nutrition, did not receive the full amount of ordered formula and water. Observations revealed that staff did not flush the tube after administering medications, and the recorded intake of formula and fluids did not meet the resident's goals. Staff failed to document reasons for the shortfall, notify the provider, or inform the family member. For Residents 73 and 77, staff did not check the placement of gastric tubes before administering medications. Observations showed that medications were prepared with visible particles, and the tubes were not flushed adequately. In one instance, fluids sprayed into the air during an attempt to flush the tube, requiring assistance to declog it. The Director of Nursing Services stated that it was expected for staff to check tube placement and implement PRN interventions as per provider's orders.
Failure to Investigate Allegations of Abuse and Neglect
Penalty
Summary
The facility failed to thoroughly investigate allegations of abuse or neglect for three residents, which prevented timely identification of abuse/neglect occurrences. For Resident 33, who was dependent on staff for all activities of daily living and had a tracheostomy, the facility did not interview the resident or other staff and residents after a family member reported neglect and aggressive behavior by staff. The incident investigation lacked documentation of interviews and failed to address the allegation of staff aggression. Resident 101, who had a history of amputation and diabetes, reported an argument with a roommate over a wheelchair blocking the door. The facility's investigation did not include interviews with other residents or staff to determine the root cause of the argument. Similarly, Resident 87, who had cognitive communication deficits and a brain injury, alleged physical abuse by staff, but the facility's investigation did not include interviews with staff or residents, leaving the alleged perpetrator unidentified.
Inconsistent Catheter Care and Management
Penalty
Summary
The facility failed to provide consistent care and management for residents with indwelling urinary catheters, as observed in three sampled residents. Resident 7, who had a history of neuromuscular dysfunction of the bladder, sepsis, and urinary tract infection, was found to have improper catheter management. Observations showed that the catheter tubing was not properly drained into the catheter bag, and the catheter bag was placed above the bladder level, which is against the facility's policy. Additionally, there was a lack of documentation for catheter care after the resident's hospitalization, and discrepancies were noted in the type of catheter documented versus observed. Resident 90, diagnosed with muscle weakness and neuromuscular dysfunction of the bladder, also experienced inadequate catheter care. There was no documentation of how a urine sample was collected, and catheter care was not documented on specific dates. Observations revealed that the catheter bag was lifted above the bladder without draining the urine from the tubing, and the catheter was not secured properly, lacking a securement device. Resident 77, in a persistent vegetative state with respiratory failure, had a urinary catheter without current provider orders or a qualifying diagnosis. There was no documentation of catheter care for a significant period, and observations showed dark yellow urine in the catheter tubing. Interviews with staff confirmed that the lack of documentation and improper catheter management did not meet the facility's expectations.
Failure to Provide Routine Dental Care
Penalty
Summary
The facility failed to provide routine dental care for a resident, identified as Resident 55, who was admitted with diagnoses including type two diabetes, dependence on renal dialysis, and depression. Upon observation and interview, it was noted that Resident 55 had multiple missing teeth and was not wearing a denture, which the resident confirmed they did not have. The admission minimum data set assessment indicated that the resident had obvious or likely cavities or broken natural teeth, yet there was no care plan addressing the missing teeth or denture use. Despite dental consultations on two occasions, in August 2023 and August 2024, which recommended x-rays, tooth extractions, and denture evaluation, no follow-up care was provided. Interviews with facility staff, including the Resident Care Manager/LPN and the Director of Nursing Services, revealed that the expected follow-up on these dental recommendations was not conducted, failing to meet the facility's standards for resident care.
Infection Control Deficiencies in Resident Care
Penalty
Summary
The facility failed to implement proper infection control and prevention measures for several residents, leading to increased risk of healthcare-associated infections. Resident 74, who was on contact precautions due to a multi-drug resistant organism, was observed receiving care from staff who did not adhere to the required precautions, such as wearing an isolation gown and performing hand hygiene. Similarly, Resident 14, who required enhanced barrier precautions, was provided care by a staff member who failed to perform hand hygiene and used soiled gloves to handle clean linens, further compromising infection control protocols. Resident 90, who had multiple wounds and a urinary tract infection, received wound care that did not meet infection control standards. The staff member performing the care did not change gloves or perform hand hygiene between treating different wounds, and contaminated surfaces were used during the procedure. This lack of adherence to proper wound care protocols increased the risk of cross-contamination and infection. Resident 7, who had a urinary catheter and was on enhanced barrier precautions, did not receive appropriate catheter care. Staff members were observed touching the catheter with gloves that had been used for other tasks, and catheter care was not performed as expected. These actions were not in line with the facility's infection control expectations, as confirmed by interviews with the facility's nursing leadership.
Mechanical Lift Safety Deficiency
Penalty
Summary
The facility failed to maintain the mechanical lifts used to assist residents in moving from one surface to another across three sampled halls (100, 300, and 400 Halls). This deficiency was identified through observation, interview, and record review. The Mechanical Lift Checklist, dated January 2024, indicated that the swivel bar bolts and sling hooks should be free from damage, bends, or deflections. However, during an observation on September 17, 2024, it was noted that the mechanical lifts on these halls lacked safety clips attached to the sling hooks. In interviews conducted on the same day, the Maintenance Director, Staff W, confirmed that the facility's protocol involved quarterly audits to ensure the safety of mechanical lifts, which should include safety clips on sling hooks. Staff W acknowledged the absence of safety clips on the lifts in the 100, 300, and 400 Halls, which did not meet the facility's expectations. Similarly, the Administrator, Staff A, stated that mechanical lifts could pose a safety risk without safety clips and that missing clips should be corrected immediately. Staff A also confirmed that the lack of safety clips on the lifts in the specified halls 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 a resident or their responsible party, specifically for one of the two sampled residents reviewed for hospitalization. This deficiency involved Resident 256, who was admitted to the facility with diagnoses including chronic respiratory failure, asthma, and dependence on a respirator. The resident was capable of making their needs known. The electronic health record (EHR) indicated that Resident 256 experienced a hospitalization and subsequent readmission to the facility, but there was no documentation of a transfer notice. During an interview, the Director of Nursing Services stated that the expectation was for residents to receive written documentation regarding the reason for transfer and for a transfer form to be completed.
