Pine Ridge Post Acute
Inspection history, citations, penalties and survey trends for this long-term care facility in Edmonds, Washington.
- Location
- 21008 76th Avenue West, Edmonds, Washington 98026
- CMS Provider Number
- 505527
- Inspections on file
- 25
- Latest survey
- March 25, 2026
- Citations (last 12 mo.)
- 18
Citation history
Health deficiencies cited at Pine Ridge Post Acute during CMS and state inspections, most recent first.
A resident with dementia and severe cognitive impairment experienced a fall resulting in a hematoma and nasal fracture. The facility's investigation did not include required interviews with the social worker who reported the fall, the resident's representative present at the time, or all relevant staff, and contained conflicting information about the resident's cognition. This incomplete investigation did not meet the facility's policy for abuse and neglect investigations.
A resident with moderately impaired thinking and at risk of elopement was found away from the facility. A wander alarm was placed on the resident, but the care plan was not updated when the alarm was moved from the ankle to the wheelchair. Staff confirmed the care plan should have been revised to reflect this change.
A resident with moderately impaired thinking and a history of elopement attempts left the facility unsupervised and was found by law enforcement at a store 1.5 miles away. The resident, who used a wheelchair, fell and sustained a knee injury. Staff confirmed the resident's risk for elopement and the unsuitability of leaving unsupervised.
The facility failed to adequately monitor the use of diuretics, anticoagulants, and antibiotics for several residents, as evidenced by the lack of documentation in the MAR/TAR. Staff interviews revealed that monitoring was expected to occur through care plans and alert charting, but this was not consistently documented. Residents on medications such as furosemide, apixaban, and doxycycline were at risk due to insufficient monitoring practices.
The facility failed to routinely check the dishwasher temperature and test the sanitizing solution, as required by professional standards for food service safety. The Dietary Director and Aide admitted to not logging the necessary information due to a lack of test strips, leading to incomplete records. This oversight placed residents at risk for foodborne illness.
The facility failed to implement Enhanced Barrier Precautions for a resident with a feeding tube, as required by policy. Additionally, clean linens were improperly handled, and medical equipment, including glucometers and vital signs equipment, was not disinfected after use with residents. Staff interviews confirmed lapses in following infection control guidelines.
A facility failed to obtain informed consent before administering psychotropic medications to a resident with depression, insomnia, and anxiety. Despite the facility's policy requiring informed consent, there was no documentation of consent for the prescribed medications, including Trazodone, Sertraline, and Buspirone. Staff interviews confirmed the expectation of obtaining consent, but records showed no evidence of informing the resident or their representative about the risks and benefits.
A resident requiring assistance for bed mobility reported discomfort due to the lack of fitted sheets on their air mattress, leading to sleepless nights. Despite requests, staff cited regulations against fitted sheets, yet observations showed other residents with fitted sheets on similar mattresses. Staff interviews revealed inconsistencies in practices and a lack of awareness of the resident's needs.
A facility failed to ensure a resident's advance directive was properly completed. The resident's DPOA form, signed in 2019, lacked notarization or witness signatures as required by state law. The Social Services Director acknowledged the oversight, noting the resident has a guardian. This failure risked the resident's healthcare preferences not being honored.
A facility failed to provide a written transfer or discharge notice to a resident and/or their representative, as required by regulations. The resident was discharged to an acute hospital twice due to a change in condition, but no documentation of the notice was found in the EHR. Interviews with staff confirmed the absence of the notice, despite the facility's policy requiring it.
A facility failed to provide a bed hold notice to a resident or their representative during a transfer to a hospital, as required by policy. The oversight was confirmed through record reviews and staff interviews, indicating a lapse in following the facility's procedures for informing residents of their rights during transfers.
The facility failed to accurately assess two residents' MDS, leading to omissions and inaccuracies. One resident's antibiotic use was not recorded, and another's MDS inaccurately marked surgical wound care. These errors were acknowledged by the MDS Coordinator, highlighting deficiencies in the assessment process.
A facility failed to complete a PASARR Level I for a resident with major depressive disorder, as the form did not indicate a mood disorder despite the resident's diagnosis and prescription for antidepressants. The Social Services Director admitted the oversight, and a new PASARR was only completed 22 days after admission, delaying necessary evaluations.
A facility failed to notify the State PASARR Coordinator after a resident with SMI experienced a significant change in condition, including electing hospice services and being certified with a terminal illness. Despite the facility's policy requiring notification, staff did not inform the state authorities, placing the resident at risk for unmet care needs.
The facility failed to develop and implement comprehensive care plans for two residents, leading to unmet care needs. One resident had incomplete plans for skin, pain, vision, antibiotic use, and urostomy, while another resident with diabetes and blindness had unaddressed nail care needs. Staff interviews confirmed the lack of necessary goals and interventions in the care plans.
A resident with diabetes and legal blindness did not receive necessary nail care, resulting in long, untrimmed fingernails with debris. Despite the facility's policy, staff failed to coordinate and provide timely nail care, as observed in multiple instances. Interviews revealed a lack of communication and missing physician orders for nail trimming.
A facility failed to follow physician orders for a resident discharged with abdominal drains, as the orders to empty and document drain output daily were not implemented until 19 days after admission. Staff interviews confirmed the oversight, acknowledging that the orders should have been followed from the time of admission.
The facility failed to properly maintain, label, date, and store respiratory equipment for three residents, leading to deficiencies in care. A resident's oxygen tubing was not changed as required, and another resident's nebulizer mask was improperly stored. Additionally, a resident received oxygen at a higher rate than ordered without proper documentation. Staff interviews confirmed these lapses in following physician orders and facility policies.
A resident with a history of falls and osteoporosis fell and fractured their right leg during therapy due to the therapist's failure to use a required gait belt and provide hands-on contact, as per facility policy.
Failure to Thoroughly Investigate Resident Fall Incident
Penalty
Summary
The facility failed to thoroughly investigate a fall incident involving a resident with severe cognitive impairment and dementia. The resident, who was on a blood thinner, experienced a fall resulting in a hematoma and nasal fracture. The investigation report did not include interviews with key individuals such as the social services director who initially reported the fall, the resident's representative who was present at the time, or other staff who had contact with the resident during the incident. There were also conflicting statements regarding the resident's cognitive status and insufficient documentation of how the fall was discovered and managed. The facility's policy requires that all reports of abuse, neglect, or injuries of unknown origin be thoroughly investigated, including interviews with the person reporting the incident, the resident or their representative, staff on all shifts, and documentation of the investigation. However, the investigation into this incident lacked interviews from the social worker who reported the fall and the resident's representative, despite both being directly involved or present. The investigation also failed to clarify how the social worker became aware of the fall and did not include statements from all relevant staff. Staff interviews revealed uncertainty about the reporting process and the thoroughness of the investigation. The DON and other staff acknowledged that interviews with the social worker and the resident's representative would be expected, but these were not conducted. The investigation report contained inconsistencies and did not fully comply with the facility's own policy for abuse and neglect investigations, leading to an incomplete assessment of the incident.
