Puget Sound Transitional Care
Inspection history, citations, penalties and survey trends for this long-term care facility in Des Moines, Washington.
- Location
- 2800 South 224th Street,, Des Moines, Washington 98198
- CMS Provider Number
- 505513
- Inspections on file
- 34
- Latest survey
- March 5, 2026
- Citations (last 12 mo.)
- 35 (1 serious)
Citation history
Health deficiencies cited at Puget Sound Transitional Care during CMS and state inspections, most recent first.
Surveyors found that the facility failed to follow physician orders and professional standards for PEG tube management for two residents. One resident with a brain injury and swallowing difficulty had a care plan and MD order for a specific daily tube feeding volume, but MAR review showed that on most days the resident received less formula than ordered. Another resident with a history of cardiac arrest, respiratory failure, and dysphagia had tube feeding discontinued after establishing adequate oral intake, yet the PEG tube remained in place despite the resident’s expressed discomfort and repeated requests for removal, as well as a PA note indicating removal was pending. The record contained no documented follow-up by nursing staff to coordinate PEG removal.
A resident with a venous leg ulcer and multiple comorbidities had a right lower leg dressing that was repeatedly observed without a date or staff initials, despite facility policy and care plan requirements to document wound care and monitor healing. The resident reported the dressing had not been changed that day, and an RN stated they changed the dressing every other day but did not label it. Review of the Treatment Administration Record showed multiple dates where the ordered wound dressing change was left blank and not signed off, indicating incomplete and inaccurate documentation of the wound care actually provided.
The facility did not provide required written transfer or discharge notices to several residents or their representatives during hospitalizations, nor did it notify the LTCO as required. Staff interviews revealed a lack of awareness of these requirements, and records showed that reports were not communicated to receiving hospitals for two residents. These deficiencies affected residents with serious medical conditions and were not in accordance with facility policy.
Surveyors found that care plans were not updated or revised as needed for several residents, including those with changes in hearing aid use, mental health diagnoses, nutritional needs, and ADL support. Staff interviews and record reviews confirmed that care plans did not reflect current resident preferences, diagnoses, or therapy recommendations.
The facility did not ensure that the Dietary Manager had completed the required certification, and the Registered Dietician was only present on site one day per week and worked remotely on two other days. The facility was unable to provide documentation confirming that the Dietary Manager's experience or qualifications met regulatory requirements.
Surveyors found unsanitary food storage in two unit refrigerators, including unlabeled and moldy items, lack of temperature monitoring, and confusion among staff about maintenance responsibilities. Additionally, a CNA delivered two meal trays at once to a shared room, resulting in the trays being given to the wrong residents, contrary to facility policy and staff expectations.
The facility did not educate staff on the COVID-19 vaccine or offer the vaccine to all staff, and failed to maintain documentation of staff vaccination status or education, contrary to facility policy. Interviews revealed that neither Human Resources nor the Infection Preventionist provided or tracked this required education or vaccine offering.
The facility did not obtain necessary consents for the administration of a psychoactive medication to a resident and for the use of safety devices, such as fall mats and a bed against the wall, for two other residents. Staff confirmed that consents were not secured prior to implementing these interventions, contrary to facility policy.
Two residents with severe cognitive impairment did not receive required information or assistance to formulate advance directives, despite documented requests and facility policy mandating such support. Staff interviews and record reviews confirmed the lack of documentation and follow-through for both cases.
Comprehensive MDS assessments were not completed within regulatory timeframes for multiple residents, with some assessments finalized up to 15 days late. The absence of an MDS Coordinator contributed to delays, hindering the care planning process and timely provision of appropriate care.
Surveyors found that two residents' MDS assessments were inaccurate: one resident with a neurogenic bladder and indwelling catheter was incorrectly coded as always incontinent, and another resident receiving antidepressant medication for depression was not identified with a depression diagnosis on the MDS. The MDS Coordinator confirmed both errors.
Two residents identified as needing further mental health assessment after PASRR level 1 screenings did not receive timely level 2 evaluations. One resident with depression began antidepressant treatment, but the facility delayed updating the PASRR and did not follow up for the required evaluation. Another resident with a psychiatric mood disorder had a referral sent for a level 2 evaluation, but no follow-up occurred for over a year, and the evaluation was not completed.
Surveyors found that several residents did not receive care in accordance with physician orders, including improper air mattress settings for pressure ulcer prevention, administration of medications outside prescribed parameters, lack of timely documentation of medication administration, and provision of care such as supplemental oxygen and specialized mattresses without appropriate orders or clarification. Staff interviews confirmed these deficiencies and the absence of required clarifications.
A resident with multiple medical conditions and no memory issues, who did not speak English, was not provided with effective communication support. Staff did not use interpreter services or communication aids as outlined in the care plan, relying instead on non-verbal cues. The absence of a communication binder and lack of a facility policy for language needs contributed to the deficiency.