Inaccurate Resident Assessments in MDS
Penalty
Summary
The facility failed to accurately assess three residents, leading to discrepancies in their Minimum Data Set (MDS) assessments. Resident 95 was incorrectly marked with a diagnosis of dementia, which was not present in their electronic health record (EHR). This error was acknowledged by the Registered Nurse/Minimum Data Set Coordinator, who was unable to explain the incorrect coding. Resident 36, who was receiving oxygen through a tracheostomy, was inaccurately documented as not receiving oxygen in their admission MDS, despite evidence to the contrary in their EHR. This mistake was confirmed by a Regional Nurse, who admitted the MDS was coded incorrectly. Resident 90's admission MDS inaccurately reported four pressure ulcers and moisture-associated skin damage (MASD), while the EHR indicated two pressure wounds and two hematoma wounds. The Licensed Practical Nurse and Regional Nurse both acknowledged the inaccuracies, attributing them to a lack of communication and the presence of new wound care nurses. Additionally, the Assistant Director of Nursing Services (DNS) could not find documentation of MASD and noted the absence of a dental assessment. The DNS confirmed that the admission MDS did not meet expectations, highlighting a failure in the facility's assessment process.
Failure to Provide Scheduled Showers and Personal Hygiene
Penalty
Summary
The facility failed to consistently provide bathing and personal hygiene according to the plan of care for two residents, leading to a deficiency in their care. Resident 33, who was dependent on staff for all activities of daily living due to acute and chronic respiratory failure with a tracheostomy, did not receive the expected two showers per week. Interviews revealed that the assigned shower aide was not present, and other aides did not compensate for the missed showers. The electronic health record indicated that Resident 33 only received three showers and one bed bath over a 30-day period, contrary to the facility's expectations. Similarly, Resident 87, who required assistance with personal care and had reduced mobility, experienced a lapse in scheduled showers. The resident reported going eight days without a shower and was unaware of the shower schedule. Observations confirmed that the resident wore the same clothing for multiple days. The facility's records showed only one documented shower in the past 30 days, despite being scheduled for showers twice a week. Staff interviews indicated that the resident's preference for showers after physical therapy was not accommodated, and the absence of the bath aide further contributed to the missed showers.
Deficiencies in Bowel, Diabetic, and Edema Care
Penalty
Summary
The facility failed to monitor and implement interventions for bowel and diabetic care for two residents, leading to deficiencies in their care. Resident 38, who had kidney and lung disease, diabetes, depression, and anxiety, experienced diarrhea for two weeks without receiving the prescribed Imodium medication. Despite having a care plan to manage bowel incontinence, the medication administration record showed no documentation of Imodium being administered, even though the resident had multiple episodes of diarrhea. Interviews with staff revealed that the expectation was for certified nurse aides to inform licensed nurses about the resident's condition so that the medication could be administered as ordered. Resident 156, who had multiple diagnoses including stroke, hemiplegia, Parkinson's disease, diabetes, heart and kidney disease, and was legally blind, did not receive proper diabetic care. The resident's medication administration record showed that Semaglutide, a medication for diabetes, was not administered due to unavailability, and there was no follow-up with the pharmacy or notification to the provider or resident representative. Additionally, the resident's blood glucose was not monitored daily as required, and the facility lacked access to the necessary app to read the continuous glucose monitoring device. Furthermore, the resident did not receive a scheduled shower, and staff failed to re-offer it at the next opportunity. Resident 87, who had generalized muscle weakness, reduced mobility, and deep vein thrombosis, experienced unmonitored edema. Observations showed that the resident's left leg was more swollen than the right, but no interventions were offered to address the swelling. Interviews with staff indicated that edema assessments were not documented, and the condition was not identified until several days later. The lack of monitoring and documentation for edema did not meet the facility's expectations, as confirmed by the Director of Nursing Services.
Inadequate Pressure Ulcer Care for Resident
Penalty
Summary
The facility failed to provide pressure ulcer care consistent with professional standards for a resident who was dependent on staff for repositioning and unable to communicate needs. The resident had three pressure ulcers, including one on the left lower leg identified upon arrival, but there were no follow-up assessments documented in the electronic health record (EHR). Additionally, the left ear pressure ulcer was not present on arrival and was first identified later. The outside wound provider was not requested to consult on the left lower leg wound, leading to a lack of documentation and follow-up. During an observation of wound care, a Licensed Practical Nurse (LPN) failed to apply wound cleanser to the left ear pressure ulcer and did not offload the ear, instead repositioning the resident with the ear against the pillow. The sacral wound dressing was also inadequate, as redness was noted on the uncovered skin, indicating that a larger or modified dressing was needed. Interviews with the Assistant Director of Nursing and the Director of Nursing Services confirmed that the wound care did not meet expectations, and orders were not followed as required.
Inadequate Tracheostomy Care for Resident
Penalty
Summary
The facility failed to provide appropriate tracheostomy care for a resident, identified as Resident 7, who was dependent on staff for all care and required a ventilator and oxygen due to chronic respiratory failure and brain damage. On one occasion, two CNAs entered the resident's room and observed yellow fluids in the ventilator tubing. Despite this, they turned the resident onto their right side, causing the fluid to move into the tracheostomy, leading to coughing and a high-pressure alarm on the ventilator. The CNAs left the room without waiting for the respiratory therapist (RT) to arrive, who later had to remove a significant amount of fluid from the resident. Further observations revealed that Resident 7 continued to have issues with fluid accumulation around the tracheostomy site and in the ventilator tubing. On another day, the resident was turned twice without the RT being paged, despite the presence of fluids. Interviews with staff indicated that the RT had not been notified to provide necessary care, and the Director of Nursing Services acknowledged that the staff actions did not meet expectations. This lack of appropriate care placed the resident at risk for unmet care needs and potential negative outcomes.
Failure to Implement GDR and Monitor Psychotropic Medications
Penalty
Summary
The facility failed to implement gradual dose reductions (GDR) and monitor adverse side effects for psychotropic medications for two residents, leading to unnecessary medication use and potential risks. Resident 43, diagnosed with aphasia, unspecified psychosis, and dementia, was prescribed Seroquel for paranoia/psychosis. Despite a provider's recommendation for a GDR due to the resident's stable condition, the reduction was not implemented due to miscommunication, as confirmed by the Resident Care Manager and the Director of Nursing. Resident 456, with diagnoses including dementia, COPD, and diabetes, experienced a fall and was prescribed quetiapine, an antipsychotic with a black box warning for increased mortality in elderly dementia patients. The facility failed to perform an AIMS test and complete scheduled orthostatic blood pressure monitoring, as acknowledged by the RCM and DNS. These oversights in monitoring and implementing provider recommendations placed residents at risk of adverse side effects and medical complications.
