Port Washington Post Acute
Inspection history, citations, penalties and survey trends for this long-term care facility in Bremerton, Washington.
- Location
- 140 South Marion Avenue, Bremerton, Washington 98312
- CMS Provider Number
- 505240
- Inspections on file
- 44
- Latest survey
- March 20, 2026
- Citations (last 12 mo.)
- 61
Citation history
Health deficiencies cited at Port Washington Post Acute during CMS and state inspections, most recent first.
Surveyors found that the facility failed to ensure effective discharge planning for two residents, including coordination with community agencies and medication management. The discharge policy lacked guidance on pre-discharge needs such as medication ordering, medication teaching, arranging home care services, equipment, and follow-up appointments. One resident with diabetes and dementia was discharged home with family caregivers but without documented medication teaching or scheduled follow-up, and the community case manager was not notified, preventing caregiver scheduling and leaving the family without insulin administration training. Another resident with cognitive impairment and prior documented safety concerns at home was discharged without in-home care ordered, medication refills sent, or a follow-up physician appointment arranged, and the resident later returned after not receiving care and running out of medications. The SSD reported not handling medication re-ordering or teaching and typically not making follow-up appointments, while leadership staff acknowledged they were unaware of the lack of discharge coordination.
Surveyors found that meals were unappealing, poorly prepared, and not consistently served in a timely manner. A sample tray showed mixed and run-together vegetables, burnt bits in creamed corn, stringy green beans, bland unseasoned chicken, thin gray pudding with minimal flavor, and no butter for the roll. A resident with tracheal cancer and a pureed diet refused an untouched tray of unidentifiable pureed food, stating it looked unappealing and had no flavor. Another cognitively intact resident received a delayed lunch tray from a cart left in the hall and reported the food was cold and consistently terrible, citing past breakfasts of a glob of eggs, an unpalatable muffin, and dry cereal without milk. A third cognitively intact resident reported that food quality, consistency, and flavor had declined and that liquid eggs were used excessively, including at dinner, while the nutrition manager reported being unaware of these complaints and relying on meetings and floor staff to convey concerns.
The facility failed to provide ordered altered-consistency liquids and adequate hydration for two residents with post-stroke dysphagia. One cognitively intact resident was observed with an untouched meal tray lacking any fluids, had dry skin and chapped lips, and reported receiving unpalatable meals and dry cereal without milk, while staff were unclear about the "no drinks on the tray" diet slip and only later identified the need for Level 2 (nectar thick) liquids. Another cognitively intact resident with an order for Level 2 liquids received a tray with no liquid texture information and regular juices, and reported that CNAs bring regular juice on request despite disliking thickened fluids and recognizing inadequate fluid intake. The RD/Kitchen Manager acknowledged that residents should receive correct-consistency fluids, be monitored for hydration and compliance, and have their fluid consistency needs clearly communicated to floor staff.
A resident with encephalopathy related to glioblastoma and moderate cognitive impairment was started on Seroquel by the DON for anxiety and depression despite a psychiatry note stating there was no obvious need for psychotropic intervention and without documentation of behaviors to justify use. No psychopharmacologic informed consent was obtained, and the care plan misidentified Seroquel as an anxiolytic, lacking appropriate assessment, non-pharmacologic interventions, antipsychotic-specific monitoring, or a plan for gradual dose reduction. The DON later acknowledged not knowing why the medication had been started and that there was no documentation supporting the drug regimen.
The facility did not identify or address dementia-related behaviors for several residents, including one with severe cognitive impairment who exhibited wandering, yelling, and sexually inappropriate actions. Two residents reported repeated uninvited room entries and distressing incidents, while another resident's frequent yelling and aggression disrupted others. Staff documentation and care plans lacked interventions or guidance for managing these behaviors, and staff were unaware of or did not investigate reported incidents.
Two residents did not receive scheduled care and services as ordered, including timely weight monitoring and bathing, with care plans lacking directions for staff on refusals and specific care needs. Documentation was incomplete, and staff were unaware of equipment status and proper documentation practices.
A resident with a fractured femur, legal blindness, and moderate cognitive impairment did not receive the full number of occupational and physical therapy sessions as outlined in their care plan, receiving significantly fewer therapy visits than ordered before being discharged after insurance coverage ended.
A resident with a dehisced abdominal surgical wound and amputated toes was admitted with orders for wound vac therapy and dressing changes, but the facility failed to assess, monitor, or document care for the abdominal wound for over three weeks. The resident also developed a new lower extremity ulcer that was not identified until it required debridement. Staff were unaware of the abdominal wound, and necessary orders were not transcribed or implemented, resulting in the abdominal wound worsening in size before it was finally addressed.
The facility did not ensure timely and accurate receipt, dispensing, and administration of medications for all residents reviewed, resulting in multiple missed doses of critical medications such as anticoagulants, antibiotics, and cardiac drugs. These failures were due to inadequate staff training, lack of awareness of pharmacy procedures, and insufficient use of emergency medication access systems.
A resident who was cognitively intact reported that cash was stolen from their unsecured nightstand drawer after returning from a hospital stay. Despite requests for a lock and staff awareness of the cash, no secure storage was provided, and the incident was not properly investigated or reported to authorities.
The facility did not complete comprehensive skin assessments or proper documentation for three residents with wounds or skin conditions. For example, a resident with chronic wounds lacked ongoing wound measurements and documentation, another did not receive prescribed skin treatments as ordered and had undocumented wounds, and a third had wounds that were not properly assessed or described until seen by a wound management company. Staff interviews revealed confusion and inconsistent practices regarding skin assessment documentation.
A resident with a history of heart disease received multiple doses of 81mg aspirin for chest pain from an agency LPN without a provider's order, resulting in a total of 324mg administered in addition to the prescribed daily dose. The LPN acted based on agency training rather than facility protocol, and facility leadership confirmed that no protocol or physician order authorized this medication administration.
A resident with paraplegia who depended on staff for transfers was not provided with a standing frame needed to maintain or improve mobility, as the equipment had been loaned to another facility and was not returned promptly. Despite repeated requests and communication between nursing and therapy, the standing frame was not made available or set up for use, and the care plan lacked specific interventions or restorative services to address the resident's mobility needs.
The facility did not ensure that two residents who smoked were properly assessed and that required safety interventions were followed, resulting in residents smoking outside the designated area, not using required protective equipment, and cigarette smoke entering resident rooms. Staff and leadership were unaware that interventions were not being followed and that unsafe smoking practices were occurring.
A resident with a history of gastric ulcers, type 2 diabetes, and anemia was found to have multiple pills stored in a seasoning bottle at their bedside, despite facility policy requiring an assessment before allowing medications at bedside. The resident had refused all medications except for a weekly diabetes injection, and both the LPN and DON confirmed that no assessment had been completed to permit bedside storage.
Mechanical beds in several rooms were not maintained in safe, working order, resulting in one resident experiencing a bed collapse and others using beds with malfunctioning controls or components. Staff reported frequent breakdowns, lack of routine audits, and inconsistent reporting of maintenance issues, leading to unresolved equipment problems.
A resident with a peripheral IV device did not receive care in accordance with professional standards, as the device was used beyond the intended duration, lacked proper orders for flushing, was not routinely monitored, and was not removed prior to discharge. The resident experienced pain and a skin tear due to the delayed removal.
Three staff members did not follow CDC PPE protocols when caring for residents with confirmed COVID-19, including not wearing N95 respirators or eye protection as required, wearing surgical masks under N95s, and failing to remove PPE before leaving rooms. Staff interviews revealed confusion and lapses in understanding of proper PPE use, and the facility's Infection Preventionist confirmed these actions did not meet infection control expectations.
Two residents in a facility experienced inadequate assistance with ADLs, including incontinent care and positioning. One resident was left in a wet brief for over three hours, while another faced delays due to staff availability and lift equipment issues. The facility's failure to follow care instructions contributed to these deficiencies.
The facility failed to follow physician orders and monitor clinical conditions for two residents, leading to significant health complications. One resident did not receive a urinalysis for suspected bladder infection, resulting in a urinary tract infection and septic shock. Another resident with a chronic ulcer did not receive prescribed daily dressing changes, as confirmed by discrepancies in medical records and staff interviews.
A resident at risk for pressure ulcers due to immobility was not repositioned or provided with necessary care, leading to the development of a pressure ulcer on the right ankle and redness on the left heel. The facility's DNS was unaware of the wound, and the care plan was not updated with appropriate interventions. A hospice nurse and wound consultant confirmed the presence of a pressure ulcer and recommended interventions, which were not promptly implemented.
The facility failed to follow infection control standards for PPE use with two residents on transmission-based precautions. A resident with infectious gastroenteritis was not properly attended to by staff who ignored PPE requirements, while another resident with a skin infection was assisted without appropriate PPE due to staff misunderstanding of precautionary needs. The Director of Nursing confirmed the staff's actions did not meet facility policy.