Failure to Revise Elopement Care Plan
Penalty
Summary
The facility failed to revise the elopement care plan for a resident who was at risk of elopement. The resident, who had moderately impaired thinking and used a wheelchair for mobility, was found by local law enforcement approximately 1.5 miles away from the facility. Following this incident, a wander alarm was placed on the resident to alert staff when the resident approached monitored exit doors. However, the care plan was not updated to reflect changes in the placement of the wander alarm. Initially, the wander alarm was placed on the resident's left ankle, as indicated in the care plan. However, it was later moved to the arm of the resident's wheelchair at the resident's request. Despite this change, the care plan was not revised to reflect the new location of the wander alarm. Staff interviews confirmed that the care plan should have been updated to ensure consistency with the actual placement of the wander alarm.
Resident Elopement Due to Inadequate Supervision
Penalty
Summary
The facility failed to provide necessary supervision, resulting in the elopement of a resident with moderately impaired thinking who used a wheelchair for mobility. The resident, identified as being at risk for elopement upon admission, left the facility unsupervised and was found by local law enforcement at a store approximately 1.5 miles away. The resident had a history of elopement attempts and was known to sit by the door, indicating a desire to leave. Surveillance footage confirmed the resident left the facility at 12:47 AM by entering the code to open the door. Upon being found, the resident reported falling out of their wheelchair while attempting to navigate a curb, resulting in a bruise and scratch on their left knee. The resident was assisted by strangers and subsequently returned to the facility by law enforcement. Interviews with staff, including a CNA, LPN, Resident Care Manager, and Assistant Director of Nursing Services, confirmed the resident's risk for elopement and the unsuitability of leaving the facility unsupervised, especially at night.
Inadequate Monitoring of Medications
Penalty
Summary
The facility failed to ensure adequate monitoring for the use of diuretics, anticoagulants, and antibiotics for several residents, leading to potential risks of unnecessary medications and adverse side effects. Resident 3, who was on furosemide for congestive heart failure, was not adequately monitored for diuretic use as indicated by the absence of documentation in the Medication Administration Record (MAR) and Treatment Administration Record (TAR). Staff interviews revealed that monitoring was expected to occur for three days after initiating the medication, but this was not reflected in the records. Resident 26 was prescribed both furosemide and apixaban, yet there was no documentation of monitoring for either medication in the MAR/TAR. Staff indicated that monitoring was included in the care plan rather than the MAR/TAR, and residents were placed on alert charting for 72 hours when starting these medications. Similarly, Resident 28, who was on apixaban for atrial fibrillation, also lacked documentation of monitoring in the MAR/TAR, with staff stating that monitoring was part of the care plan. Resident 10, also on apixaban, showed no evidence of monitoring for anticoagulant use in the MAR/TAR, with staff indicating that monitoring was done through care plans and documented by exception. Resident 11 was on doxycycline without a stop date and lacked documentation of monitoring for antibiotic use. Staff interviews revealed that there was no active monitoring for adverse side effects, and Resident 11 did not have a care plan for antibiotic use, which should have included monitoring interventions.
Failure to Monitor Dishwasher Temperature and Sanitizer Levels
Penalty
Summary
The facility failed to ensure that the dishwasher temperature was checked and the sanitizing solution was tested routinely in accordance with professional standards for food service safety. This deficiency was identified during an observation and interview with the Dietary Director and Dietary Aide, who stated that they were responsible for checking the dishwasher temperature and sanitizer concentration three times a day. However, the December 2024 Dishwasher Temperature/Sanitizer Log form was found to be incomplete, with missing entries for specific dates. Staff K admitted that they had run out of test strips and were unable to test the sanitizing solution, leading to a lapse in the required safety checks. The facility's policy, adopted on August 1, 2024, mandates that dishes and other multi-use items be cleaned and sanitized properly after each use, with proper logging of temperatures. Despite this policy, the staff failed to log the necessary information, and the Dietary Director confirmed the expectation for staff to perform these checks and maintain records. The Administrator also acknowledged the expectation for staff to adhere to the facility's process for checking dishwasher temperatures and testing the sanitizing solution. These failures placed residents at risk for foodborne illness and a diminished quality of life.
Infection Control Deficiencies in EBP and Equipment Disinfection
Penalty
Summary
The facility failed to implement Enhanced Barrier Precautions (EBP) for Resident 119, who was admitted with a feeding tube. Despite the facility's policy requiring gown and glove use for residents with feeding tubes, observations revealed that no EBP signage or personal protective equipment (PPE) cart was present outside Resident 119's room. Staff members, including LPNs and the Resident Care Manager, acknowledged that Resident 119 should have been on EBP since admission, but they were not following the necessary precautions. Additionally, the facility did not adhere to proper infection control practices regarding the handling of clean linens. A Certified Nurse Assistant was observed carrying clean towels and linens against their body, contrary to the facility's policy that requires linens to be carried away from the body to prevent contamination. Interviews with staff confirmed that clean linens should not touch staff clothing, indicating a lapse in following established infection control guidelines. The facility also failed to disinfect medical equipment, such as glucometers and vital signs equipment, after use with residents. Observations showed that LPNs did not sanitize glucometers after checking blood sugar levels for two residents, and vital signs equipment was not disinfected after use with two other residents. Staff interviews revealed a lack of adherence to the facility's infection control policies, which require equipment to be cleaned and disinfected between resident uses to prevent the transmission of infections.
Failure to Obtain Informed Consent for Psychotropic Medications
Penalty
Summary
The facility failed to inform a resident and/or their representative before administering psychotropic medications, which is a violation of their policy and regulatory requirements. The resident, identified as Resident 10, was admitted with diagnoses including depression, insomnia, and anxiety. The facility's policy on psychotropic medication use, revised in July 2022, mandates that residents or their representatives must be informed of the risks and benefits of such medications before administration. However, a review of the clinical records revealed that there was no documentation of informed consent for the psychotropic medications prescribed to Resident 10, which included Trazodone, Sertraline, and Buspirone. Interviews with facility staff, including the Resident Care Manager, Regional Clinical Nurse, and Assistant Director of Nursing, confirmed that informed consent was expected to be obtained and documented prior to administering psychotropic medications. Despite this expectation, the records lacked evidence of informed consent for Resident 10's medications. Staff acknowledged the absence of initial informed consents and the failure to provide information related to the risks and benefits of the medications to the resident or their representative, as required by the facility's policy and regulatory standards.