Medication Administration Timing Error
Penalty
Summary
The facility failed to maintain a medication error rate of less than five percent, as evidenced by two errors occurring in twenty-five medication administration opportunities. This deficiency was identified during the administration of medications to one of the sampled residents, Resident 77. On the morning of September 16, 2024, a registered nurse, Staff V, administered baclofen and tizanidine, both muscle relaxants, to Resident 77 via an artificial tube. However, the medications were given at 9:12 AM, contrary to the provider's orders, which specified an administration time of 8:00 AM. During an interview, the Director of Nursing Services, Staff B, acknowledged that the expectation was for nurses to adhere to the prescribed medication administration times, and the observed practice did not meet these expectations. This discrepancy placed the residents at risk of receiving medications that might not be effective or could be less effective, potentially diminishing their quality of life.
Medication Storage and Labeling Deficiencies
Penalty
Summary
The facility failed to ensure proper storage and labeling of medications across multiple medication carts and rooms, which placed residents at risk for receiving expired medications and ineffective treatment. During observations, it was noted that the 300 hall medication room contained an open vial of Tubersol solution without an opened date, and the same issue was observed in the 100 hall medication room. Staff P, a Resident Care Manager/LPN, acknowledged that the Tubersol solution should be dated when opened to track its expiration. Further observations revealed additional issues with medication storage. The 400 front medication cart contained Timolol eye drops with an opened date but past the expiration date. The 300 back medication cart had atropine eye drops that were opened but not dated, and insulin pens that were past their 28-day usage period. Additionally, scheduled narcotics records showed missing nurse signatures on multiple dates. The 400 back medication cart had house supply eye drops with no opened dates. Staff B, the Director of Nursing Services, confirmed that multidose medications should be dated when opened and that narcotic medications should be double signed by nurses at the end of each shift, which was not done as expected.
Failure to Administer Pneumococcal Vaccine
Penalty
Summary
The facility failed to provide a pneumococcal vaccine to Resident 97, who was one of the five residents reviewed for vaccinations. Resident 97 was admitted to the facility with a diagnosis of diabetes and surgical amputation of the legs. The electronic health record indicated that Resident 97 consented to receive the pneumococcal vaccine on June 3, 2024. However, a review conducted on September 17, 2024, showed no documentation of the vaccine being administered. During an interview on September 18, 2024, the infection preventionist/LPN acknowledged that Resident 97 should have received the vaccine and admitted that there was no process in place for screening and administering vaccines to residents who requested them. Additionally, the Director of Nursing Services stated that it was their expectation for residents to be educated, offered, and administered the pneumococcal vaccine if requested.
Failure to Post Actual Nursing Staffing Hours
Penalty
Summary
The facility failed to post the actual nursing staffing hours daily, which is a requirement to ensure transparency for residents, family members, and visitors regarding the availability of nursing staff. On the morning of September 18, 2024, an observation and record review revealed that the nursing staff posting, located in the facility's entrance hallway, did not reflect the actual adjustments for staff absences due to call-offs or illness. This posting also lacked reconciliation to show the actual hours worked by the nursing staff. During interviews conducted on the same day, the Staffing Coordinator admitted to being unaware of the requirement to post the actual hours worked daily. The Administrator expressed that it was their expectation for the Staffing Coordinator to ensure the posting of actual nursing staff hours worked. This oversight led to a deficiency in the facility's compliance with posting accurate staffing information.
Failure to Document and Update CPR Directives
Penalty
Summary
The facility failed to ensure that a resident had clear and accessible Cardiopulmonary Resuscitation (CPR) directives documented, which is crucial for informing staff of the resident's wishes in case of an emergency. The resident was admitted with a Do Not Resuscitate (DNR) status documented in their electronic health record (EHR), but there was no Physician Orders for Life Sustaining Treatment (POLST) form or advance directive available. During a visit, the resident's daughter requested a change from DNR to CPR, and a POLST form was filled out to reflect this change. However, the staff did not update the EHR with the new code status, and the POLST form could not be located after the resident passed away. The Resident Care Manager (RCM) acknowledged that the EHR was not updated with the new code status, and the Director of Nursing Services (DNS) stated that the admitting nurse should have obtained an order for the new code status and entered it into the EHR. In the absence of a POLST form, the resident should have been considered full code. This oversight placed the resident at risk of not receiving care in accordance with their wishes if their heart stopped beating or breathing ceased.
Failure to Investigate Suspected Abuse in Resident with Shoulder Injury
Penalty
Summary
The facility failed to protect a resident's rights to be free from abuse by not implementing its policies and procedures for investigating suspected abuse or neglect. A resident, who was severely cognitively impaired and dependent on staff for assistance, was assessed with bilateral shoulder subluxation. Despite the assessment, no investigation was conducted to rule out abuse or neglect, and the incident was not logged in the facility's incident log. Additionally, the resident's care plan was not updated to reflect the suspected injury, and the resident was not placed on alert status for monitoring. Staff interviews revealed a lack of awareness and communication regarding the resident's injury. The Resident Care Manager was not informed of the injury until days after the initial assessment, and the Director of Nursing Services was unaware of the injury until informed by the state. The facility's policy required that any injury of unknown origin should prompt notification of the resident's representative, provider, and state hotline, along with a thorough investigation to rule out abuse or neglect. These steps were not taken, indicating a failure to adhere to established protocols, thereby placing all residents at risk of abuse and a diminished quality of life.
Failure to Provide Written Notification for Transfer/Discharge
Penalty
Summary
The facility failed to provide written notification of the reason for transfer or discharge to the hospital, the reason why a resident could not be readmitted to the facility, and appeal contact information to the resident or responsible party. This deficiency was identified for one resident who was admitted with a diagnosis of malignant neoplasm of the brain and was dependent on staff for transfers, bed mobility, and dressing. The resident was assessed as severely cognitively impaired and was discharged to the hospital with the anticipation of return. However, there was no documentation in the electronic health record that a written notice of transfer or discharge was provided to the resident or responsible party. The facility's staff, including the Director of Nursing Services and the Executive Director, cited the resident's code status and complex medical needs as reasons for denying readmission. The resident required daily labs and frequent hospitalizations due to fluid volume overload, which the facility claimed it could not manage sustainably. Despite these claims, the facility was unable to provide documentation of notifying the hospital or family about the decision to decline readmission, nor was there a bed hold notice for the discharge to the hospital.