A resident with hemiparesis and hemiplegia was unable to reach their call light, which was repeatedly found wedged in the bed frame, leading to unmet care needs and pain. Despite staff instructions to attach the call light to the resident's gown, this was not consistently done. Additionally, a medical provider's recommendation for a bed extender was not followed, despite the facility having them available.
The facility failed to develop and implement personalized discharge plans for two residents, leading to delayed discharges and unmet care needs. One resident, with kidney disease and diabetes, was unable to return home due to a lack of documented interventions and family opposition. Another resident, requiring wound care, was unable to transfer to an Adult Family Home due to the facility's failure to arrange necessary medical equipment and secure a primary care physician. Staff admitted to not having proper discharge plans, contributing to the delays.
The facility failed to follow prescribed diet textures for two residents at risk for aspiration, serving them regular textured foods instead of pureed diets. Additionally, the facility did not honor a resident's food preferences, leading to dissatisfaction and potential weight loss. The triple-check process for meal accuracy was ineffective due to staffing issues, and dietary staff did not use recipes for pureed diets.
The facility failed to provide dining services in a respectful manner, as some residents did not receive their meals while others at their tables had finished eating. Trays were distributed based on how they were loaded on the cart, leading to delays and residents questioning staff about the wait. Staff acknowledged that tables should have been served simultaneously to ensure a dignified dining experience.
The facility did not provide quarterly personal fund statements to residents with trust accounts, affecting four residents. During a resident council meeting, some residents reported never receiving statements, and one was unaware of having a trust account. The Business Office Manager admitted that the most recent documentation was from December 2023, indicating statements were likely not completed for subsequent months. The Administrator confirmed the expectation for consistent delivery of quarterly statements.
The facility failed to notify the state Ombudsman and provide written notices to residents and their representatives regarding hospital transfers, affecting six residents. Staff interviews revealed a lack of awareness and documentation of these required notifications.
The facility failed to provide written notification of its bed-hold policy to residents or their representatives during hospital transfers. This affected four residents, including one who was cognitively intact and another who was moderately impaired. Staff were unsure of the process, and there was no training on bed-hold procedures.
The facility did not ensure periodic reconciliation of controlled medications for two medication carts. Nurses failed to consistently count medications at shift changes or co-sign the ledger, as expected. This issue was noted on several dates, and the Regional Director of Operations confirmed the inconsistency.
The facility failed to monitor five residents for adverse side effects and target behaviors related to their prescribed psychotropic medications. Residents were prescribed medications such as trazadone, lorazepam, quetiapine, and Abilify without proper monitoring orders in their EHRs. The Director of Nursing Services confirmed the absence of necessary monitoring orders.
A facility failed to properly label and discard expired medications, as observed in a medication room and two medication carts. A registered nurse identified expired and undated medications, including insulin pens and intravenous ceftriaxone, which were not disposed of according to professional standards. Additionally, an unlabeled syringe with an unknown solution was found and discarded. These deficiencies posed a risk to residents' health.
The facility failed to maintain effective infection control practices, as staff did not perform hand hygiene between glove changes during wound care for three residents and did not adhere to PPE protocols for residents on transmission-based precautions. Additionally, staff did not use hand sanitizer during meal tray delivery, increasing the risk of infections.
The facility failed to ensure residents' mail was delivered unopened, violating their privacy rights. A Business Office Manager admitted to routinely opening mail, particularly social security checks, without residents' consent. This practice affected several residents, including one who was unaware their checks were being opened and deposited. The Administrator was unaware of this practice and stated that staff would be educated on proper mail handling procedures.
The facility failed to provide Advanced Directives (ADs) for two residents, risking their healthcare preferences not being honored. One resident, mildly cognitively impaired, and another, cognitively intact, both had signed documents indicating ADs, but no records were found in the Electronic Health Record (EHR). The Director of Nursing Services confirmed the absence of these documents in the EHR.
A resident reported a missing Motorola G turquoise blue phone, but the facility failed to properly file and address the grievance. Despite the resident's cognitive ability to recall the event, the grievance was not recorded in the facility's logs, and no follow-up was provided. Staff acknowledged the oversight, indicating a lapse in the grievance handling process, which risked diminishing the resident's quality of life.
A facility failed to complete a Significant Change MDS assessment for a resident admitted to hospice care, as required by the Resident Assessment Instrument manual. The resident, who was severely cognitively impaired, was admitted to hospice, necessitating an MDS assessment within 14 days. However, only an admission MDS was completed, with no further assessments found. The DON confirmed the oversight.
The facility failed to accurately document the health status of two residents in their MDS. One resident's terminal diagnosis was omitted despite hospice care, and another resident's major injury from a fall was incorrectly recorded. Staff acknowledged these inaccuracies.
A facility failed to ensure a PASRR assessment accurately reflected a resident's mental health diagnoses. The resident, who was cognitively intact, had anxiety and depressive disorders and was receiving related medications. However, the PASRR indicated no serious mental illness, despite active treatment for these conditions. The DON acknowledged the need to redo the PASRR.
A facility failed to create a comprehensive care plan for a resident with a femur fracture, omitting opioid-specific interventions despite the resident being on a pain medication regimen that included opioids. Staff acknowledged the care plan should have included opioid-specific monitoring, highlighting a deficiency in addressing the resident's opioid management needs.
The facility failed to conduct timely care conferences and update care plans for two residents. One resident, admitted with severe cognitive impairment and medical conditions, did not have a care conference documented. Another resident, with multiple diagnoses and referred to hospice, had an outdated care plan that did not reflect changes in their condition, such as the removal of a urinary catheter. The DON acknowledged that care plans were not updated as needed.
The facility failed to provide adequate pressure ulcer care for two residents, leading to deficiencies in treatment and monitoring. One resident with a stage 2 ulcer experienced inconsistent dressing changes and monitoring, while another with a stage 4 ulcer was found without a dressing. Staff acknowledged lapses in procedure, and the Director of Nursing confirmed expectations were not met.
A resident with a history of femur fracture surgery continued to receive scheduled pain medication despite reporting zero pain in most assessments. The facility failed to reassess the effectiveness of the medication and inconsistently documented non-pharmacological interventions. Staff interviews revealed a lack of communication and oversight in managing the resident's pain regimen, contributing to the deficiency.
A facility failed to maintain a medication error rate below five percent, resulting in an eight percent error rate. An LPN incorrectly administered eye drops to a resident, not following physician orders or manufacturer's guidelines, and admitted to being unaware of the required separation time between different eye drops.
A resident with a urinary catheter experienced delays in UTI diagnosis due to improper handling of urine samples, leading to frozen specimens and rejected lab results. Staff interviews revealed inadequate procedures for sample collection and storage, contributing to the deficiency.
A facility failed to notify a provider of abnormal lab results for a resident with a urinary catheter, leading to a delay in addressing a UTI. The resident's urinalysis and culture results were reported to the facility, but there was no documentation of provider notification. The facility's policy required prompt notification and documentation, which was not followed, resulting in the provider having to look up the results themselves.
The facility failed to ensure dietary staff were trained and competent in preparing pureed diets for two residents, resulting in them receiving incorrect diet textures. Staffing issues and lack of supervision contributed to the error, as a new cook was not adequately trained due to the absence of a dietary aide and the delayed arrival of a Certified Dietary Manager.
A resident with a known apple allergy and on a cardiac diet was repeatedly provided with apple juice, which was not documented in their electronic health record. The Dietary Manager was only informed of the allergy after multiple observations of the resident receiving apple juice. This oversight highlights a failure in accommodating the resident's dietary needs and preferences.
The facility failed to address the nutritional needs of two residents, leading to significant weight loss. One resident, with a history of bariatric surgery, experienced a 23.75% weight loss due to inconsistent weight monitoring and lack of physician notification. Another resident's weight loss was linked to unaddressed food dislikes and unimplemented RD recommendations. These deficiencies resulted in delayed nutritional interventions and unmet needs.
The facility failed to ensure a clean and comfortable environment for residents, with observations of unclean rooms, unmade beds, and inadequate linen changes. A resident was left in a room with a sticky substance and urine smell, while another could not lie down due to an unmade bed. The DON acknowledged the rooms did not meet expectations.