Failure to Provide Comfortable Bed Sheets for Resident
Penalty
Summary
The facility failed to provide a comfortable bed sheet for Resident 10, who required maximum physical assistance for bed mobility and total assistance for transfers. Resident 10 reported discomfort due to the lack of fitted sheets on their air mattress, which caused the flat sheet to slip, leaving them lying on the cold vinyl surface. Despite the resident's repeated requests for a fitted sheet, staff informed them that it was against regulations to use fitted sheets on air mattresses, citing safety concerns. However, observations revealed that fitted sheets were available in the facility's linen rooms, and other residents with air mattresses were using fitted sheets. Interviews with staff members, including a CNA and the Assistant Director of Nursing, indicated a lack of awareness and inconsistency in the facility's practices regarding the use of fitted sheets on air mattresses. Staff members provided conflicting information about the safety and regulations concerning fitted sheets, and there was no evidence that Resident 10's preferences were adequately considered or addressed. This oversight placed Resident 10 at risk for unmet care needs and discomfort, as their concerns about the bed sheets were not communicated or resolved effectively.
Failure to Complete Advance Directive for a Resident
Penalty
Summary
The facility failed to ensure that an advance directive was properly obtained and completed for one of the residents reviewed. Specifically, Resident 4's Durable Power of Attorney (DPOA) form, which was signed and dated in 2019, was not notarized or witnessed by two different witnesses as required by Washington State law. This oversight was identified during a joint record review with the Social Services Director, who acknowledged the incomplete status of the DPOA form and mentioned that Resident 4 has a guardian. The facility's policy on advance directives, revised in September 2022, mandates that the social services director or designee inquire about the existence of any written advance directives prior to or upon a resident's admission. If a resident or their representative has not established an advance directive, the facility staff is expected to offer assistance in doing so. However, in this case, the staff did not ensure that Resident 4's advance directive was completed according to the legal requirements, placing the resident at risk of not having their healthcare preferences honored.
Failure to Provide Written Transfer/Discharge Notice
Penalty
Summary
The facility failed to provide a written transfer or discharge notice to a resident and/or their representative, as required by state and federal regulations. This deficiency was identified during a review of the facility's policy titled 'Notice of Transfer or Discharge,' which mandates the provision of written notice in accordance with regulations. The review of Resident 27's discharge Minimum Data Set and nursing progress notes indicated that the resident was discharged to an acute hospital on two separate occasions due to a change in condition. However, there was no documentation in the resident's Electronic Health Record (EHR) that a written notice of transfer or discharge was provided. Interviews with facility staff, including the Regional Nurse, Assistant Director of Nursing, and Administrator, confirmed that no written notice was given to Resident 27 or their representative. Staff F, the Regional Nurse, acknowledged the absence of the written notice in the EHR, and Staff B, the Assistant Director of Nursing, confirmed that no notice was provided. The Administrator stated that it was expected for staff to provide such notices, indicating a lapse in following the facility's policy and regulatory requirements.
Failure to Provide Bed Hold Notice During Hospital Transfer
Penalty
Summary
The facility failed to provide a bed hold notice to a resident or their representative during a transfer to an acute hospital. The facility's policy, revised on April 7, 2023, mandates that upon transfer, the resident and/or their representative should be offered the option to hold the bed, and a copy of the bed hold policy should be provided. However, a review of Resident 27's records, including the discharge Minimum Data Set and nursing progress notes, revealed no documentation that such a notice was offered or provided when the resident was transferred to the hospital on October 3, 2024. Interviews with facility staff, including the Regional Nurse, Assistant Director of Nursing, and Administrator, confirmed that the bed hold notice was not offered or provided to Resident 27 or their representative. This oversight placed the resident or their representative at risk of not being informed about their right to hold the bed during the hospital stay, as required by the facility's policy and regulatory standards.
Inaccurate MDS Assessments for Two Residents
Penalty
Summary
The facility failed to accurately assess two residents, leading to deficiencies in their Minimum Data Set (MDS) assessments. For one resident, the November 2024 Medication Administration Record (MAR) and Treatment Administration Record (TAR) indicated the use of bacitracin ointment, a topical antibiotic, over a five-day period. However, this antibiotic use was not marked in Section N of the resident's admission MDS. The MDS Coordinator, Staff J, acknowledged the omission and confirmed that the bacitracin should have been included, indicating an inaccurate assessment. For another resident, the admission MDS inaccurately marked surgical wound care in Section M, despite the absence of a surgical wound care treatment order during the look-back period. The November 2024 TAR showed orders to flush a drain, which Staff J clarified was not a skin treatment. This discrepancy further highlighted the inaccuracy in the resident's MDS assessment. These failures in accurate assessment placed the residents at risk for unidentified and/or unmet care needs, potentially affecting their quality of life.
Failure to Complete PASARR Level I for Resident with Depression
Penalty
Summary
The facility failed to ensure the completion of a Preadmission Screening and Resident Review (PASARR) Level I for a resident with a diagnosis of major depressive disorder. Upon admission, the resident's PASARR Level I form did not indicate the presence of a mood disorder, despite the resident having a diagnosis of depression and being prescribed an antidepressant medication shortly after admission. This oversight meant that the resident was not flagged for a Level II evaluation, which is necessary to determine if additional mental health services are required. The facility's policy requires that the Admissions Coordinator, Medical Records Director, or designee ensure a PASARR Level I is included in the admission paperwork and updated as necessary. However, the Social Services Director acknowledged that the PASARR form for the resident was not updated to reflect the diagnosis of depression, and a Level II evaluation was not requested in a timely manner. It was only 22 days after the resident's admission that a new Level I PASARR was completed and sent for a Level II evaluation, indicating a lapse in the facility's adherence to its own procedures.
Failure to Notify State PASARR Coordinator of Significant Change in Resident's Condition
Penalty
Summary
The facility failed to notify the State PASARR Coordinator after a significant change in condition occurred for a resident with serious mental illness (SMI). The resident, who was admitted with diagnoses including bipolar disorder, anxiety disorder, and major depressive disorder, had a Level I PASARR indicating SMI and was referred for a Level II PASARR evaluation. Despite a significant change in status, as evidenced by the resident electing to receive hospice services and being certified with a terminal illness, the facility did not notify the appropriate state authorities as required by their policy. Interviews with facility staff revealed that the Social Services Director acknowledged the resident's Level II PASARR related to SMI but admitted to not notifying the state mental health authority or the PASARR Coordinator about the resident's significant change in status. The facility's administrator also confirmed the expectation that staff should notify the State PASARR Coordinator when such changes occur, indicating a lapse in following established procedures. This oversight placed the resident at risk for unmet care needs and a diminished quality of life.