Failure to Implement Post-Op Orders and Coordinate Appointments
Penalty
Summary
The facility failed to implement post-operative recommendations and coordinate visits with outside specialty providers for a resident who underwent a laryngectomy. The resident, who was moderately cognitively impaired, was supposed to follow a specific diet of clear liquids for 1-2 days and full liquids for two weeks as per the post-operative orders from a follow-up appointment. However, these orders were not communicated to the Speech Language Pathologist or the kitchen, resulting in the resident not receiving the appropriate diet until nearly a month later. The oversight occurred because the Resident Care Manager was not working when the resident returned from the appointment, and the packet containing the orders was misplaced. Additionally, the facility failed to ensure the resident attended several critical medical appointments. The resident missed a PET/CT scan, a urology appointment, an ENT post-op appointment, and an oncology/hematology appointment. The missed appointments were due to a lack of communication and coordination within the facility, as well as staffing issues that prevented a licensed nurse from accompanying the resident, which was necessary due to the resident's tracheostomy. The Director of Nursing Services acknowledged the breakdown in the process, noting that the Resident Care Managers were responsible for reviewing appointment packets and communicating with medical records to set up transportation. However, the system failed, as evidenced by the lack of records for the missed appointments and the absence of transportation arrangements. This deficiency in coordination and communication placed the resident at risk for delayed healing and health complications.
Failure to Provide Written Decision for Grievance
Penalty
Summary
The facility failed to provide a written decision for a grievance when requested by a resident's representative. The facility's policy, revised in August 2023, states that residents or their representatives have the right to obtain a written decision regarding their grievances. However, the representative of a resident had not received a response to the grievances they had submitted. The grievances included issues related to staff neglecting to wear personal protective equipment, delays in informing about quarantine protocols, inaccurate information in the resident's medical record, and missing medication patches. Despite the representative's request for a written decision on these grievances, the facility did not comply. The facility's progress notes indicated that the representative had requested copies of the outcomes of all grievances filed on behalf of the resident, including the latest grievances. The facility responded that they had provided copies of past grievances and would meet with the representative to discuss the grievance procedure. However, the administrator believed that some grievances had already been addressed and sent to the representative in September 2023. The issue of missing medication patches was treated as a medication error, and the facility did not provide a written decision for this grievance. The administrator acknowledged that residents and their representatives have the right to obtain a written decision of a grievance.
Failure to Follow Physician Orders for Medication Administration
Penalty
Summary
The facility failed to ensure services provided met professional standards of practice for one resident with a diagnosis of chronic pain. Specifically, the facility nurses did not follow physician orders for the application and removal of a Lidoderm Patch. The physician's order required the patch to be applied daily at 8:00 AM and removed twelve hours later. However, an observation on 04/29/2024 revealed that the patch dated 04/27/2024 was still on the resident's lower back, indicating it had not been changed as required. The Medication Administration Record inaccurately documented that the patch was removed and reapplied on 04/28/2024. The Director of Nursing confirmed that the licensed nurse should have removed the patch on the evening of 04/27/2024 and applied a new one on 04/28/2024, but this did not occur.
Infection Control Deficiencies in PPE Use and Hand Hygiene
Penalty
Summary
The facility failed to ensure infection control standards were followed, particularly in the use of required Personal Protective Equipment (PPE) and hand hygiene practices. Staff D, a Certified Nursing Assistant (CNA), was observed entering Resident 2's room, which had a sign indicating Enhanced Barrier Precautions (EBP) were necessary. Staff D donned gloves but did not wear a gown while changing the pillowcase and bed pads. Similarly, Staff E, another CNA, was observed taking vital signs for multiple residents without performing hand hygiene or cleaning the vital sign machine between residents. This included interactions with Residents 1, 3, 4, and 5. Staff F, a Nursing Assistant Registered (NAR), also failed to perform hand hygiene before entering Resident 6's room and did not wear a gown while providing care, despite the EBP sign on the door. Staff D was again observed taking vital signs for Resident 2 and then Resident 7 without cleaning the vital sign machine in between uses. The facility's policies on Transmission-Based Precautions, Hand Hygiene, and Resident Equipment Sanitation were not adhered to by the staff. The Infection Preventionist, Staff G, confirmed that staff were expected to perform hand hygiene before and after resident contact and to clean equipment between uses. Staff G also stated that staff should wear gowns and gloves when providing care to residents on EBP. Despite recent education on these protocols, staff failed to comply, placing residents at risk for healthcare-associated infections.
Latest citations in Washington
A resident with cerebral palsy and a court-appointed guardian experienced multiple episodes of nausea, vomiting, loose stools, abdominal discomfort, fatigue, and later refusal of meals and medications, leading to changes in the care plan including close monitoring, lab testing, and IV fluid administration. Despite a facility policy recognizing court-appointed guardians as resident representatives with decision-making authority, staff did not document any notification to the guardian during these changes in condition or treatment decisions. The guardian reported not being contacted when the resident stopped eating or developed stomach issues and felt the facility did not respect the guardianship, while the DON acknowledged there were multiple missed opportunities to notify the guardian of the resident’s change from baseline.
A resident with depression, anxiety, moderate cognitive impairment, and urinary incontinence, care-planned for q2h checks and assistance with toileting, was found by a visitor to be soaking wet, unusually agitated, and reporting they had been told to wait to be changed and referred to with a derogatory remark. The visitor filed a written grievance alleging abuse/neglect related to delayed incontinence care and removal of the resident’s tablet as a consequence. Although an incident report noted that the matter was reported to the state and that the resident was not soaking wet, a CNA who actually changed the resident later reported the resident’s brief, pants, wheelchair, and socks were soaked and that the resident was acting timid and repeatedly saying they had to sit for five minutes, but this CNA was never interviewed. The DON acknowledged not investigating the resident’s behavior or interviewing this CNA, and the grievance official acknowledged the facility did not fully investigate or communicate findings and resolution to the complainant, resulting in a failure to follow the facility’s grievance policy.
A resident with dementia, respiratory failure, and heart failure developed new shortness of breath with an O2 sat of 90%, and a physician ordered transfer to the ED for tx and eval. An RN completed an SBAR, notified the MD and family, and reported to the oncoming nurse that the resident needed ED transfer and that paramedics should be contacted, then left the facility. Instead of calling 911 for this emergent respiratory distress, staff arranged non-emergent transport through a contracted ambulance service, resulting in the resident remaining at the facility for several hours without pickup until the dispatcher later instructed staff to call 911. The DON stated that 911 is expected to be used for emergent conditions and the contracted service only for non-emergent transport.