Failure to Coordinate Discharge Planning, Community Services, and Medication Management
Penalty
Summary
Surveyors identified a deficiency in the facility’s discharge planning process related to lack of coordination with community agencies and inadequate medication management for two residents. The facility’s Discharge Policy, revised 12/16/2026, did not address pre-discharge needs such as medication ordering, medication teaching, coordination of home care services, equipment needs, or ensuring follow-up appointments were made before discharge. For Resident 1, who had diabetes and dementia but was assessed as cognitively intact, the Discharge Plan of Care documented that assistance with bathing, toileting, and dressing would be provided by family and personal caregivers, but there was no documentation of medication teaching or follow-up appointments. The Home and Community Services case manager reported they were not notified of this resident’s discharge, so caregivers could not be scheduled, and the family later called with questions about sliding scale insulin administration because they had not received training from facility nurses before discharge. For Resident 2, who had unspecified cognitive impairment, adult failure to thrive, and needed assistance with personal care, the admission documentation included prior hospital case management concerns about safety at home and the family’s ability to provide care. The Discharge Plan of Care stated the resident was cognitively intact and would receive assistance with most ADLs from family, but in-home care was not ordered, medication refills were not sent to a pharmacy, and no follow-up appointment with the primary physician was made. The resident was later readmitted after not receiving care at home and running out of medications about a week after discharge. The Home and Community Services case manager stated they had not been notified of this resident’s discharge and indicated that, based on identified concerns, involvement would have been expected upon referral. The Social Services Director acknowledged not knowing about medication re-ordering or teaching for discharges and reported typically not making follow-up appointments, while leadership staff acknowledged lack of awareness of the coordination issues and that the discharges for these residents were not safe.
Failure to Provide Palatable, Attractive, and Properly Served Meals
Penalty
Summary
Surveyors observed that the facility failed to provide attractive, palatable, and flavorful food at safe and appetizing temperatures. A sample tray from the kitchen contained creamed corn and green beans running together on the plate, with the corn showing burnt bits and the green beans containing tough strings that had to be removed. The baked chicken breast was unseasoned and bland, the pudding was light gray, thin, and dripping off the spoon with only a faint chocolate taste, and there was no butter provided for the roll. The facility’s Registered Nutritionist/Kitchen Manager stated they were unaware of food complaints and relied on food council meetings and floor staff to communicate resident concerns. One resident with tracheal cancer, a voice box removal, moderate cognitive impairment, and a pureed diet had an untouched lunch tray consisting of a large pile of unidentifiable pureed food and reported the food looked unappealing, had no flavor, and they had no desire to eat it. Another cognitively intact resident did not receive their lunch tray when the cart was first passed; the tray remained on the cart in the hall until a CNA was prompted to deliver it, and the resident then reported the food was cold and terrible, describing prior breakfasts as a glob of eggs and an unpalatable muffin, and receiving two bowls of dry cereal without milk. A third cognitively intact resident reported that the food was terrible, that quality, consistency, and flavor had declined after a period of improvement, and that the facility used too many liquid eggs, including at dinner. The Administrator stated they believed food quality was improving and that managers would increase tasting and post-meal rounds to assess satisfaction.
Failure to Provide Ordered Thickened Liquids and Adequate Hydration
Penalty
Summary
The facility failed to ensure residents received liquids consistent with their ordered altered consistencies and hydration needs. One resident with post-stroke swallowing difficulties, cognitively intact per an admission MDS, was observed with an untouched lunch tray that had no fluids. The resident had chapped lips and dry facial skin and reported that meals had been cold and unpalatable since admission, describing breakfast as a glob of eggs and an unmanageable muffin, and receiving dry cereal without milk on two mornings. A CNA, upon checking the diet slip, noted it stated no drinks on the tray and did not know what that meant, indicating they would need to ask the nurse. An LPN then reviewed the orders and identified that the resident required Level 2 (nectar thick) liquids, retrieved a single carton of nectar thick juice from a locked nourishment room, and provided it, with no other Level 2 beverages observed in the refrigerator. The LPN stated that aides would need to ask the nurse to know what type of liquid to give a resident. Another resident, also admitted with post-stroke swallowing difficulties and cognitively intact per the admission MDS, had a dietary order for Level 2 liquids. During a meal observation, this resident’s tray diet slip contained no information about liquid textures, and the tray included two containers of normal-consistency juice. Later, the resident was observed in bed drinking normal-consistency cranberry juice and reported that aides bring juice containers upon request, expressing dislike for nectar thickened fluids, especially water, but acknowledging not getting enough fluids. The Registered Dietician/Kitchen Manager stated that all residents should receive sufficient fluids of the correct consistency, that residents with altered fluid consistency should be monitored for compliance and hydration, and that there should be a quick reference system to communicate residents’ fluid consistency needs to floor staff. The report states that these failures placed residents at risk for dehydration, aspiration, and decreased quality of life.
Antipsychotic Medication Initiated Without Assessment, Consent, or Proper Care Planning
Penalty
Summary
Surveyors found that the facility failed to ensure a resident’s drug regimen was free from unnecessary drugs when Seroquel, an antipsychotic medication, was initiated and continued without proper assessment, diagnosis, or monitoring. The resident was admitted with encephalopathy related to glioblastoma, was moderately cognitively impaired, and required extensive assistance with most activities of daily living. A psychiatry note documented that the resident was confused and minimally engaged, with an impression of unspecified cognitive disorders worsening due to recent medical events, and specifically stated there was no obvious need for psychotropic intervention. Despite this, the former Director of Nursing Services obtained an order for Seroquel 50 mg every morning and 150 mg at bedtime for anxiety and depression, without documentation of behaviors or other clinical justification explaining why the medication was started. There was no Psychopharmacologic Medication Informed Consent signed by the resident to show that risks, benefits, side effects, or the need for gradual dose reduction had been reviewed. The care plan later identified Seroquel incorrectly as an anxiolytic medication and, even when revised, did not include an appropriate assessment, non-pharmacologic interventions, or monitoring specific to an antipsychotic medication, nor did it address a plan for gradual dose reduction. When interviewed, the Director of Nursing Services stated they did not know why Seroquel had been started and acknowledged there was no documentation to support the drug regimen. The report states that this failure to complete a thorough evaluation before starting the medication and to provide necessary monitoring during therapy placed residents at risk for sedation, decreased quality of life, and death.
Failure to Address and Manage Dementia-Related Behaviors
Penalty
Summary
The facility failed to identify, address, and adjust care needs for five residents who exhibited dementia-related behaviors or were negatively impacted by such behaviors. One resident with a history of Neurocognitive Disorder with Lewy Bodies demonstrated severe cognitive impairment and exhibited behaviors such as yelling, wandering, and sexually inappropriate actions, as documented on behavior monitoring forms. Despite these documented behaviors, no interventions were added or recorded, and the resident's care plan and Kardex lacked any mention of these behaviors or guidance for staff on how to manage them. Other residents were directly affected by these deficiencies. Two cognitively intact residents reported that the resident with dementia repeatedly entered their room uninvited, with one incident involving urination on a bed and another involving an attempted sexual contact. Both residents expressed anger, frustration, and helplessness, and staff interviews revealed a lack of awareness or investigation into these incidents. Staff relied on the Kardex for intervention guidance, but it did not provide any relevant information for managing the behaviors. Another resident with dementia and behavioral disturbances was documented as frequently yelling, screaming, and exhibiting aggressive behaviors such as kicking, hitting, grabbing, and using abusive language. These behaviors were noted by staff and affected nearby residents, one of whom reported significant distress and sleep disruption. However, the care plan for this resident only addressed medication interventions and did not include strategies for managing the documented behaviors. Staff confirmed that the care plans and Kardexes did not provide adequate or person-centered interventions for these residents' behavioral needs.
Failure to Provide Scheduled Care and Services per Orders and Resident Preferences
Penalty
Summary
The facility failed to provide scheduled care and services according to physician orders and resident preferences for two residents reviewed for quality of care. One resident, admitted with a fractured femur and legal blindness, required extensive assistance with activities of daily living (ADLs) and was assessed as moderately cognitively impaired. Orders specified that weights should be obtained weekly for four weeks, but documentation showed that weights were not recorded until nearly two weeks after admission, with only one additional weight recorded before discharge, revealing a 10-pound loss. The resident's care plan, completed two days before discharge, did not address care needs such as bathing, obtaining weights, or instructions for staff regarding refusals of care, despite the resident being at nutritional risk due to multiple co-morbidities. No documentation was provided regarding showers or bathing during the resident's stay. Another resident, who was cognitively intact and required extensive assistance with ADLs, had a care plan indicating a bath should be provided twice weekly and as needed, with a sponge bath as an alternative if a full bath or shower could not be tolerated. The care plan lacked directions for staff on how to handle refusals. Documentation showed inconsistent bathing records, with some days marked as "not applicable" and others as "refused," and only one shower documented during the review period. Orders for weekly weights were not consistently followed, with only three weights documented and no further records. Staff interviews revealed a lack of awareness regarding the functionality of the wheelchair scale and uncertainty about documentation practices for showers and baths. The administrator confirmed that care plans should reflect personalized care needs, including interventions for refusals, but these were not present.
Failure to Provide Consistent Rehabilitative Services per Care Plan
Penalty
Summary
The facility failed to provide consistent specialized rehabilitative services as required by the care plan for a resident admitted with a fractured femur and legal blindness, who was moderately cognitively impaired and required extensive assistance with activities of daily living. According to the care plan and therapy orders, the resident was to receive occupational therapy (OT) and physical therapy (PT) five times per week for four weeks. During the certification period, the resident received only nine OT visits and fourteen PT visits, which was eleven OT visits and six PT visits fewer than planned. The resident was notified that insurance coverage would end and was discharged before the end of the planned therapy period. The administrator confirmed that all residents should receive specialized services according to their care plan.