Incomplete Care Plans and Unmet Care Needs for Two Residents
Penalty
Summary
The facility failed to develop and implement comprehensive, person-centered care plans for two residents, leading to unmet care needs. Resident 11, who was admitted with an ostomy, antibiotics, and opioid use, had incomplete care plans for skin, pain/opioid use, vision, antibiotic use, and urostomy. Staff interviews confirmed that the care plans lacked necessary goals and interventions, which were required to address the resident's specific needs. Resident 20, admitted with type 2 diabetes and legal blindness, required assistance with personal hygiene. Observations revealed that the resident had long, untrimmed fingernails with debris, which were not addressed despite being part of the care plan. Staff interviews indicated that the responsibility for nail care was not properly executed, as the care plan specified that a nurse should trim the nails due to the resident's diabetes. The failure to follow the care plan resulted in the resident experiencing discomfort.
Failure to Provide Nail Care for Diabetic Resident
Penalty
Summary
The facility failed to provide necessary assistance with nail care for a resident, identified as Resident 20, who was unable to perform this activity independently. Resident 20, who was admitted with diagnoses including type 2 diabetes mellitus and legal blindness, required set-up assistance with personal hygiene. Observations on two separate occasions revealed that Resident 20 had long, untrimmed fingernails with brown debris underneath, which were causing discomfort. Despite the resident's requests and the facility's policy to maintain personal hygiene, the necessary nail care was not provided. Interviews with staff members revealed a lack of coordination and communication regarding the responsibility for nail care, particularly for residents with diabetes. Staff N, a CNA, indicated that shower aides typically cut residents' nails, but for those with diabetes, a nurse should perform the task. However, Staff O, an LPN, acknowledged the oversight and offered to cut the resident's nails. Further, Staff E, the Resident Care Manager, noted that a physician's order was required for nail trimming for diabetic residents, which was missing in Resident 20's records. The Assistant Director of Nursing, Staff B, confirmed that nurses should provide nail care for diabetic residents and expected CNAs to coordinate with nurses to ensure timely nail care, which did not occur in this case.
Failure to Follow Physician Orders for Drain Management
Penalty
Summary
The facility failed to implement and follow physician orders for a resident who was discharged from the hospital with abdominal drains. The hospital discharge orders required the facility to empty and record the output from the drains at least once a day and to document this information. However, upon review, it was found that there were no orders or documentation indicating that the resident's drain was emptied or that the drainage output was recorded daily until 19 days after the resident's admission to the facility. Interviews with facility staff, including the Resident Care Manager and the Assistant Director of Nursing, confirmed that the orders to manage the resident's drain were not followed as per the hospital's discharge instructions. The staff acknowledged that the orders should have been implemented from the time of the resident's admission, but they were only started much later. This oversight placed the resident at risk of not receiving necessary care services and having unmet care needs.
Deficiencies in Respiratory Care and Equipment Management
Penalty
Summary
The facility failed to maintain, label, date, and properly store oxygen tubing, nasal cannula, and nebulizer masks for three residents, leading to deficiencies in respiratory care. Resident 5 had an order for oxygen at 2 liters via nasal cannula at bedtime for sleep apnea, but there was no documentation indicating that the oxygen tubing had been changed in November or December 2024. Observations revealed that Resident 5's nasal cannula was improperly stored and not labeled or dated. Interviews with staff confirmed that the nasal cannula should have been stored in a bag and dated, but it was not changed because there were no issues reported. Resident 32 had an order for oxygen at 2 liters per minute via nasal cannula, but their oxygen tubing was also not labeled or dated. During an observation, it was noted that Resident 32's nasal cannula was undated, and the oxygen concentrator had an undated bottle of distilled water attached. Staff interviews revealed that the facility had stickers for labeling, but the tubing was not dated, and there was no order to change the oxygen tubing documented in the MAR. Resident 120 had orders for inhalation medication via nebulizer four times a day and oxygen at 2 liters per minute continuously. However, the nebulizer mask was not properly stored, and the oxygen tubing and nasal cannula were undated. Observations showed that Resident 120 was receiving oxygen at a higher rate than ordered, and there was no physician order to increase the oxygen during activity. Staff interviews confirmed that the nebulizer mask should have been stored in a bag and that the oxygen orders were not followed correctly.
Failure to Use Required Assistive Device During Therapy
Penalty
Summary
The facility failed to ensure the use of a required assistive device, specifically a gait belt, and hands-on contact during therapy for a resident with a history of falls and osteoporosis. The resident, who required assistance for activities of daily living, experienced a fall in the therapy gym while working with a therapist. The resident's right knee gave out, leading to a fall on their right hip and back, resulting in a right leg fracture and subsequent hospitalization. Interviews with staff, including the Director of Rehabilitation and a Physical Therapy Assistant, confirmed that it was the policy and procedure of the therapy department to use a gait belt when working with residents on exercise equipment. The staff acknowledged that the therapist should have used a gait belt and provided contact guard assistance to stabilize the resident during the exercise. The failure to adhere to these policies placed the resident at risk for falls and injury.
Latest citations in Washington
A resident with cerebral palsy and a court-appointed guardian experienced multiple episodes of nausea, vomiting, loose stools, abdominal discomfort, fatigue, and later refusal of meals and medications, leading to changes in the care plan including close monitoring, lab testing, and IV fluid administration. Despite a facility policy recognizing court-appointed guardians as resident representatives with decision-making authority, staff did not document any notification to the guardian during these changes in condition or treatment decisions. The guardian reported not being contacted when the resident stopped eating or developed stomach issues and felt the facility did not respect the guardianship, while the DON acknowledged there were multiple missed opportunities to notify the guardian of the resident’s change from baseline.
A resident with depression, anxiety, moderate cognitive impairment, and urinary incontinence, care-planned for q2h checks and assistance with toileting, was found by a visitor to be soaking wet, unusually agitated, and reporting they had been told to wait to be changed and referred to with a derogatory remark. The visitor filed a written grievance alleging abuse/neglect related to delayed incontinence care and removal of the resident’s tablet as a consequence. Although an incident report noted that the matter was reported to the state and that the resident was not soaking wet, a CNA who actually changed the resident later reported the resident’s brief, pants, wheelchair, and socks were soaked and that the resident was acting timid and repeatedly saying they had to sit for five minutes, but this CNA was never interviewed. The DON acknowledged not investigating the resident’s behavior or interviewing this CNA, and the grievance official acknowledged the facility did not fully investigate or communicate findings and resolution to the complainant, resulting in a failure to follow the facility’s grievance policy.