A resident with anoxic brain injury, dysarthria, and documented lack of decisional capacity alleged physical abuse and expressed fear of their identified representative, yet social services only reported the allegation to the state and did not complete an incident report, revise the care plan, or implement protective interventions. The same representative continued to be treated as the resident’s decision-maker and visited frequently, with staff noting suspicious odors of foreign substances and concerns about possible illicit substance use. Psychiatry later documented concern that the representative was providing illicit substances, and the resident was subsequently hospitalized for altered mental status and overdose, after which the representative was banned. Key staff, including the DON, unit manager, and administrator/abuse coordinator, were unaware of the initial abuse allegation, and social services did not timely explore or clarify legal decision-making authority or alternative representation for the resident.
A resident with severe cognitive impairment, osteoarthritis, and spinal spondylosis, care planned for 2-person Hoyer transfers, was being moved by two CNAs using a mechanical lift when one corner loop of the sling became disengaged, causing the resident to fall about four feet, strike the floor and the lift, and sustain head abrasion, multiple rib fractures, and lumbar vertebral fractures. Facility policy required staff to verify secure sling attachment, examine hooks, clips, fasteners, and strap stability, and ensure the sling bar was sound before lifting, but during this transfer the sling loop detached despite staff believing it was properly fastened and hearing it click into place; post-incident assessment showed the loop had come loose, the sling appeared in good condition, and a CNA later reported thinking one of the round metal disks on the lift might have been slightly loose, while maintenance logs documented no prior concerns with the lifts or slings.
The facility failed to revise and individualize care plans to reflect current needs and preferences for multiple residents, including one cognitively intact resident with hemiplegia, hemiparesis, and mononeuropathy who had bilateral shoulder surgery and could not tolerate BP measurements on the upper arms but preferred forearm readings. Despite repeatedly informing staff, this preference was not documented in the care plan or Kardex, and direct care staff and the RN/UM were unaware of it. Another cognitively intact resident with hemiplegia, contractures, and weakness reported they were supposed to get out of bed for two hours daily, but some NACs did not know this, even though the MAR/TAR contained an order to document times up and back to bed. The surveyors concluded that care plans were not accurately revised for several residents, placing them at risk for unidentified and unmet care needs and diminished quality of life.
Surveyors found that two residents with hemiplegia, hemiparesis, weakness, and contractures did not receive restorative nursing services, including ROM exercises and splint/brace or orthotic assistance, after therapy discharge. Although PT and OT discharge summaries documented established restorative ROM and transfer programs, recommended PROM to affected extremities, and recommended splint/brace use and assistance with orthotic wear, these recommendations were not entered as restorative referrals in the EHR. As a result, the residents’ care plans and records showed no restorative programs, and both residents reported that therapy and restorative exercises had stopped, while the DON, rehab director, and MDS coordinator confirmed they were unaware of and had not implemented the recommended restorative services.
A resident with cancer, cognitive impairment, and declining strength experienced multiple unwitnessed falls, most occurring while attempting to toilet or move toward the bathroom, culminating in a fractured ankle requiring ED treatment. Although assessments identified fall and incontinence risks and the facility’s policy required individualized interventions, the comprehensive care plan lacked a toileting plan and did not include several interventions that were discussed in incident investigations, such as consistent wheelchair placement and frequent rounding for bathroom assistance. Staff reported relying on verbal reminders and education to use the call light, despite acknowledging the resident’s impulsivity and failure to call for help, and the resident’s bed remained furthest from the bathroom while repeated bathroom-related falls occurred without the trend being recognized or addressed in the care plan.
A resident with a history of acute urinary retention and acute kidney injury had a Foley catheter deemed permanent by the hospital, with instructions that it not be removed in the SNF. At a later urology visit, the catheter was removed, and the resident returned with no new orders documented. Facility staff did not document bladder assessments, post-void residuals, or urine output, and CNA documentation showed the resident did not void that evening. Over the next day, the resident had vomiting, poor intake, altered level of consciousness, tachycardia, hypotension, and no documented wet briefs. A bladder scan eventually showed more than 2000–2500 mL of retained urine, and a new catheter drained a large volume. The resident and a roommate reported moaning, crying out in pain, and repeatedly alerting staff that the resident was not urinating and that the catheter was not draining, while nurses documented catheter care when no catheter was in place and later had to flush and replace the catheter due to continued complaints.
Surveyors found that nurses and nurse aides did not consistently administer medications according to professional standards and facility policy. Multiple residents reported that agency nurses were slow with medications, did not fully follow instructions, and often gave routine meds late. Observations showed an LPN administering expired Humalog/Lispro insulin well past the scheduled time, an LPN giving several scheduled meds (including Tizanidine) late and all at once, and an RN attempting to give sliding-scale insulin nearly two hours late, which a resident refused after already eating. Another resident received Methocarbamol two hours late after questioning the RN, and a resident on scheduled Tramadol had doses given without timely documentation, with a discrepancy between the narcotic count and pills remaining. These events demonstrated failures in timely administration, use of non-expired medications, and immediate, accurate MAR and narcotic documentation.
Failure to Notify Court-Appointed Guardian of Resident’s Clinical Changes
Penalty
Summary
The deficiency involves the facility’s failure to notify a resident’s court-appointed guardian of significant clinical changes and care decisions, contrary to its own policy and state requirements. The facility’s policy on Resident Representatives, revised 02/2021, states that a resident representative includes a court-appointed guardian or conservator and that the facility treats the representative’s decisions as those of the resident to the extent delegated or required by the court. Resident 1, admitted with cerebral palsy, had a Superior Court guardianship letter dated 02/07/2025 indicating a guardian of person and conservator of the estate with full authority, identifying Collateral Contact 1 (CC1) as the guardian. Despite this, multiple clinical events and changes in condition were documented without any corresponding documentation that CC1 was notified. Progress notes and provider notes show that Resident 1 experienced an episode of nausea and vomiting, frequent loose stools, abdominal discomfort, bloating, worsening fatigue, generalized weakness, and later refusal of meals and medications over at least a 24-hour period, with observations that the resident appeared frailer, more fatigued, and had no energy or interest to talk. The provider developed care plans including close monitoring for deterioration, sending stool to the lab, and later initiating IV fluids for rehydration, with a plan to call family/POA for discussion. However, there was no documentation that the guardian was notified at any of these points, including when IV fluids were started. CC1 reported that they were not contacted when the resident stopped eating or developed stomach issues, and expressed that the facility did not respect their guardianship and that involvement in care planning took too long. The DON confirmed on record review that there were many opportunities to notify the guardian when the resident’s condition changed from baseline and that there was no evidence staff did so.