Failure to Assess and Monitor Wounds Resulting in Wound Deterioration
Penalty
Summary
The facility failed to assess, monitor, and provide appropriate care for a resident with a non-pressure abdominal wound and a newly developed lower extremity (LE) ulcer. Upon admission, the resident had a dehisced surgical wound to the midline abdomen and amputated toes on the right foot, with diagnoses including peripheral vascular disease and diabetes. The admission assessment noted the presence of the abdominal wound and wound vac, but did not include wound measurements or detailed wound characteristics. Hospital transfer orders specified wound vac settings and dressing change frequency, but these were not transcribed into the facility's records, and no care plan interventions were developed to address the wound or minimize further breakdown. From admission, there was no documentation of wound care, assessment, or monitoring for the abdominal wound until 24 days later, nor for the right calf wound until 13 days after admission. The Treatment Administration Records (TARs) and electronic medical record (EMR) lacked any entries regarding the abdominal wound, wound vac, or required dressing changes during this period. The resident developed a new ulcer on the right posterior calf, which was not present on admission and was only identified after it had progressed to 75% slough and required mechanical debridement. Staff interviews confirmed that the abdominal wound was not assessed or treated because staff were unaware of its presence, and the necessary wound care orders were not implemented. When the abdominal wound was finally assessed 24 days after admission, it had increased in size, indicating a worsening condition. The wound care consult documented the wound's increased area and provided new treatment recommendations. The Director of Nursing acknowledged that the facility failed to identify and treat the wounds in a timely manner, and that the right LE ulcer should have been detected earlier, especially given the resident's need for maximal assistance with lower body dressing.
Failure to Ensure Timely Medication Administration Due to Inadequate Pharmacy Procedures
Penalty
Summary
The facility failed to develop and implement effective pharmacy procedures to ensure that medications were timely and accurately received, dispensed, and administered to meet the needs of all seven residents reviewed for admission medication reconciliation. The pharmacy delivery schedule required that medications ordered before 10:00 AM would be delivered in the evening, and those ordered after 10:00 AM but before 7:30 PM would be delivered overnight. If medications were needed before the next scheduled delivery and the cutoff time was missed, staff were expected to request STAT delivery and utilize emergency access systems such as Omnicell. However, there was no documentation that staff followed these procedures, resulting in multiple missed doses of critical medications for several residents. Residents admitted with time-sensitive and high-risk medication needs, such as anticoagulants, antibiotics, cardiac medications, and antipsychotics, experienced significant omissions. For example, one resident with a history of blood clots did not receive scheduled doses of rivaroxaban, despite the medication being available in the Omnicell system. Another resident with a C. difficile infection missed 12 out of 25 scheduled vancomycin doses due to failures in transcribing a formulary interchange and lack of staff follow-through. Additional residents failed to receive IV antibiotics, anticonvulsants, and other essential medications due to similar lapses in order entry, pharmacy communication, and emergency medication access. Interviews with staff revealed a lack of training and awareness regarding pharmacy ordering deadlines, STAT medication requests, and the use of emergency medication systems. Some nurses were unaware of the need to fax certain medication orders or the existence of pharmacy order cutoff times. The Director of Nursing confirmed that several staff members did not have access to the Omnicell system, further contributing to the delays and omissions. These systemic failures in medication management and staff competency led to repeated missed doses and inadequate medication administration for all residents reviewed.
Failure to Protect Resident's Property from Theft
Penalty
Summary
A cognitively intact resident was admitted to the facility and, according to the quarterly Minimum Data Set, was able to make independent decisions. The resident reported being unable to lock the top drawer of their nightstand and stated that they had made at least two requests for maintenance to install a lock, which were not fulfilled. The resident kept $376 in the top drawer, with another resident as a witness to the amount. After being hospitalized for several days, the resident returned to find only one dollar remaining in the drawer. The missing money was immediately reported to the Social Services Director. Facility staff interviews revealed that the Social Services Director received the complaint and reported it to their supervisor but did not notify law enforcement or initiate a formal investigation, only speaking to the witness who denied seeing the money. The Business Office Manager was aware the resident had cash in the room and encouraged the use of a facility trust account, but did not verify the security of the drawer. The Maintenance Director was unaware of any request for a lock and confirmed the drawer was not lockable. The administrator, newly in position, acknowledged the incident should have been investigated and reported. Documentation confirmed the resident's report of theft and the lack of a secure storage solution for their belongings.
Failure to Complete Comprehensive Skin Assessments and Documentation
Penalty
Summary
The facility failed to ensure comprehensive skin assessments were completed for three residents who required services meeting professional standards. For one resident with multiple chronic wounds on admission, there was no documentation of wound measurements or characteristics on weekly skin evaluations after the initial assessment, and no skin evaluations were completed following hospitalizations for cellulitis and skin tears. Staff interviews confirmed that nurses were expected to document wound location, measurements, characteristics, and notify providers of changes, but this was not consistently done. Another resident with skin conditions in the abdominal folds, groin, and under the breasts reported that prescribed treatments were not administered as ordered, and documentation lacked details about a coccyx wound and the characteristics of skin conditions. The DON was unaware of the coccyx wound and acknowledged possible incomplete documentation of care and treatment refusals. A third resident had a wound care order, but skin evaluations did not document the wound or its characteristics, and a new skin tear was not measured or described until the wound management company became involved. Staff interviews revealed confusion about proper documentation and incomplete use of skin evaluation forms.
Significant Medication Error Due to Unordered Aspirin Administration
Penalty
Summary
A facility failed to ensure that a resident was free from significant medication errors when an agency LPN administered multiple doses of 81mg chewable aspirin without a provider's order. The resident, who had a history of myocardial infarction and heart disease and was assessed as mildly cognitively impaired, began experiencing chest pain late in the evening. The LPN gave a total of 324mg of aspirin in 81mg increments every five minutes while simultaneously calling 911, despite the resident already having received their prescribed daily dose of 81mg aspirin that morning. There were no standing or emergency orders in place for additional aspirin administration for chest pain. The LPN stated that their agency training directed them to begin an aspirin protocol for chest pain, but acknowledged that no physician order was obtained prior to administering the medication. Facility leadership, including the Administrator and DON, confirmed that there was no facility protocol authorizing this action and that a physician should have been contacted before administering any additional medication. The incident was documented in the nursing progress notes and confirmed through staff interviews and record review.
Failure to Provide Required Equipment and Restorative Services for Mobility
Penalty
Summary
A resident with paraplegia, who was dependent on staff for transfers and required a Hoyer lift, was not provided with the necessary equipment to maintain or improve mobility. The resident had been requesting access to a standing frame for several months, but the device had been loaned to a sister facility and was not returned in a timely manner. Despite communication between nursing and therapy staff regarding the resident's need for the standing frame to assist with mobility, the equipment remained unavailable for an extended period. The resident expressed ongoing frustration about the lack of access to the standing frame, and observations confirmed that the device was not present or set up for use during multiple visits. Additionally, the resident's care plan did not include specific interventions, exercises, or therapy to maintain or improve mobility, nor did it reflect the resident's preference for a restorative program utilizing the standing frame. The lack of appropriate equipment and individualized care planning resulted in the resident not receiving restorative services necessary to maintain or improve range of motion and mobility.
Failure to Enforce Smoking Safety Policies and Interventions
Penalty
Summary
The facility failed to ensure that residents who smoked were properly assessed and that safety interventions were followed, as required by their own smoking policy. Two residents, both moderately cognitively impaired and with significant physical or cognitive limitations, were not managed according to their Smoking Evaluations. One resident, who required a smoking apron, was observed smoking without it, and another resident, who had been deemed not safe to smoke, was also observed smoking. Additionally, residents were not restricted to the designated smoking area, with several observed smoking along the sidewalks outside the designated structure. Observations revealed that residents were flicking ashes onto the ground and pocketing cigarette butts, and that cigarette smoke was drifting into rooms with open windows, affecting other residents. Staff interviews confirmed that required interventions based on Smoking Evaluations were not being followed, and that facility leadership was unaware of these lapses. The facility's policy required quarterly smoking evaluations and adherence to safety interventions, but these were not consistently implemented or monitored.
Failure to Secure Medications at Bedside Without Assessment
Penalty
Summary
A deficiency was identified when a resident, who was cognitively intact and had a history of gastric ulcers, type 2 diabetes, and anemia, was found to have a variety of pills stored in a garlic seasoning bottle inside a Kleenex box at their bedside. The resident stated they only wanted to take their weekly Mounjaro injection and did not want to take the other medications, which included omeprazole, a probiotic, a multivitamin, Vitamin D, and iron. The medication administration record confirmed these medications were prescribed, and the care plan documented the resident's refusal to take any medication other than Mounjaro. Despite the resident's refusal, there was no assessment found that allowed for medications to be left at the bedside, as required by facility policy and professional standards. Both the LPN Unit Manager and the DON confirmed that medications should not be left at the bedside unless an assessment had been completed. The lack of an assessment and the presence of unsecured medications at the resident's bedside constituted a failure to store medications appropriately, as required by regulation.