A resident with dementia, respiratory failure, and heart failure developed new shortness of breath with an O2 sat of 90%, and a physician ordered transfer to the ED for tx and eval. An RN completed an SBAR, notified the MD and family, and reported to the oncoming nurse that the resident needed ED transfer and that paramedics should be contacted, then left the facility. Instead of calling 911 for this emergent respiratory distress, staff arranged non-emergent transport through a contracted ambulance service, resulting in the resident remaining at the facility for several hours without pickup until the dispatcher later instructed staff to call 911. The DON stated that 911 is expected to be used for emergent conditions and the contracted service only for non-emergent transport.
A resident with anoxic brain injury, dysarthria, and documented lack of decisional capacity alleged physical abuse and expressed fear of their identified representative, yet social services only reported the allegation to the state and did not complete an incident report, revise the care plan, or implement protective interventions. The same representative continued to be treated as the resident’s decision-maker and visited frequently, with staff noting suspicious odors of foreign substances and concerns about possible illicit substance use. Psychiatry later documented concern that the representative was providing illicit substances, and the resident was subsequently hospitalized for altered mental status and overdose, after which the representative was banned. Key staff, including the DON, unit manager, and administrator/abuse coordinator, were unaware of the initial abuse allegation, and social services did not timely explore or clarify legal decision-making authority or alternative representation for the resident.
A resident with severe cognitive impairment, osteoarthritis, and spinal spondylosis, care planned for 2-person Hoyer transfers, was being moved by two CNAs using a mechanical lift when one corner loop of the sling became disengaged, causing the resident to fall about four feet, strike the floor and the lift, and sustain head abrasion, multiple rib fractures, and lumbar vertebral fractures. Facility policy required staff to verify secure sling attachment, examine hooks, clips, fasteners, and strap stability, and ensure the sling bar was sound before lifting, but during this transfer the sling loop detached despite staff believing it was properly fastened and hearing it click into place; post-incident assessment showed the loop had come loose, the sling appeared in good condition, and a CNA later reported thinking one of the round metal disks on the lift might have been slightly loose, while maintenance logs documented no prior concerns with the lifts or slings.
The facility failed to revise and individualize care plans to reflect current needs and preferences for multiple residents, including one cognitively intact resident with hemiplegia, hemiparesis, and mononeuropathy who had bilateral shoulder surgery and could not tolerate BP measurements on the upper arms but preferred forearm readings. Despite repeatedly informing staff, this preference was not documented in the care plan or Kardex, and direct care staff and the RN/UM were unaware of it. Another cognitively intact resident with hemiplegia, contractures, and weakness reported they were supposed to get out of bed for two hours daily, but some NACs did not know this, even though the MAR/TAR contained an order to document times up and back to bed. The surveyors concluded that care plans were not accurately revised for several residents, placing them at risk for unidentified and unmet care needs and diminished quality of life.
Surveyors found that two residents with hemiplegia, hemiparesis, weakness, and contractures did not receive restorative nursing services, including ROM exercises and splint/brace or orthotic assistance, after therapy discharge. Although PT and OT discharge summaries documented established restorative ROM and transfer programs, recommended PROM to affected extremities, and recommended splint/brace use and assistance with orthotic wear, these recommendations were not entered as restorative referrals in the EHR. As a result, the residents’ care plans and records showed no restorative programs, and both residents reported that therapy and restorative exercises had stopped, while the DON, rehab director, and MDS coordinator confirmed they were unaware of and had not implemented the recommended restorative services.
A resident with cancer, cognitive impairment, and declining strength experienced multiple unwitnessed falls, most occurring while attempting to toilet or move toward the bathroom, culminating in a fractured ankle requiring ED treatment. Although assessments identified fall and incontinence risks and the facility’s policy required individualized interventions, the comprehensive care plan lacked a toileting plan and did not include several interventions that were discussed in incident investigations, such as consistent wheelchair placement and frequent rounding for bathroom assistance. Staff reported relying on verbal reminders and education to use the call light, despite acknowledging the resident’s impulsivity and failure to call for help, and the resident’s bed remained furthest from the bathroom while repeated bathroom-related falls occurred without the trend being recognized or addressed in the care plan.
A resident with a history of acute urinary retention and acute kidney injury had a Foley catheter deemed permanent by the hospital, with instructions that it not be removed in the SNF. At a later urology visit, the catheter was removed, and the resident returned with no new orders documented. Facility staff did not document bladder assessments, post-void residuals, or urine output, and CNA documentation showed the resident did not void that evening. Over the next day, the resident had vomiting, poor intake, altered level of consciousness, tachycardia, hypotension, and no documented wet briefs. A bladder scan eventually showed more than 2000–2500 mL of retained urine, and a new catheter drained a large volume. The resident and a roommate reported moaning, crying out in pain, and repeatedly alerting staff that the resident was not urinating and that the catheter was not draining, while nurses documented catheter care when no catheter was in place and later had to flush and replace the catheter due to continued complaints.
Surveyors found that nurses and nurse aides did not consistently administer medications according to professional standards and facility policy. Multiple residents reported that agency nurses were slow with medications, did not fully follow instructions, and often gave routine meds late. Observations showed an LPN administering expired Humalog/Lispro insulin well past the scheduled time, an LPN giving several scheduled meds (including Tizanidine) late and all at once, and an RN attempting to give sliding-scale insulin nearly two hours late, which a resident refused after already eating. Another resident received Methocarbamol two hours late after questioning the RN, and a resident on scheduled Tramadol had doses given without timely documentation, with a discrepancy between the narcotic count and pills remaining. These events demonstrated failures in timely administration, use of non-expired medications, and immediate, accurate MAR and narcotic documentation.
Failure to Notify Court-Appointed Guardian of Resident’s Clinical Changes
Penalty
Summary
The deficiency involves the facility’s failure to notify a resident’s court-appointed guardian of significant clinical changes and care decisions, contrary to its own policy and state requirements. The facility’s policy on Resident Representatives, revised 02/2021, states that a resident representative includes a court-appointed guardian or conservator and that the facility treats the representative’s decisions as those of the resident to the extent delegated or required by the court. Resident 1, admitted with cerebral palsy, had a Superior Court guardianship letter dated 02/07/2025 indicating a guardian of person and conservator of the estate with full authority, identifying Collateral Contact 1 (CC1) as the guardian. Despite this, multiple clinical events and changes in condition were documented without any corresponding documentation that CC1 was notified. Progress notes and provider notes show that Resident 1 experienced an episode of nausea and vomiting, frequent loose stools, abdominal discomfort, bloating, worsening fatigue, generalized weakness, and later refusal of meals and medications over at least a 24-hour period, with observations that the resident appeared frailer, more fatigued, and had no energy or interest to talk. The provider developed care plans including close monitoring for deterioration, sending stool to the lab, and later initiating IV fluids for rehydration, with a plan to call family/POA for discussion. However, there was no documentation that the guardian was notified at any of these points, including when IV fluids were started. CC1 reported that they were not contacted when the resident stopped eating or developed stomach issues, and expressed that the facility did not respect their guardianship and that involvement in care planning took too long. The DON confirmed on record review that there were many opportunities to notify the guardian when the resident’s condition changed from baseline and that there was no evidence staff did so.