Failure to Thoroughly Investigate and Resolve Resident Grievance Regarding Incontinence Care and Staff Conduct
Penalty
Summary
The deficiency involves the facility’s failure to thoroughly investigate and resolve a grievance alleging neglect and disrespect toward a resident, as required by its grievance policy. The resident had depression, anxiety, moderate cognitive impairment, occasional urinary incontinence, and required moderate assistance with toileting, with a care plan directing staff to check the resident every two hours, ask about toileting needs, and ensure they were clean and dry. A collateral contact reported arriving to visit the resident and finding them soaking wet and agitated, with behavior that was not typical for the resident. The collateral contact documented in a written grievance that the resident’s tablet was off, the resident appeared upset, and the resident reported being told they had to wait five minutes to be changed and that staff would change their “nasty *ss” in five minutes, leading the collateral contact to believe the resident had been given a consequence of no tablet and sitting in wet clothes, which they characterized as abuse/neglect and requested immediate removal of the responsible staff and a report filed. The facility documented receipt of the grievance and created an incident report indicating the matter was reported to the state agency, and that the unit manager interviewed the collateral contact and the resident, with the resident described as confused and denying being soaking wet. The incident report stated that a different nursing assistant was assigned to assist with the brief change and that the unit manager believed the resident was not soaking wet, and that the resident and collateral contact were satisfied when they left the room. However, a CNA who actually changed the resident reported that the resident’s brief was soaked through their pants onto the wheelchair and their socks were soaked, and that the resident was timid, repeatedly saying they had to sit for five minutes, and not acting like themselves; this CNA stated they were never interviewed or asked about the grievance or the resident’s condition. The DON acknowledged not interviewing this CNA or investigating the resident’s behavior and why they were upset, and the unit manager did not recall whether the collateral contact was present during follow-up and did not believe they followed up with the collateral contact regarding the grievance. The administrator, identified as the Grievance Official, stated the facility should have thoroughly investigated the grievance and discussed findings and resolution with the collateral contact, indicating the grievance process was not fully carried out in accordance with policy and WAC 388-97-0460.
Failure to Obtain Timely Emergency Transport for Resident in Respiratory Distress
Penalty
Summary
The deficiency involves the facility’s failure to obtain timely emergency medical services for a resident experiencing new-onset respiratory distress. The resident had dementia, respiratory failure, and heart failure, with severe cognitive impairment and a need for substantial assistance with activities of daily living. On the day the resident was sent to the hospital, a collateral contact observed the resident having difficulty breathing, appearing unable to get enough air, and looking as if they were sleeping or unconscious, and reported this to staff with a request to contact the doctor. An SBAR Communication Form documented that the resident was experiencing shortness of breath that had not occurred before, with an oxygen saturation of 90%. The physician was notified and ordered the resident sent to the emergency department for treatment and evaluation, and the collateral contact was notified shortly thereafter. Progress notes later documented that, despite the order for emergency department transfer, the resident was still awaiting pickup by Olympic transportation several hours later, with no estimated time of arrival. At approximately 3:30 AM, the dispatcher informed the facility that they could not provide transportation and instructed that 911 be called; only then was 911 contacted and the resident transported to the hospital via ambulance for respiratory distress. The RN caring for the resident stated they completed the SBAR, notified the physician and family, and at the end of their shift reported to the oncoming nurse that the resident needed to be sent to the emergency department for respiratory distress and that paramedics should be contacted, then left assuming 911 would be called. The DON stated that staff are expected to contact 911 for emergent conditions such as shortness of breath or respiratory distress, and that Olympic Ambulance is used only for non-emergent transport.
Failure to Provide Social Service Advocacy After Abuse Allegation and Questionable Representative
Penalty
Summary
The deficiency involves the facility’s failure to provide appropriate medically-related social services and advocacy for a resident following an allegation of abuse and concerns about the resident’s representative. The resident had an anoxic brain injury, dysarthria, moderate cognitive impairment, and was dependent on staff for activities of daily living. A hospital palliative care note documented that the resident lacked decisional capacity, had no DPOA, that the legal next of kin (CC4) did not want to be part of care decisions, and that care decisions were being deferred to another contact (CC5). CC5 accompanied the resident on admission, signed admission forms, and was listed as the primary contact in the medical record profile. On a date in February, during communication therapy, the resident reported that CC5 had done something to them, pounded their hands on their chest, recalled being hit in the back of the head by an unknown person, and stated they were sometimes afraid of CC5. A social services staff member reported this allegation to the state agency but did not complete a facility incident report, did not initiate care plan changes or interventions, and took no further action. CC5 continued to be treated as the resident’s representative, and progress notes documented CC5 at the bedside on multiple dates, including an entry noting the room smelled like foreign substances and that CC5 was seen waking the resident and then asking the nurse to administer pain medications. A psychiatry note later documented concern that CC5 was providing the resident with illicit substances and stated it would be prudent for the resident to identify a POA. Subsequently, the resident was found unresponsive, transported to the hospital, and later readmitted after altered mental status and overdose, with a provider note stating that CC5 posed a significant danger to the resident and was banned from visiting. After readmission, staff attempted to contact CC4 for consent to treat but initially reached someone who stated they were not CC4. The social service director acknowledged that, beyond reporting the initial allegation, no additional interventions were implemented, that CC5 continued to be used as the resident’s representative after the allegation, and that they had not explored legal authority for decision making following the abuse allegation or concerns about substances. The social service assistant reported they did not speak with the resident about the hospital stay or CC5 and did not complete an incident report or care plan changes after the allegation. The unit manager and DON were unaware of the initial abuse allegation, and the administrator, who served as abuse coordinator, also stated they were unaware of the allegation and that an investigation should have been initiated and a representative for the resident investigated at a minimum.