Failure to Maintain Mechanical Beds in Safe Working Condition
Penalty
Summary
The facility failed to maintain mechanical beds in a fully functional and safe condition for four out of four beds reviewed. One resident reported that their bed collapsed while they were sitting on the edge, resulting in a significant drop. Staff attempted to identify the issue at the time but were unable to resolve it, and the resident was moved to another bed. Maintenance was notified of the broken bed through the TELS system, and a part was ordered for repair. However, staff interviews revealed that other beds were also malfunctioning, including beds that would not raise or lower, beds with non-functioning remotes, and beds where the head section would not operate, requiring staff to physically support residents during transfers. Observations confirmed that several beds were not operating as intended, with issues such as motors making loud grinding noises and remotes being jammed. Staff reported that the bed frames were old and prone to frequent breakdowns, with two frames breaking in the previous week. Maintenance staff indicated that there was no routine audit of mechanical beds to ensure proper functioning, and communication about bed issues was inconsistent, with some staff using the TELS system and others only mentioning problems informally, leading to unresolved maintenance needs.
Failure to Follow Professional Standards for IV Device Management
Penalty
Summary
The facility failed to implement proper procedures for the care and management of a peripheral intravenous (IV) device for one resident. The resident was admitted with a peripheral IV device that was intended for use for less than six days, but records showed the device was used for more than six days. There were no documented orders for flushing the IV with saline after antibiotic infusions, and the IV was not routinely assessed or monitored for signs and symptoms of infection or other concerns, as required by facility policy and professional standards. The care plan and treatment administration record did not reflect appropriate monitoring or care of the IV device. Additionally, the IV was not removed prior to the resident's discharge from the facility. The resident reported not being aware that the IV was still in place until after leaving the facility and required removal at their primary doctor's office. The resident experienced pain and a skin tear due to the delayed removal of the IV dressing. The Director of Nursing confirmed that the IV should have had orders for flushing, should have been monitored, and should have been removed before discharge.
Failure to Adhere to CDC PPE Guidelines for COVID-19 Precautions
Penalty
Summary
Three of seven staff members failed to use personal protective equipment (PPE) in accordance with CDC guidelines when caring for residents with confirmed COVID-19 infections. Observations showed that staff entered rooms marked with aerosol precaution signs without wearing the required N95 respirator and eye protection, and sometimes only wore surgical masks, gowns, and gloves. In several instances, staff wore a surgical mask underneath the N95 respirator, which the Infection Preventionist later confirmed was not appropriate as it prevents a proper seal. Staff were also observed exiting resident rooms while still wearing PPE such as N95 respirators and surgical masks, and walking through hallways and to other units without removing or properly discarding the PPE as required. Staff interviews revealed a lack of understanding or adherence to PPE protocols, with some staff admitting they forgot to wear eye protection or believed that N95 respirators and eye protection were only necessary when providing direct care. The Infection Preventionist confirmed that the facility's expectation was for staff to wear a N95 respirator, eye protection, gown, and gloves when entering rooms of residents on aerosol precautions, and to remove all PPE upon exiting the room. The failure to follow these procedures was acknowledged as not being in line with the facility's infection control policies.
Inadequate ADL Assistance and Equipment Issues
Penalty
Summary
The facility failed to provide adequate assistance with Activities of Daily Living (ADL) for two residents, leading to issues with incontinent care, cleanliness, and positioning in bed. Resident 1, who was cognitively intact and required substantial assistance, was observed lying in bed for over three hours without receiving necessary incontinent care or repositioning. When staff eventually attended to Resident 1, they found the resident in a wet brief and lying on wet sheets, indicating a lack of timely care. The staff changed the sheets and the resident's brief but did not wash the resident's body before dressing them in a new nightgown. Resident 2, also cognitively intact and requiring substantial assistance, expressed dissatisfaction with the delays in receiving care, particularly in the mornings and afternoons. The resident reported having to wait for extended periods to be changed and transferred, often due to staff being occupied with other tasks or issues with lift equipment. On one occasion, the resident had been waiting since 3:00 PM for a brief change, but the lift's battery was not charged, causing further delays. Staff confirmed the ongoing issue with lift batteries and the discomfort caused by using a manual lift. The facility's failure to adhere to the care instructions outlined in the residents' Kardexes contributed to the deficiencies observed. Staff were expected to follow these instructions, which included scheduled checks and changes for incontinence, but were unable to do so consistently due to equipment issues and staffing constraints. This lack of adherence to care plans resulted in residents experiencing discomfort and potential risks to their skin integrity and dignity.
Failure to Follow Physician Orders and Monitor Clinical Conditions
Penalty
Summary
The facility failed to follow physician orders and monitor clinical conditions for two residents, leading to significant health complications. Resident 3, who was cognitively intact, expressed concerns about a possible bladder infection and had a physician order for a urinalysis on 11/22/2024, which was not completed by the nursing staff. Despite continued complaints of pain during urination, there was no documentation of nursing assessment or monitoring from 11/22/2024 to 12/06/2024. Resident 3 was eventually sent to the emergency department on 12/07/2024 and diagnosed with a urinary tract infection, leading to admission to the intensive care unit for septic shock. Resident 4, also cognitively intact, had a chronic ulcer on their right foot and was under orders for daily dressing changes from a wound clinic. However, the facility failed to implement these orders, as evidenced by the resident arriving at the wound clinic with the same dressing from a week prior. The facility's electronic medical records showed discrepancies in the documentation of dressing changes, and the resident's care was not adjusted according to the wound clinic's orders. This oversight was acknowledged by the Resident Care Manager, who noted that the orders should have been followed upon the resident's return from the clinic. The deficiencies in care for both residents were confirmed through interviews with facility staff and review of medical records. The Director of Nursing and other staff members acknowledged the lack of documentation and failure to follow through with physician orders, which contributed to the residents' deteriorating health conditions. These failures highlight significant lapses in the facility's adherence to care protocols and monitoring of residents' clinical conditions.
Failure to Prevent Pressure Ulcers in a Resident
Penalty
Summary
The facility failed to implement necessary interventions to prevent the development of pressure ulcers for a resident who was at risk due to immobility. The resident, who was cognitively intact and required substantial assistance with activities of daily living, was observed lying in bed for several hours without being repositioned or receiving incontinent care. This lack of care resulted in the resident developing redness and a black area on the right lateral ankle bone, as well as redness on the left heel. Despite the facility's policy to consider all residents at risk for skin impairment and to implement preventive measures, these interventions were not carried out effectively for this resident. The Director of Nursing (DNS) was unaware of the wound on the resident's ankle until it was pointed out during an observation. The care plan for the resident was not updated to reflect the new skin concerns, and no interventions such as floating the heels or applying skin prep were documented. A hospice nurse confirmed the presence of a pressure ulcer on the right ankle and noted that the resident's heels were not floated as expected. The wound consultant later recommended the use of cushioned boots and floating the ankles and heels off the mattress, but these recommendations were not implemented in a timely manner.
Infection Control Deficiency Due to Improper PPE Use
Penalty
Summary
The facility failed to adhere to infection control standards concerning the use of personal protective equipment (PPE) for residents on transmission-based precautions (TBP). Resident 1, diagnosed with infectious gastroenteritis and colitis, was on contact precautions. However, on two separate occasions, staff members entered Resident 1's room without donning the required PPE or washing their hands, despite clear signage indicating the need for such precautions. Staff A, a Certified Nursing Assistant (CNA), entered and exited the room without washing hands or wearing a gown and gloves, claiming not to have noticed the sign. Similarly, Staff D entered the room, turned off the call light, and handled the food tray without PPE or hand hygiene, also stating they did not notice the sign until after exiting. Resident 2, with a diagnosis of a skin infection, was on enhanced barrier precautions (EBP) due to a wound. Staff B, a Resident Care Manager (RCM), and Staff C, a CNA, entered Resident 2's room without donning the required PPE while assisting with a manual lift. Both staff members incorrectly believed that only Resident 2's roommate was on EBP, not Resident 2. Upon review, Staff B acknowledged that Resident 2 was indeed on EBP and that they should have worn gowns and gloves during the transfer. The Director of Nursing confirmed that the staff did not follow the facility's policy, which required PPE for close contact tasks such as transferring and changing briefs.