Failure to Thoroughly Investigate and Resolve Resident Grievance Regarding Incontinence Care and Staff Conduct
Penalty
Summary
The deficiency involves the facility’s failure to thoroughly investigate and resolve a grievance alleging neglect and disrespect toward a resident, as required by its grievance policy. The resident had depression, anxiety, moderate cognitive impairment, occasional urinary incontinence, and required moderate assistance with toileting, with a care plan directing staff to check the resident every two hours, ask about toileting needs, and ensure they were clean and dry. A collateral contact reported arriving to visit the resident and finding them soaking wet and agitated, with behavior that was not typical for the resident. The collateral contact documented in a written grievance that the resident’s tablet was off, the resident appeared upset, and the resident reported being told they had to wait five minutes to be changed and that staff would change their “nasty *ss” in five minutes, leading the collateral contact to believe the resident had been given a consequence of no tablet and sitting in wet clothes, which they characterized as abuse/neglect and requested immediate removal of the responsible staff and a report filed. The facility documented receipt of the grievance and created an incident report indicating the matter was reported to the state agency, and that the unit manager interviewed the collateral contact and the resident, with the resident described as confused and denying being soaking wet. The incident report stated that a different nursing assistant was assigned to assist with the brief change and that the unit manager believed the resident was not soaking wet, and that the resident and collateral contact were satisfied when they left the room. However, a CNA who actually changed the resident reported that the resident’s brief was soaked through their pants onto the wheelchair and their socks were soaked, and that the resident was timid, repeatedly saying they had to sit for five minutes, and not acting like themselves; this CNA stated they were never interviewed or asked about the grievance or the resident’s condition. The DON acknowledged not interviewing this CNA or investigating the resident’s behavior and why they were upset, and the unit manager did not recall whether the collateral contact was present during follow-up and did not believe they followed up with the collateral contact regarding the grievance. The administrator, identified as the Grievance Official, stated the facility should have thoroughly investigated the grievance and discussed findings and resolution with the collateral contact, indicating the grievance process was not fully carried out in accordance with policy and WAC 388-97-0460.
Failure to Obtain Timely Emergency Transport for Resident in Respiratory Distress
Penalty
Summary
The deficiency involves the facility’s failure to obtain timely emergency medical services for a resident experiencing new-onset respiratory distress. The resident had dementia, respiratory failure, and heart failure, with severe cognitive impairment and a need for substantial assistance with activities of daily living. On the day the resident was sent to the hospital, a collateral contact observed the resident having difficulty breathing, appearing unable to get enough air, and looking as if they were sleeping or unconscious, and reported this to staff with a request to contact the doctor. An SBAR Communication Form documented that the resident was experiencing shortness of breath that had not occurred before, with an oxygen saturation of 90%. The physician was notified and ordered the resident sent to the emergency department for treatment and evaluation, and the collateral contact was notified shortly thereafter. Progress notes later documented that, despite the order for emergency department transfer, the resident was still awaiting pickup by Olympic transportation several hours later, with no estimated time of arrival. At approximately 3:30 AM, the dispatcher informed the facility that they could not provide transportation and instructed that 911 be called; only then was 911 contacted and the resident transported to the hospital via ambulance for respiratory distress. The RN caring for the resident stated they completed the SBAR, notified the physician and family, and at the end of their shift reported to the oncoming nurse that the resident needed to be sent to the emergency department for respiratory distress and that paramedics should be contacted, then left assuming 911 would be called. The DON stated that staff are expected to contact 911 for emergent conditions such as shortness of breath or respiratory distress, and that Olympic Ambulance is used only for non-emergent transport.
Failure to Provide Social Service Advocacy After Abuse Allegation and Questionable Representative
Penalty
Summary
The deficiency involves the facility’s failure to provide appropriate medically-related social services and advocacy for a resident following an allegation of abuse and concerns about the resident’s representative. The resident had an anoxic brain injury, dysarthria, moderate cognitive impairment, and was dependent on staff for activities of daily living. A hospital palliative care note documented that the resident lacked decisional capacity, had no DPOA, that the legal next of kin (CC4) did not want to be part of care decisions, and that care decisions were being deferred to another contact (CC5). CC5 accompanied the resident on admission, signed admission forms, and was listed as the primary contact in the medical record profile. On a date in February, during communication therapy, the resident reported that CC5 had done something to them, pounded their hands on their chest, recalled being hit in the back of the head by an unknown person, and stated they were sometimes afraid of CC5. A social services staff member reported this allegation to the state agency but did not complete a facility incident report, did not initiate care plan changes or interventions, and took no further action. CC5 continued to be treated as the resident’s representative, and progress notes documented CC5 at the bedside on multiple dates, including an entry noting the room smelled like foreign substances and that CC5 was seen waking the resident and then asking the nurse to administer pain medications. A psychiatry note later documented concern that CC5 was providing the resident with illicit substances and stated it would be prudent for the resident to identify a POA. Subsequently, the resident was found unresponsive, transported to the hospital, and later readmitted after altered mental status and overdose, with a provider note stating that CC5 posed a significant danger to the resident and was banned from visiting. After readmission, staff attempted to contact CC4 for consent to treat but initially reached someone who stated they were not CC4. The social service director acknowledged that, beyond reporting the initial allegation, no additional interventions were implemented, that CC5 continued to be used as the resident’s representative after the allegation, and that they had not explored legal authority for decision making following the abuse allegation or concerns about substances. The social service assistant reported they did not speak with the resident about the hospital stay or CC5 and did not complete an incident report or care plan changes after the allegation. The unit manager and DON were unaware of the initial abuse allegation, and the administrator, who served as abuse coordinator, also stated they were unaware of the allegation and that an investigation should have been initiated and a representative for the resident investigated at a minimum.