Several residents dependent on staff for ADLs such as bathing, grooming, dressing, oral hygiene, and getting out of bed did not receive the required assistance. Observations and interviews showed that residents remained in bed in hospital gowns, with unkempt hair and unbrushed teeth, and did not receive scheduled showers or help with dressing as outlined in their care plans. Staff confirmed that required morning care was not consistently provided and that refusals of care were not documented.
Two residents who were dependent on staff for mobility and care did not receive individualized activity plans or consistent offers of activities, and refusals were not documented. Despite care plans and assessments indicating preferences for music, religious services, and social engagement, observations and staff interviews revealed that these residents were often left in bed without meaningful activities, and staff did not ensure or document that activities were offered as required.
Two residents did not receive required weekly skin assessments as ordered, and new skin issues such as bruising and a scab with drainage were not documented or reported to providers. Staff failed to follow care plans and physician orders for monitoring, documentation, and notification regarding non-pressure skin issues.
A resident admitted with an indwelling catheter was not assessed for the continued need for the device, and no attempt was made to remove it as required by facility protocol. Staff did not document the reason for the catheter, consult with a provider, or perform a trial removal, resulting in a failure to follow established procedures for catheter management.
The facility did not complete required safety assessments or obtain necessary documentation for the use of safety devices and positioning interventions for three residents, including placing a bed against the wall, using fall mats, and utilizing a tilt-in-space wheelchair. Staff confirmed that expected assessments, physician orders, and informed consent were missing for these interventions.
Two RNs failed to administer medications as ordered, resulting in a medication error rate of 6.25%. Errors included giving a resident an incorrect form of a blood thinner and substituting artificial tears for prescribed medicated eye drops, both contrary to physician orders.
Drugs and biologicals were not labeled according to professional standards, and medications, including controlled drugs, were not stored in locked or separately locked compartments as required.
The facility did not obtain or document required laboratory results to support antibiotic treatments for two residents admitted with infections, as required by its antibiotic stewardship policy. The Infection Preventionist confirmed that staff failed to collect necessary supporting data at admission, resulting in incomplete records for antibiotic use.
Surveyors found that toilets on two floors were not flushing properly and remained filled with waste, while call light cords in several shared bathrooms were either out of reach or missing. Staff and residents reported these issues had persisted despite multiple notifications to maintenance, and maintenance logs showed no record of repairs. Additionally, a bathroom faucet with jagged metal was identified as a safety hazard.
A resident with a Full Code order was found unresponsive, not breathing, and without a pulse, but staff failed to initiate CPR or call EMS as required by facility policy. The nurse present did not start CPR and instead notified the DON, while two CNAs with expired CPR certifications were also present. This failure placed other residents with Full Code status at risk.
Several staff members, including RNs, LPNs, and CNAs, lacked current CPR certification and had not completed required emergency response training. During an incident where a resident was found unresponsive and not breathing, staff present did not initiate CPR due to lack of knowledge or expired certification. Additionally, an LPN was unaware of the location of the AED, and the device was missing from one nurse's station, leaving only one functioning AED in the facility.
A resident admitted for short-term rehab after a heart procedure was found dead unexpectedly, and the facility failed to report the death to the SSA or conduct an investigation as required by policy. The DON did not recognize the death as unexpected and did not report it, and the administrator was unaware of the omission.
A resident admitted for short-term rehab after a heart procedure was found deceased unexpectedly, and the facility failed to conduct a thorough investigation as required by its abuse prohibition policy. The DON did not recognize the death as unexpected and did not initiate an investigation, and only a brief, undated timeline was provided instead of a complete review and documentation of the incident.
The facility failed to maintain a clean and sanitary kitchen environment, with issues such as peeling floors, dirty stove tops, and rusted refrigerator racks. Improper food handling was observed, including a dietary aide not changing gloves after handling raw eggs. Additionally, food labeling and storage practices were inadequate, with undated and expired items found. The sanitizing solution was ineffective, further contributing to unsanitary conditions. These deficiencies placed residents at risk for food-borne illnesses.
The facility failed to assist and document the formulation of Advance Directives (AD) for several residents, despite their medical conditions requiring clear healthcare wishes. Interviews and record reviews revealed incomplete or missing AD Acknowledgement forms and a lack of follow-up, placing residents at risk of not having their treatment preferences honored.
The facility failed to conduct Care Conferences (CCs) for several residents with complex medical conditions, as required. Residents and their representatives reported not having CCs, and medical records lacked documentation of these meetings. The Social Services Director confirmed the absence of CCs, which should occur quarterly and within 72 hours of admission.