Failure to Provide Accessible Call Light and Bed Extender
Penalty
Summary
The facility failed to provide a call light within reach and a bed extender for a resident with hemiparesis and hemiplegia on the left side due to a stroke. The resident, who was cognitively intact and required extensive assistance for most activities of daily living, was unable to reach the call light, which was observed multiple times wedged in the bed frame and dangling towards the floor. The resident expressed that this inability to reach the call light led to periods of laying in soiled briefs and experiencing pain due to feet pressing against the footboard. Staff were instructed to attach the call light to the front of the resident's gown, but this was not consistently done. Additionally, a medical provider noted that the resident complained of right foot pain from hitting the end of the bed and recommended an extended bed and regular repositioning to prevent pressure injuries. Despite the facility having bed extenders available, the resident did not receive one. Staff, including a housekeeper, expressed frustration with the situation, and a grievance was filed. The Director of Nursing Services acknowledged that the resident should have had access to the call light and that staff should have followed the medical provider's recommendations.
Failure in Discharge Planning for Two Residents
Penalty
Summary
The facility failed to develop and implement personalized discharge plans for two residents, leading to delayed discharges and unmet care needs. Resident 1, who was admitted with kidney disease and diabetes, expressed a desire to return home once well. Despite this, the facility did not document any interventions in the discharge care plan beyond the initial admission date. The resident repeatedly expressed frustration about not being able to go home, even contacting emergency services. Staff acknowledged the lack of a discharge care plan and noted that the resident's spouse did not want them to return home, contributing to the resident feeling trapped. Resident 2, who was cognitively intact and required wound care and a pressure-reducing device, had secured a spot at an Adult Family Home (AFH) but was unable to transfer due to the facility's failure to arrange necessary medical equipment and secure a primary care physician. Despite the resident's eagerness to transfer, the facility did not follow through with the arrangements, and the discharge care plan lacked further interventions. Staff admitted to not having a discharge plan and retained information mentally, which contributed to the delay. The Social Service Director acknowledged the oversight in discharge planning, citing being busy with other tasks as a reason for the delay. The facility's administrator recognized that the discharge planning did not meet expectations and indicated a need for staff education on identifying barriers to discharge and care planning.
Failure to Follow Diet Textures and Honor Food Preferences
Penalty
Summary
The facility failed to ensure that menus were followed and that modified diet textures were prepared according to established guidelines and physicians' orders for two residents at risk for aspiration, pneumonia, and choking. Resident 35, who had severe cognitive impairment and was on a mechanically altered diet, experienced episodes of choking and coughing during meals. Despite being on a pureed diet, Resident 35 was served regular textured scrambled eggs and chopped sausage, which were not in accordance with the prescribed diet. Similarly, Resident 125, who also had severe cognitive impairment and required an altered texture diet, was served regular textured scrambled eggs and chopped sausage instead of the prescribed pureed diet. The facility's system for ensuring the correct food texture was not effective, as evidenced by the failure of the triple-check process intended to verify the accuracy of meal trays. Staff D, the Head Cook/Dietary Manager in Training, explained that the triple-check process involved the cook, dietary aide, and direct care staff verifying the diet type and texture. However, due to staffing issues and lack of oversight, the new cook was not adequately supervised, leading to errors in diet texture for Residents 35 and 125. Additionally, dietary staff did not have access to or utilize recipes when preparing pureed diets, contributing to the inconsistency in meal preparation. Furthermore, the facility failed to honor food preferences for Resident 61, who was cognitively intact and had significant weight loss. Despite multiple communications and a completed food preference form indicating a dislike for pasta and vegetables, the resident continued to receive meals that did not align with their preferences. The dietary staff did not input the resident's food preferences into the dietary computer, resulting in continued dissatisfaction with meals and potential risk for further weight loss.
Failure to Provide Dignified Dining Services
Penalty
Summary
The facility failed to provide dining services in a respectful and dignified manner for five of the fourteen residents eating in the dining room. During the observation, it was noted that trays were passed out according to how they were loaded on the cart, rather than ensuring all residents at a table were served simultaneously. As a result, Residents 54, 33, 15, 60, and 22 did not receive their trays while others at their tables had already finished eating. This led to residents questioning staff about the delay, and staff responded that they were looking for the food. The facility's policy stated that residents have the right to be treated with respect, and staff acknowledged that each table should have been served at the same time to ensure the best dining experience.
Failure to Provide Quarterly Personal Fund Statements
Penalty
Summary
The facility failed to provide quarterly personal fund statements to residents with personal fund accounts, affecting four sampled residents. During a resident council meeting, three residents reported never receiving a quarterly statement for their trust account balance, while another resident was unaware of having a trust account. A review of the facility's document titled 'Trial Balance' showed that three residents had a balance in their trust fund, while one had a balance of zero dollars. The Business Office Manager admitted that the most recent documentation available was from December 2023 and acknowledged that if documentation was missing, the statements were likely not completed for those months. The Administrator confirmed that the expectation was for residents or their representatives to receive quarterly statements consistently.
Failure to Notify Ombudsman of Resident Transfers
Penalty
Summary
The facility failed to provide timely written notifications to residents, their representatives, and the state Ombudsman regarding hospital transfers, as required by regulations. This deficiency was identified for six residents who were hospitalized during the review period. The lack of documentation in the Electronic Health Records (EHR) indicated that the facility did not notify the Ombudsman for any of these transfers, which is a regulatory requirement. Interviews with staff, including the Director of Nursing Services and the Social Services Director, confirmed the absence of such notifications and revealed a lack of awareness about the requirement to notify the Ombudsman. Specific cases highlighted include Resident 18, who was cognitively intact and hospitalized due to a fall, and Resident 19, who was moderately cognitively impaired and hospitalized three times without Ombudsman notification. Other residents, such as Resident 67, Resident 30, Resident 16, and Resident 73, also experienced hospital transfers without the required notifications. Staff interviews further confirmed the absence of documentation and awareness, with the Social Services Director admitting to not knowing about the requirement and the Director of Nursing Services acknowledging the issue.
Failure to Provide Bed-Hold Policy Notification
Penalty
Summary
The facility failed to provide written notification of its bed-hold policy to residents or their representatives at the time of transfer to a hospital for four residents. Resident 18, who was cognitively intact, was hospitalized due to a fall, but the bed-hold notice was filled out after the resident had already left the facility, and there was no documented notification to the resident or their representative. Resident 19, who was moderately cognitively impaired, was hospitalized three times, but no bed-hold forms were present for the first two hospitalizations, and the forms for the third hospitalization lacked signatures from the resident or their representative. Staff involved were unsure of the process and did not review the bed-hold with the patient before their departure. Resident 30, who was cognitively intact, was hospitalized, but no documentation of a transfer notice was found. Staff acknowledged the absence of notices. Similarly, Resident 73 was transferred to an acute care hospital, but there was no documentation that a written notice of the bed-hold policy was provided at the time of transfer. The facility's failure to provide these notifications was confirmed by staff, including the Director of Nursing Services and the Regional Director of Operations, who admitted there was no current process for training staff on bed-hold procedures.
Failure to Reconcile Controlled Medications
Penalty
Summary
The facility failed to implement a system ensuring periodic reconciliation and accounting for all controlled medications, affecting two medication carts (C cart & A cart). Facility nurses did not consistently reconcile controlled medications at shift change or co-sign the ledger to confirm the accuracy of the controlled medication count. This failure was observed on multiple dates in May and June 2024 for the C-cart and in June 2024 for the A-cart. The Regional Director of Operations acknowledged that it was expected for both nurses to perform a controlled medication count and co-sign the ledger, but confirmed that this was not consistently occurring.
Failure to Monitor Psychotropic Medication Effects
Penalty
Summary
The facility failed to monitor five residents for adverse side effects and target behaviors related to their prescribed psychotropic medications. Resident 10, who was severely cognitively impaired, was prescribed trazadone for insomnia and lorazepam and diazepam for anxiety, but there were no orders for monitoring target behaviors or side effects in the Electronic Health Record (EHR). Similarly, Resident 68, moderately cognitively impaired, was prescribed quetiapine for dementia and psychosis without any monitoring orders for target behaviors or side effects. Resident 38, also moderately cognitively impaired, was prescribed lorazepam for anxiety and citalopram for major depressive disorder, but the EHR lacked documentation for monitoring target behaviors or side effects. Resident 62, cognitively intact, was prescribed mirtazapine for depression and appetite increase, yet there were no monitoring orders in the EHR. Lastly, Resident 18, cognitively intact with frequent mood disturbances, was prescribed Abilify for psychosis and sertraline for depression, but there were no monitoring orders for adverse side effects or target behaviors. The Director of Nursing Services confirmed the absence of necessary monitoring orders for these residents.