Injury from Mechanical Lift Sling Detachment During Transfer
Penalty
Summary
The facility failed to ensure a safe mechanical lift transfer when a resident was being moved with a Hoyer lift and sling, resulting in a fall and injury. Facility policy for using a mechanical lifting machine required staff to securely attach sling straps to the sling bar according to manufacturer’s instructions, double-check the security of the sling attachment before lifting, examine all hooks, clips, or fasteners, check strap stability, and ensure the sling bar was securely attached and sound. Despite these requirements, during a transfer for dinner, two CNAs placed the sling under the resident, attached the loops at each corner of the sling to the lift, and raised the resident off the bed into the space between the bed and wheelchair when the bottom left corner of the sling became disengaged from the lift. The resident involved had multiple diagnoses including osteoarthritis, cervical and thoracic spondylosis, and Alzheimer’s disease, with the Minimum Data Set documenting severely impaired cognitive skills for daily decision-making. The resident’s care plan required the assistance of two staff during Hoyer lift transfers. During the transfer, the resident fell approximately four feet, landing on her buttocks, bouncing, and then falling backward and striking her head on the leg of the Hoyer lift. Hospital records documented that the resident sustained an abrasion to the back of the head, fractures of the 6th, 7th, 8th, and 10th ribs, and fractures of the 1st and 2nd lumbar vertebra. Staff interviews and observations showed that staff believed the sling loops had been securely fastened and reported hearing the loops click into place before lifting. One CNA stated that they had barely lifted the resident off the bed when the bottom left loop became disconnected and the resident fell. Another CNA reported being shocked and unable to figure out what had happened. A nurse who assessed the resident and then examined the equipment after the fall noted that one of the loops of the sling had become disengaged but stated the sling appeared to be in good condition. During a later demonstration, a CNA indicated she thought one of the round metal disks on the lift might have been a little loose. Maintenance logs for Hoyer slings and lifts for the preceding months documented no concerns with the slings or lifts, and the DON acknowledged expecting a citation due to the resident’s injury from the fall.
Failure to Revise Care Plans to Reflect Resident Needs and Preferences
Penalty
Summary
The deficiency involves the facility’s failure to revise and individualize comprehensive care plans to reflect residents’ current needs and preferences, as required by its own care planning policy. For one resident with hemiplegia, hemiparesis following cerebrovascular disease, and mononeuropathy of the upper limb, the admission MDS showed intact cognition and upper extremity impairment. This resident reported having bilateral shoulder surgery and an inability to tolerate blood pressure measurements on the upper arms due to pain, and stated a preference for BP measurements on the forearms. The resident reported having informed multiple nursing staff of this preference, but staff continued to place the cuff on the upper arms. Review of the resident’s care plan and Kardex showed no interventions or instructions regarding forearm BP cuff placement. A NAC confirmed they were unaware of the preference until the resident told them directly and that this instruction was not documented in the Kardex. The RN/Unit Manager, who stated they were responsible for revising and reviewing care plans when there were changes, also confirmed they were not aware of the resident’s preference and that it should have been updated in the care plan. Another resident, readmitted with hemiplegia and hemiparesis following a nontraumatic subarachnoid hemorrhage, contracture of the left hand, and weakness, was cognitively intact and required maximum assistance for bed mobility per a quarterly MDS. This resident stated they were supposed to get out of bed for two hours every day, but some NACs were not aware of this care requirement. Review of the resident’s March 2026 MAR/TAR showed an order to document the time the resident got up and the time they returned to bed daily. The report states that, overall, the facility failed to revise care plans accurately to reflect residents’ needs for three of four residents reviewed for care plan revision, placing them at risk for unidentified and unmet care needs and a diminished quality of life.
Failure to Implement Restorative Nursing and Splint/Brace Programs After Therapy Discharge
Penalty
Summary
The deficiency involves the facility’s failure to provide restorative nursing services, including range of motion (ROM) exercises and splint/brace assistance, to maintain or prevent decline in mobility and contractures for two residents with significant motor impairments. The facility’s undated Restorative Nursing Services policy stated that residents would receive restorative care as needed to achieve and maintain optimal functioning and that residents may initiate a restorative program upon discharge from rehabilitative care. Despite this, surveyors found that residents with documented hemiplegia, hemiparesis, weakness, and contractures were not placed on restorative programs and had no restorative interventions documented in their electronic health records (EHRs). Resident 1 was admitted with hemiplegia and hemiparesis following cerebrovascular disease, a left lower leg fracture, and weakness, and the admission MDS showed intact cognition, moderate assistance needs for bed mobility and transfers, and one-sided upper and lower extremity impairment. During observation, the resident was seen lying in bed with a bent inward left forearm and hand and reported no longer receiving therapy or nursing-assisted exercises. The care plan initiated in January showed no restorative services, and the care plan history and EHR contained no restorative nursing interventions. However, the PT discharge summary from February documented that restorative ROM and transfer programs had been established and trained, including PROM to the left upper and lower extremities and stand-by assist with transfers, and the OT discharge summary recommended a splint/brace to prevent contracture. The OT stated that the splint/brace was not tried due to lack of time before insurance was discontinued, and both the Director of Rehab and the MDS coordinator confirmed there was no restorative referral in the EHR and they were unaware of the recommendations. Resident 2 was readmitted with hemiplegia and hemiparesis following a nontraumatic subarachnoid hemorrhage, a left-hand contracture, and weakness, and the quarterly MDS showed intact cognition, maximum assistance needs for bed mobility, total assistance for transfers, bilateral upper and lower extremity impairment, and no therapy or restorative programs. The resident reported that therapy had been discontinued months earlier and that no restorative staff were assisting with exercises. The care plan and EHR showed no restorative services. OT evaluation documented left upper extremity ROM impairment, a left-hand contracture, and prior use of a left orthotic to manage flexion tone, and the OT discharge summary recommended restorative care and assistance with donning/doffing the orthotic. The PT discharge summary recommended restorative programs if Medicaid Part B services did not continue. The Director of Rehab confirmed therapy was discontinued and that restorative nursing programs were recommended, but both the Director of Rehab and the MDS coordinator stated there were no restorative referrals in the EHR after readmission, and the MDS coordinator confirmed the resident had no restorative programs since readmission.