Injury from Mechanical Lift Sling Detachment During Transfer
Penalty
Summary
The facility failed to ensure a safe mechanical lift transfer when a resident was being moved with a Hoyer lift and sling, resulting in a fall and injury. Facility policy for using a mechanical lifting machine required staff to securely attach sling straps to the sling bar according to manufacturer’s instructions, double-check the security of the sling attachment before lifting, examine all hooks, clips, or fasteners, check strap stability, and ensure the sling bar was securely attached and sound. Despite these requirements, during a transfer for dinner, two CNAs placed the sling under the resident, attached the loops at each corner of the sling to the lift, and raised the resident off the bed into the space between the bed and wheelchair when the bottom left corner of the sling became disengaged from the lift. The resident involved had multiple diagnoses including osteoarthritis, cervical and thoracic spondylosis, and Alzheimer’s disease, with the Minimum Data Set documenting severely impaired cognitive skills for daily decision-making. The resident’s care plan required the assistance of two staff during Hoyer lift transfers. During the transfer, the resident fell approximately four feet, landing on her buttocks, bouncing, and then falling backward and striking her head on the leg of the Hoyer lift. Hospital records documented that the resident sustained an abrasion to the back of the head, fractures of the 6th, 7th, 8th, and 10th ribs, and fractures of the 1st and 2nd lumbar vertebra. Staff interviews and observations showed that staff believed the sling loops had been securely fastened and reported hearing the loops click into place before lifting. One CNA stated that they had barely lifted the resident off the bed when the bottom left loop became disconnected and the resident fell. Another CNA reported being shocked and unable to figure out what had happened. A nurse who assessed the resident and then examined the equipment after the fall noted that one of the loops of the sling had become disengaged but stated the sling appeared to be in good condition. During a later demonstration, a CNA indicated she thought one of the round metal disks on the lift might have been a little loose. Maintenance logs for Hoyer slings and lifts for the preceding months documented no concerns with the slings or lifts, and the DON acknowledged expecting a citation due to the resident’s injury from the fall.
Failure to Revise Care Plans to Reflect Resident Needs and Preferences
Penalty
Summary
The deficiency involves the facility’s failure to revise and individualize comprehensive care plans to reflect residents’ current needs and preferences, as required by its own care planning policy. For one resident with hemiplegia, hemiparesis following cerebrovascular disease, and mononeuropathy of the upper limb, the admission MDS showed intact cognition and upper extremity impairment. This resident reported having bilateral shoulder surgery and an inability to tolerate blood pressure measurements on the upper arms due to pain, and stated a preference for BP measurements on the forearms. The resident reported having informed multiple nursing staff of this preference, but staff continued to place the cuff on the upper arms. Review of the resident’s care plan and Kardex showed no interventions or instructions regarding forearm BP cuff placement. A NAC confirmed they were unaware of the preference until the resident told them directly and that this instruction was not documented in the Kardex. The RN/Unit Manager, who stated they were responsible for revising and reviewing care plans when there were changes, also confirmed they were not aware of the resident’s preference and that it should have been updated in the care plan. Another resident, readmitted with hemiplegia and hemiparesis following a nontraumatic subarachnoid hemorrhage, contracture of the left hand, and weakness, was cognitively intact and required maximum assistance for bed mobility per a quarterly MDS. This resident stated they were supposed to get out of bed for two hours every day, but some NACs were not aware of this care requirement. Review of the resident’s March 2026 MAR/TAR showed an order to document the time the resident got up and the time they returned to bed daily. The report states that, overall, the facility failed to revise care plans accurately to reflect residents’ needs for three of four residents reviewed for care plan revision, placing them at risk for unidentified and unmet care needs and a diminished quality of life.
Failure to Implement Restorative Nursing and Splint/Brace Programs After Therapy Discharge
Penalty
Summary
The deficiency involves the facility’s failure to provide restorative nursing services, including range of motion (ROM) exercises and splint/brace assistance, to maintain or prevent decline in mobility and contractures for two residents with significant motor impairments. The facility’s undated Restorative Nursing Services policy stated that residents would receive restorative care as needed to achieve and maintain optimal functioning and that residents may initiate a restorative program upon discharge from rehabilitative care. Despite this, surveyors found that residents with documented hemiplegia, hemiparesis, weakness, and contractures were not placed on restorative programs and had no restorative interventions documented in their electronic health records (EHRs). Resident 1 was admitted with hemiplegia and hemiparesis following cerebrovascular disease, a left lower leg fracture, and weakness, and the admission MDS showed intact cognition, moderate assistance needs for bed mobility and transfers, and one-sided upper and lower extremity impairment. During observation, the resident was seen lying in bed with a bent inward left forearm and hand and reported no longer receiving therapy or nursing-assisted exercises. The care plan initiated in January showed no restorative services, and the care plan history and EHR contained no restorative nursing interventions. However, the PT discharge summary from February documented that restorative ROM and transfer programs had been established and trained, including PROM to the left upper and lower extremities and stand-by assist with transfers, and the OT discharge summary recommended a splint/brace to prevent contracture. The OT stated that the splint/brace was not tried due to lack of time before insurance was discontinued, and both the Director of Rehab and the MDS coordinator confirmed there was no restorative referral in the EHR and they were unaware of the recommendations. Resident 2 was readmitted with hemiplegia and hemiparesis following a nontraumatic subarachnoid hemorrhage, a left-hand contracture, and weakness, and the quarterly MDS showed intact cognition, maximum assistance needs for bed mobility, total assistance for transfers, bilateral upper and lower extremity impairment, and no therapy or restorative programs. The resident reported that therapy had been discontinued months earlier and that no restorative staff were assisting with exercises. The care plan and EHR showed no restorative services. OT evaluation documented left upper extremity ROM impairment, a left-hand contracture, and prior use of a left orthotic to manage flexion tone, and the OT discharge summary recommended restorative care and assistance with donning/doffing the orthotic. The PT discharge summary recommended restorative programs if Medicaid Part B services did not continue. The Director of Rehab confirmed therapy was discontinued and that restorative nursing programs were recommended, but both the Director of Rehab and the MDS coordinator stated there were no restorative referrals in the EHR after readmission, and the MDS coordinator confirmed the resident had no restorative programs since readmission.