Expired and Undated Medications Found in Facility
Penalty
Summary
The facility failed to ensure that drugs and biologicals were labeled and dated according to accepted professional standards, and expired medications were not discarded. During an observation of the medication room, a registered nurse identified several expired and undated medications. These included an opened Byetta pen for a resident that should have been discarded 30 days after opening, an opened vial of Humulin R insulin for another resident that was opened more than 28 days prior, and five bags of intravenous ceftriaxone that were brown and discolored. The nurse confirmed that these medications needed to be disposed of. Further observations of two medication carts revealed additional issues. On one cart, an opened and undated Lispro insulin pen and an opened Aspart insulin pen dated beyond the recommended discard date were found. On the second cart, a syringe containing an unidentified red syrup-like solution was found without any labeling or indication of when it was prepared. The nurse was unable to identify the medication or its preparation date and subsequently discarded the syringe. These deficiencies placed residents at risk of receiving expired medications and potential negative health outcomes.
Infection Control Deficiencies in Wound Care and PPE Use
Penalty
Summary
The facility failed to establish and maintain effective infection prevention and control practices, as evidenced by multiple observations of staff not adhering to established protocols. During wound care for three residents, staff did not perform hand hygiene between glove changes, which is a critical step in preventing the spread of infections. Specifically, Staff P was observed changing gloves multiple times without using hand sanitizer or washing hands between changes while providing wound care to Residents 62, 40, and 69. Additionally, Staff P was seen using the same box of gloves across different resident rooms, which further compromised infection control measures. In addition to the issues with wound care, staff also failed to adhere to transmission-based precautions. For instance, Staff JJ, a Physical Therapy Assistant, did not wear gloves or a gown while working with Resident 324, who was on contact precautions. Similarly, Staff II and Staff AA did not wear the required personal protective equipment, such as gowns and gloves, while providing high-contact care to Residents 53 and 10, respectively, who were under enhanced barrier precautions. These lapses in following PPE protocols increased the risk of spreading infections among residents. Furthermore, the facility's staff did not consistently perform hand hygiene during meal tray delivery. Staff AA was observed delivering meal trays to multiple rooms without using hand sanitizer before entering or after exiting the rooms. This failure to perform hand hygiene as per the facility's policy further contributed to the risk of healthcare-associated infections. The facility's policies on hand hygiene and enhanced barrier precautions were not effectively implemented, as evidenced by the staff's non-compliance with these critical infection control practices.
Violation of Resident Mail Privacy
Penalty
Summary
The facility failed to ensure that residents' mail was delivered unopened, violating their right to privacy. This deficiency was identified for four out of seven residents reviewed for resident rights. The facility's policy, dated August 2022, mandates compliance with federal law 42 U.S.C 483.10, which includes respecting residents' privacy in their communications. However, during a resident council interview, it was revealed that the Business Office Manager, Staff F, routinely opened mail, particularly social security checks, without the residents' consent. Resident 43 reported that the office manager opened envelopes that appeared to contain checks, and Resident 46 confirmed receiving opened mail that did not contain a check. Staff F admitted to opening some residents' mail, specifically social security checks for Residents 30 and 25, and did not perceive this as an issue. Resident 30 expressed dissatisfaction upon learning that their social security check was being opened and deposited without their knowledge. The Administrator, Staff A, was unaware of this practice and stated that staff would be educated on the expectation that mail should be opened at the bedside with the resident's permission. This practice of opening mail without consent placed residents at risk for a lack of privacy and a diminished quality of life.
Failure to Provide Advanced Directives for Residents
Penalty
Summary
The facility failed to provide an Advanced Directive (AD) for two residents, Residents 59 and 62, which placed them at risk of not having their healthcare preferences honored. Resident 59, who was mildly cognitively impaired, was admitted to the facility and had signed a document indicating the presence of an AD, but no record of the AD was found in the Electronic Health Record (EHR). Despite multiple requests for the AD, the Director of Nursing Services (DNS) confirmed the absence of the documentation in the EHR. Similarly, Resident 62, who was cognitively intact, had also signed a document indicating the presence of an AD, but no record was found in the EHR. The DNS acknowledged the absence of the AD in the EHR and expressed the expectation to follow up with the resident and their family to obtain the document. This deficiency was identified during a review of the facility's compliance with resident rights regarding advanced directives.
Failure to Address Resident Grievance on Missing Property
Penalty
Summary
The facility failed to properly address a grievance filed by Resident 18 regarding a missing personal item, specifically a Motorola G turquoise blue phone. Resident 18, who was admitted with diagnoses including depression and psychosis, was cognitively intact and able to recall events. The resident reported the missing phone to the activity person, but there was no follow-up or information provided about the grievance, leaving the resident upset and flabbergasted. Despite the resident's clear recollection of filing a grievance, the facility's Grievance Log and Incident Log did not reflect any record of the grievance or incident related to the missing property. Staff G, the Activities Director, confirmed that a Missing Property Report was filed, but it did not address the second phone that Resident 18 reported missing. Staff H, the Social Services Director, acknowledged that if the resident perceived the loss as theft, it should have been filed as a grievance. Staff A, the Administrator, stated that grievances should be resolved within two days, indicating a failure in the facility's grievance handling process. This oversight placed residents at risk for a diminished quality of life, as their grievances were not promptly or adequately addressed.
Failure to Complete Significant Change MDS for Hospice Resident
Penalty
Summary
The facility failed to complete a Significant Change Minimum Data Set (MDS) assessment for a resident who was reviewed for hospice and end-of-life care. According to the Resident Assessment Instrument manual, a Significant Change in Status Assessment (SCSA) is required when a terminally ill resident enrolls in a hospice program and remains at the nursing home. Resident 10, who was severely cognitively impaired, was admitted to hospice on May 11, 2024, necessitating a Significant Change MDS assessment within 14 days. However, the Electronic Health Record (EHR) showed that only an admission MDS was completed on April 24, 2024, with no further MDS assessments found. The Director of Nursing Services confirmed that an MDS assessment should have been completed within the required timeframe.
Inaccurate MDS Documentation for Residents
Penalty
Summary
The facility failed to ensure the accuracy of Minimum Data Sets (MDS) for two residents, which are crucial for reflecting residents' health status and care needs. For Resident 73, the MDS inaccurately documented the resident's health status by omitting a terminal diagnosis, despite the resident receiving hospice services and having a prognosis of six months or less to live. This discrepancy was acknowledged by the MDS Nurse, who confirmed that the MDS should have reflected the resident's terminal condition. For Resident 18, the MDS inaccurately recorded the severity of a fall-related injury. The resident had been hospitalized for a fall that resulted in a right femoral fracture, a major injury requiring surgical intervention. However, the MDS incorrectly coded the fall as resulting in no major injury. The Director of Nursing Services confirmed that the MDS should not have indicated zero major injuries, highlighting a failure to accurately document the resident's condition.
Inaccurate PASRR Assessment for Resident's Mental Health
Penalty
Summary
The facility failed to ensure that a Pre-Admission Screening and Resident Review (PASRR) assessment accurately reflected the mental health diagnoses of a resident. The resident, who was cognitively intact, had diagnoses of anxiety and depressive disorders and was receiving antidepressant, antianxiety, and antipsychotic medications. However, the Level I PASRR assessment indicated no indicators of serious mental illness, including depressive and anxiety disorders, despite the resident being actively treated for these conditions. This discrepancy was acknowledged by the Director of Nursing, who stated that the PASRR needed to be redone.
Deficiency in Opioid Management Care Plan
Penalty
Summary
The facility failed to develop and implement a comprehensive and individualized care plan for Resident 18, who was admitted with a fall and fracture of the right femur, requiring surgical intervention. The resident was cognitively intact and on a scheduled pain medication regimen, including opioids, as well as non-medication interventions for pain. However, the care plan reviewed did not specify or include opioid-specific interventions or monitoring for signs and symptoms related to opioid use. Staff members, including an LPN and an Advanced Registered Nurse Practitioner, acknowledged that the care plan should have included a specific section on opioids, indicating a deficiency in addressing the resident's needs related to opioid management.
Failure to Conduct Timely Care Conferences and Update Care Plans
Penalty
Summary
The facility failed to conduct timely care conferences for two residents, leading to deficiencies in care planning and potential risks to resident well-being. Resident 10, who was admitted with severe cognitive impairment and medical conditions including Crohn's disease and cellulitis, did not have a care conference documented after admission. Staff responsible for arranging and documenting care conferences acknowledged that an initial care conference was not conducted within 48 hours of admission, as required. Resident 38, who was admitted with major depressive disorder, muscle weakness, pressure ulcers, and severe protein-calorie malnutrition, also experienced deficiencies in care planning. Despite being referred to hospice care and having changes in their medical condition, such as the removal of a urinary catheter, the facility's care plan was not updated to reflect these changes. Observations confirmed the absence of a catheter, contradicting the care plan. The Director of Nursing Services admitted that care plans were not updated as care needs changed, indicating a lack of timely revisions to care plans.