Failure to Implement Effective Fall and Toileting Interventions for High-Risk Resident
Penalty
Summary
The deficiency involves the facility’s failure to provide adequate supervision, identify fall trends, and implement progressive, resident-centered interventions for a resident with multiple falls and declining strength. The facility’s own Falls and Fall Risk Management policy required staff to identify interventions related to residents’ specific risks and causes to prevent falls and minimize complications. The resident’s Care Area Assessment identified cancer-related risks for pain, falls, and ADL decline, and stated that falls and urinary incontinence would be addressed in the care plan with an objective of improvement and risk minimization. However, the comprehensive care plan did not include a urinary or ADL care plan and contained no toileting plan, despite the resident’s identified risks and prior fall history. Over a series of falls, the resident repeatedly fell while attempting to toilet or move toward the bathroom, yet the facility did not recognize or address this pattern in its investigations or care planning. The resident had multiple unwitnessed falls: next to the bed while getting up to use the restroom, in the bathroom while standing to use the toilet, and near or in the bathroom on several occasions. Incident investigations and post-fall assessments documented environmental factors such as clutter, items on the floor, water on the floor, and issues with footwear, as well as the resident’s increasing weakness, impulsivity, poor safety awareness, and poor insight into limitations. Interventions documented in investigations and risk reviews included encouraging use of the front-wheeled walker, keeping the wheelchair and walker accessible, ensuring proper footwear and non-skid socks, and providing resident education on safe transfers, ambulation, and assistive device use. However, several of these planned interventions, including placement of the wheelchair and frequent rounding/toileting assistance, were not added to or reflected in the care plan as stated. Staff interviews further showed that the resident frequently fell while trying to go to the bathroom and that staff relied on verbal education and reminders to use the call light, even though the resident often did not use it. Staff acknowledged the resident’s impulsivity and tendency to get up independently despite instructions, and one staff member stated that nursing assistants were verbally instructed to offer bathroom assistance, but this intervention was not documented in the care plan. The resident’s bed remained the one furthest from the bathroom throughout the stay, and none of the facility’s investigations identified the trend of bathroom-related falls or addressed toileting options in the care plan. Ultimately, the resident sustained a left ankle fracture after another bathroom-related fall, requiring transfer to the emergency department for evaluation and treatment, and later records documented additional fractures and a decline in condition. The surveyors concluded that the facility’s failures placed residents at risk of repeated falls and injuries.
Failure to Monitor Urinary Retention After Foley Removal Leading to Prolonged Pain
Penalty
Summary
The deficiency involves the facility’s failure to adequately assess and monitor a resident for complications associated with an indwelling urinary catheter and urinary retention, particularly after catheter removal. The resident had a history of acute kidney injury due to urinary retention, which improved after Foley catheter placement in the hospital. Hospital discharge documentation indicated the catheter was placed for acute urinary retention, was deemed permanent, and included instructions that, given the resident’s significant retention and acute renal failure, staff at the skilled nursing facility should not attempt Foley removal. The facility’s catheter care plan directed staff to empty the catheter as needed and record output in milliliters, but review of the last 30 days of documentation showed continence was not rated due to the indwelling catheter and there was no documented urinary output in milliliters on the treatment administration records. The resident had a scheduled urology appointment at which the urinary catheter was discontinued. Upon return from this appointment, nursing documentation initially indicated no new orders, and an alert note later stated the catheter was discontinued and staff were monitoring for retention or pain. However, there was no documented bladder assessment or urinary output following catheter removal. Nursing assistant documentation showed that the resident did not void on the evening shift that same day. Despite the catheter having been removed, the treatment administration record showed staff continued to document provision of catheter care on subsequent shifts when no catheter was in place. Over the next day, the resident experienced vomiting, decreased oral intake, and an altered level of consciousness, with vital signs showing tachycardia and low blood pressure, and staff documented decreased urine output. A bladder scan performed later revealed more than 2000–2500 milliliters of urine in the bladder, and an indwelling catheter was reinserted, initially draining a large volume of urine. The provider note indicated the resident had not eaten since the prior night, was unable to hold down fluids, and staff were unsure whether the resident had urinated in incontinence briefs, with no wet briefs reported since the resident’s return from the hospital after catheter removal. The provider expressed concern that the documented early-morning wet brief might not be accurate given the large bladder volume on scan and stated this should require further investigation. Subsequent notes described the resident moaning and complaining of pain, with limited urine output in the catheter bag and staff flushing and then replacing the catheter due to continued complaints. Interviews with the resident, the roommate, and staff indicated the resident was crying out and moaning in pain, the roommate repeatedly alerted staff that the resident was not urinating and that the catheter was not draining, and staff had to seek assistance to replace the catheter. Facility leadership and clinical staff later acknowledged that typical practice after catheter removal would include contacting the provider, placing the resident on alert, performing post-void residuals with bladder scans, and documenting monitoring, which was not done in this case.
Medication Administration Delays, Documentation Errors, and Use of Expired Insulin
Penalty
Summary
The deficiency involves the facility’s failure to ensure sufficient nursing staff with appropriate competencies and skill sets to administer medications according to professional standards of practice, facility policy, and prescriber orders. The facility’s medication administration policy required medications to be given as prescribed, in accordance with manufacturers’ specifications and good nursing principles, with no expired medications used, and doses administered within 60 minutes of the scheduled time and documented immediately after administration. Multiple residents reported that agency nurses often gave medications late, did not read full instructions, or were slow in bringing medications, and that routinely scheduled medications were not consistently provided without residents having to ask. Surveyors observed several specific medication administration failures. For a resident with diabetes, an LPN drew up and administered Humalog/Lispro insulin from a multi-dose vial that had been opened and dated “02/16” with no year, making it expired per policy, and administered the dose nearly 1 hour and 45 minutes after it was due. Another resident with care plan instructions to receive medications as ordered had multiple scheduled medications (Gabapentin, Oxybutynin, Baclofen, and Tizanidine) that were ordered at specific times throughout the day; the LPN was observed administering all four together and acknowledged that at least one (Tizanidine) was late, while the resident reported that receiving them together at that time was typical and not at their request. For another diabetic resident, an RN checked blood sugar and prepared sliding scale Humalog/Lispro insulin almost two hours after the scheduled time; the resident refused the insulin, stating they had already finished lunch. Additional deficiencies were identified with other residents’ pain and scheduled medications. One resident with a pain care plan and an order for Methocarbamol four times daily at set times approached the cart requesting Methocarbamol and Tylenol; the RN initially stated the Methocarbamol had already been given, but then administered it two hours after it was due when the resident pointed out the scheduled timing. For another resident with a risk for pain care plan and Tramadol ordered three times daily at specific times, an LPN retrieved a PRN pain medication while the electronic record showed no 8:00 AM medications documented; the LPN stated they had given them but had not yet documented. Later, an RN prepared the 2:00 PM Tramadol dose, and review of the narcotic count showed a discrepancy between the number of pills documented and the number remaining in the card. The RN stated they had given the 8:00 AM Tramadol but had not signed it out, then signed out both the 8:00 AM and 2:00 PM doses at that time. Residents interviewed consistently reported that medications were sometimes or frequently late, that agency nurses did not always follow instructions, and that they often had to request medications that were routinely scheduled.
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