Failure to Implement Effective Fall and Toileting Interventions for High-Risk Resident
Penalty
Summary
The deficiency involves the facility’s failure to provide adequate supervision, identify fall trends, and implement progressive, resident-centered interventions for a resident with multiple falls and declining strength. The facility’s own Falls and Fall Risk Management policy required staff to identify interventions related to residents’ specific risks and causes to prevent falls and minimize complications. The resident’s Care Area Assessment identified cancer-related risks for pain, falls, and ADL decline, and stated that falls and urinary incontinence would be addressed in the care plan with an objective of improvement and risk minimization. However, the comprehensive care plan did not include a urinary or ADL care plan and contained no toileting plan, despite the resident’s identified risks and prior fall history. Over a series of falls, the resident repeatedly fell while attempting to toilet or move toward the bathroom, yet the facility did not recognize or address this pattern in its investigations or care planning. The resident had multiple unwitnessed falls: next to the bed while getting up to use the restroom, in the bathroom while standing to use the toilet, and near or in the bathroom on several occasions. Incident investigations and post-fall assessments documented environmental factors such as clutter, items on the floor, water on the floor, and issues with footwear, as well as the resident’s increasing weakness, impulsivity, poor safety awareness, and poor insight into limitations. Interventions documented in investigations and risk reviews included encouraging use of the front-wheeled walker, keeping the wheelchair and walker accessible, ensuring proper footwear and non-skid socks, and providing resident education on safe transfers, ambulation, and assistive device use. However, several of these planned interventions, including placement of the wheelchair and frequent rounding/toileting assistance, were not added to or reflected in the care plan as stated. Staff interviews further showed that the resident frequently fell while trying to go to the bathroom and that staff relied on verbal education and reminders to use the call light, even though the resident often did not use it. Staff acknowledged the resident’s impulsivity and tendency to get up independently despite instructions, and one staff member stated that nursing assistants were verbally instructed to offer bathroom assistance, but this intervention was not documented in the care plan. The resident’s bed remained the one furthest from the bathroom throughout the stay, and none of the facility’s investigations identified the trend of bathroom-related falls or addressed toileting options in the care plan. Ultimately, the resident sustained a left ankle fracture after another bathroom-related fall, requiring transfer to the emergency department for evaluation and treatment, and later records documented additional fractures and a decline in condition. The surveyors concluded that the facility’s failures placed residents at risk of repeated falls and injuries.
Failure to Monitor Urinary Retention After Foley Removal Leading to Prolonged Pain
Penalty
Summary
The deficiency involves the facility’s failure to adequately assess and monitor a resident for complications associated with an indwelling urinary catheter and urinary retention, particularly after catheter removal. The resident had a history of acute kidney injury due to urinary retention, which improved after Foley catheter placement in the hospital. Hospital discharge documentation indicated the catheter was placed for acute urinary retention, was deemed permanent, and included instructions that, given the resident’s significant retention and acute renal failure, staff at the skilled nursing facility should not attempt Foley removal. The facility’s catheter care plan directed staff to empty the catheter as needed and record output in milliliters, but review of the last 30 days of documentation showed continence was not rated due to the indwelling catheter and there was no documented urinary output in milliliters on the treatment administration records. The resident had a scheduled urology appointment at which the urinary catheter was discontinued. Upon return from this appointment, nursing documentation initially indicated no new orders, and an alert note later stated the catheter was discontinued and staff were monitoring for retention or pain. However, there was no documented bladder assessment or urinary output following catheter removal. Nursing assistant documentation showed that the resident did not void on the evening shift that same day. Despite the catheter having been removed, the treatment administration record showed staff continued to document provision of catheter care on subsequent shifts when no catheter was in place. Over the next day, the resident experienced vomiting, decreased oral intake, and an altered level of consciousness, with vital signs showing tachycardia and low blood pressure, and staff documented decreased urine output. A bladder scan performed later revealed more than 2000–2500 milliliters of urine in the bladder, and an indwelling catheter was reinserted, initially draining a large volume of urine. The provider note indicated the resident had not eaten since the prior night, was unable to hold down fluids, and staff were unsure whether the resident had urinated in incontinence briefs, with no wet briefs reported since the resident’s return from the hospital after catheter removal. The provider expressed concern that the documented early-morning wet brief might not be accurate given the large bladder volume on scan and stated this should require further investigation. Subsequent notes described the resident moaning and complaining of pain, with limited urine output in the catheter bag and staff flushing and then replacing the catheter due to continued complaints. Interviews with the resident, the roommate, and staff indicated the resident was crying out and moaning in pain, the roommate repeatedly alerted staff that the resident was not urinating and that the catheter was not draining, and staff had to seek assistance to replace the catheter. Facility leadership and clinical staff later acknowledged that typical practice after catheter removal would include contacting the provider, placing the resident on alert, performing post-void residuals with bladder scans, and documenting monitoring, which was not done in this case.
Medication Administration Delays, Documentation Errors, and Use of Expired Insulin
Penalty
Summary
The deficiency involves the facility’s failure to ensure sufficient nursing staff with appropriate competencies and skill sets to administer medications according to professional standards of practice, facility policy, and prescriber orders. The facility’s medication administration policy required medications to be given as prescribed, in accordance with manufacturers’ specifications and good nursing principles, with no expired medications used, and doses administered within 60 minutes of the scheduled time and documented immediately after administration. Multiple residents reported that agency nurses often gave medications late, did not read full instructions, or were slow in bringing medications, and that routinely scheduled medications were not consistently provided without residents having to ask. Surveyors observed several specific medication administration failures. For a resident with diabetes, an LPN drew up and administered Humalog/Lispro insulin from a multi-dose vial that had been opened and dated “02/16” with no year, making it expired per policy, and administered the dose nearly 1 hour and 45 minutes after it was due. Another resident with care plan instructions to receive medications as ordered had multiple scheduled medications (Gabapentin, Oxybutynin, Baclofen, and Tizanidine) that were ordered at specific times throughout the day; the LPN was observed administering all four together and acknowledged that at least one (Tizanidine) was late, while the resident reported that receiving them together at that time was typical and not at their request. For another diabetic resident, an RN checked blood sugar and prepared sliding scale Humalog/Lispro insulin almost two hours after the scheduled time; the resident refused the insulin, stating they had already finished lunch. Additional deficiencies were identified with other residents’ pain and scheduled medications. One resident with a pain care plan and an order for Methocarbamol four times daily at set times approached the cart requesting Methocarbamol and Tylenol; the RN initially stated the Methocarbamol had already been given, but then administered it two hours after it was due when the resident pointed out the scheduled timing. For another resident with a risk for pain care plan and Tramadol ordered three times daily at specific times, an LPN retrieved a PRN pain medication while the electronic record showed no 8:00 AM medications documented; the LPN stated they had given them but had not yet documented. Later, an RN prepared the 2:00 PM Tramadol dose, and review of the narcotic count showed a discrepancy between the number of pills documented and the number remaining in the card. The RN stated they had given the 8:00 AM Tramadol but had not signed it out, then signed out both the 8:00 AM and 2:00 PM doses at that time. Residents interviewed consistently reported that medications were sometimes or frequently late, that agency nurses did not always follow instructions, and that they often had to request medications that were routinely scheduled.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release May 27, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