Deficient Pressure Ulcer Care and Monitoring
Penalty
Summary
The facility failed to provide adequate pressure ulcer care for two residents, leading to deficiencies in treatment and monitoring. Resident 69, who was admitted with a stage 2 pressure ulcer and other health issues, reported that their dressing was not consistently changed or monitored. Despite orders for regular dressing changes and monitoring, the resident experienced periods without a dressing, and staff failed to document or perform as-needed dressing changes. The resident expressed that the ulcer was painful and that staff assistance with turning was only provided upon request. Observations confirmed that the dressing was often not in place, and staff acknowledged that proper procedures were not followed. Similarly, Resident 40, who had a stage 4 pressure ulcer, was found without a dressing during a wound care observation. The resident was unaware of when the dressing had fallen off, and staff admitted that nursing assistants did not report missing dressings. The care plan for Resident 40 required monitoring of the dressing to ensure it was intact, but this was not adhered to. The Director of Nursing Services confirmed that the expectation was for nursing staff to ensure dressings were in place, highlighting a failure in communication and adherence to care protocols.
Inadequate Pain Management for a Resident
Penalty
Summary
The facility failed to provide adequate pain management for a resident who required such services, leading to a deficiency in care. The resident, who was admitted with a fall and fracture of the right femur requiring surgical intervention, was on a scheduled pain medication regimen. Despite reporting zero pain in 34 out of 45 assessments, the resident continued to receive scheduled pain medication without reassessment of its effectiveness. The resident expressed feeling overly tired and attributed this to the pain medication, indicating a potential need to taper the medication. Additionally, non-pharmacological interventions were inconsistently documented, with several days lacking any recorded interventions. Staff interviews revealed gaps in the facility's pain management practices. A Licensed Practical Nurse (LPN) acknowledged that the pain regimen should have been reassessed daily and that opioids should have been withheld if the resident appeared overly sedated. However, the LPN did not notify the provider about the resident's lack of pain despite receiving scheduled opioids. Furthermore, an Advanced Registered Nurse Practitioner was unaware of any symptoms of oversedation or the absence of as-needed opioid doses since a specific date. These oversights contributed to the deficiency in providing safe and appropriate pain management for the resident.
Medication Error Rate Exceeds Acceptable Threshold
Penalty
Summary
The facility failed to maintain a medication error rate of less than five percent, resulting in an error rate of eight percent. This deficiency was observed when Staff P, an LPN, incorrectly administered medications to Resident 39 during a medication pass. Specifically, Staff P administered three drops of cyclosporine ophthalmic emulsion into the resident's left eye and two drops into the right eye, contrary to the physician's order of one drop in each eye. Additionally, Staff P administered two drops of Refresh ophthalmic solution into the right eye and four drops into the left eye, instead of the prescribed one drop in each eye. Furthermore, Staff P did not adhere to the manufacturer's guidelines, which required a 15-minute interval between administering cyclosporine and any lubricating eye drops, and a 5-minute interval for Refresh eye drops. Staff P admitted to not knowing about the required separation time between the eye drops, which contributed to the medication errors. These actions placed residents at risk for ineffective treatment and potential adverse side effects.
Deficiency in Laboratory Services for UTI Diagnosis
Penalty
Summary
The facility failed to ensure the quality and timeliness of laboratory services for a resident with a urinary catheter, leading to delays in diagnosing a urinary tract infection (UTI). The resident, who was cognitively moderately impaired, had an elevated white blood cell count (WBC) reported on multiple occasions, indicating a potential infection. However, there were significant delays and issues with urine sample collection and processing. On several occasions, urine samples were either not successfully completed, not sent to the lab, or were rejected by the lab due to being frozen. These issues resulted in a delay in obtaining a proper diagnosis and starting appropriate treatment for the resident's UTI. Staff interviews revealed a lack of proper procedures for handling urine samples, contributing to the deficiencies. A Licensed Practical Nurse (LPN) admitted to placing urine samples on ice, which led to them being frozen and subsequently rejected by the laboratory. The Director of Nursing Services (DNS) acknowledged awareness of the issue and mentioned a recent change in laboratory procedures, but was unable to demonstrate proper storage conditions for urine samples. Additionally, an Advanced Registered Nurse Practitioner (ARNP) noted a lack of follow-up on missing lab results, indicating a breakdown in communication and persistence in obtaining necessary diagnostic information.
Failure to Notify Provider of Abnormal Lab Results
Penalty
Summary
The facility failed to promptly notify the provider of laboratory results that were outside of normal ranges for a resident who was reviewed for urinary catheter or Urinary Tract Infection (UTI). The resident, who was cognitively moderately impaired and had an indwelling urinary catheter, was admitted to the facility and had a urinalysis and culture ordered. The sample was collected and received by the lab, and the results were reported to the facility. However, there was no documentation of provider notification from the date the facility received the results to the date the provider first documented the positive UTI. The facility's policy required nurses to document the receipt of lab results, provider notification, and any new orders received. For non-critical abnormal labs, the provider should be called with the results, and for critical values, repeat calls should occur if there is no response. In this case, the Advanced Registered Nurse Practitioner had to look up the results themselves, as there was no notification from the staff. The Director of Nursing Services could not provide documentation of provider notification by staff, only a provider progress note showing the provider discussed the urinalysis results with the patient.
Dietary Staff Training Deficiency
Penalty
Summary
The facility failed to ensure that sufficient dietary staff were trained and competent in preparing and providing pureed diets for two residents who required such diets. This deficiency was identified through observation, interview, and record review. Both residents were admitted with orders for regular, pureed diets with thin liquids. However, during a breakfast meal observation, they were served regular texture scrambled eggs and chopped sausage, along with pureed pancakes, which did not comply with their dietary requirements. The error occurred due to staffing issues and lack of proper training. The Head Cook/Dietary Manager in Training, Staff D, explained that the facility had a process for triple-checking meal trays for accuracy, but this process failed. A new cook, who was supposed to be trained on reading resident tray cards, was not supervised adequately because the dietary aide called off, and Staff D had to assume additional duties. Furthermore, the Certified Dietary Manager from another facility, who was training Staff D, had not arrived, leading to insufficient oversight and resulting in the diet texture errors.
Failure to Accommodate Resident's Dietary Needs and Allergies
Penalty
Summary
The facility failed to ensure that Resident 67, who was cognitively intact and had a known allergy to apples, received meals that accommodated their dietary needs and preferences. Despite being on a cardiac diet and having an allergy to apples, Resident 67 was repeatedly observed with unopened containers of apple juice on their bedside table and breakfast tray over several days. A Life Enrichment Evaluation documented the apple allergy, but this information was not reflected in the electronic health record. During an interview, the Dietary Manager/Cook and the Regional Registered Dietitian acknowledged that they were informed of resident preferences and allergies upon admission, but the Dietary Manager had only been made aware of Resident 67's apple allergy on the morning of the interview.
Failure to Address Nutritional Needs and Weight Loss
Penalty
Summary
The facility failed to timely identify, assess, and address the nutritional needs of two residents, leading to significant weight loss. Resident 69, who had a history of bariatric surgery and severe protein-calorie malnutrition, experienced a 23.75% weight loss after admission. The facility did not consistently obtain weekly weights as ordered, and there was a lack of follow-up on the significant weight discrepancy between the hospital and facility records. Staff failed to notify the physician or document any interventions, despite alerts indicating weight loss concerns. Resident 61 also experienced unaddressed weight loss due to the facility's failure to honor dietary preferences. Despite multiple reports of food dislikes and a documented weight loss of 6.5% over 90 days, the facility did not implement the Registered Dietician's recommendations for increased protein and milk intake. The resident's food preferences were not recorded in the dietary system, leading to continued provision of meals that the resident disliked, contributing to poor meal intake and further weight loss. The facility's inaction in both cases resulted in delayed nutritional interventions and unmet nutritional needs. Staff failed to follow established protocols for monitoring and addressing weight loss, and there was a lack of communication and documentation regarding the residents' nutritional status and preferences. These deficiencies placed the residents at risk for continued and unidentified weight loss.
Failure to Maintain Clean and Comfortable Environment
Penalty
Summary
The facility failed to maintain a clean and comfortable environment for several residents, as evidenced by multiple observations and interviews. Resident 5 was frequently left in a room with filthy conditions, including a sticky red substance on the bedside table and floor, a wet pad with a dark yellow liquid, and a persistent smell of urine. Despite some cleaning efforts, the red substance remained on the linens and surfaces. Resident 6 was observed sitting in a wheelchair next to an unmade bed, with a full urinal on the nightstand and debris on the floor. The resident expressed a desire to lie down but was unable to do so due to the unmade bed. Staff later admitted to forgetting to make the bed and clean the room. Resident 2 was found lying on a bed with a partially off flat sheet, exposing the bare mattress. The resident mentioned that this was a frequent occurrence due to a shortage of fitted sheets. Resident 1 was observed sitting in a wheelchair next to an unmade bed and expressed dissatisfaction with the situation. The Director of Nursing acknowledged that the rooms did not meet her expectations for cleanliness and timely bed-making. These observations indicate a failure to provide a safe, clean, and homelike environment for the residents, as required by regulations.
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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