The facility failed to implement and document physician's orders for several residents, including incorrect air mattress settings for a resident with a pressure ulcer, inconsistent application of compression bandages for a resident with swelling, inappropriate administration of narcotics to a resident without pain, incomplete catheter orders, and a broken CPAP machine not replaced for months.
The facility failed to provide adequate ADL assistance, including bathing, shaving, and nail care, for several residents. A resident on hospice care did not receive bathing assistance for 30 days, while another resident requiring maximum assistance missed scheduled showers due to understaffing. Additionally, two residents experienced neglect in personal hygiene care, with one having matted hair and dirty nails, and another not receiving requested shaving assistance. Staff miscommunication and incorrect assumptions contributed to these deficiencies.
The facility failed to coordinate dialysis care for two residents, lacking proper communication and documentation with the dialysis center. One resident experienced abdominal pain before a dialysis session, but this was not communicated to the dialysis center. Another resident returned from dialysis without the required transfer communication form. The care plans for both residents did not include necessary directions for staff collaboration with the dialysis facility.
A facility experienced a medication error rate of 61.54% due to improper administration by an LPN. Two residents received medications outside the prescribed time window, and inaccurate dosage orders were not clarified with the physician. The DON confirmed the importance of adhering to scheduled times to prevent errors.
The facility failed to properly inform two residents and their representatives about the implications of signing a binding Arbitration Agreement (AA). One resident's representative, who was the DPOA-F, signed the AA without understanding it waived the right to a jury or court. Another resident's representative signed the AA without being the designated DPOA-F. The Admissions Director admitted to insufficient explanation of the AA process.
The facility failed to create comprehensive care plans for two residents, one with a hip fracture and another with a leg fracture and amputation. The first resident lacked a pain management plan despite experiencing daily pain, while the second resident's care plan did not include instructions for using a leg immobilizer, crucial for wound healing and safety. Staff confirmed the absence of necessary care instructions.
A resident with a history of falls and a recent hip fracture was observed without required fall prevention measures, such as a bed in the lowest position and floor mats, as outlined in their care plan. Staff interviews revealed these interventions were not reinstated after the resident's return from the hospital, placing them at risk for further injury.
The facility failed to maintain a safe, clean, and homelike environment, with observations of damaged walls, sharp sink edges, incomplete blinds, and strong urine odors in resident rooms. Staff confirmed the need for repairs and proper maintenance to ensure resident comfort and privacy.
The facility failed to provide required written notifications to residents, their representatives, and the LTCO at the time of transfer or discharge for three residents. Staff interviews revealed a lack of awareness of the notification process, resulting in the absence of documentation and failure to notify the LTCO, preventing proper education and advocacy for residents during the discharge process.
The facility failed to encode and transmit MDS assessments within the required timeframe for two residents. One resident's death assessment was completed late and not transmitted, while another resident's discharge assessment was not initiated or completed. Staff acknowledged these oversights.
The facility failed to accurately complete MDS assessments for three residents, leading to unrecorded issues such as loose dentures, a fall, and a range of motion limitation. These inaccuracies were confirmed through interviews and observations, highlighting the need for precise documentation to ensure proper care planning.
A resident with severe cognitive impairment and multiple diagnoses was not provided with activities as per their care plan. Despite preferences for music and group activities, the resident was left without engagement or entertainment, and staff failed to assist with provided devices. The Activities Supervisor admitted to not offering or documenting activities, contrary to facility expectations.
The facility failed to provide adequate care for two residents with skin issues and one with constipation. A resident's bruises were not documented or monitored, another's rash was not assessed or recorded, and a third resident did not receive laxatives despite constipation. Staff interviews confirmed these deficiencies.
The facility failed to provide restorative nursing program (RNP) services to three residents, leading to a deficiency in maintaining or improving their range of motion (ROM) and mobility. One resident with depression and muscle weakness received ROM exercises only a fraction of the time prescribed. Another resident with similar diagnoses did not receive consistent RNP services due to the unavailability of the restorative aide. A third resident, with a history of stroke, received passive ROM exercises only seven times in 30 days. The sole Restorative Nursing Aide was overwhelmed, leading to the failure to provide RNP as ordered.
The facility failed to maintain an effective infection prevention and control program, as staff did not adhere to Transmission Based Precautions in rooms with contact precautions, entering without required PPE. Additionally, catheter bags for two residents were improperly placed, posing a risk of contamination. Interviews confirmed these practices were against infection control protocols.
Failure to Follow PEG Tube Feeding Orders and Discontinue Unneeded PEG Tube
Penalty
Summary
The deficiency involves the facility’s failure to ensure residents with PEG tubes received treatment and services according to professional standards and physician orders. Facility policy required staff to follow physician orders, provide proper care and maintenance of gastrostomy tubes, and assess residents for pain or discomfort at the tube site. For one resident with impaired memory, inability to communicate verbally, a brain injury, and swallowing difficulty, the care plan identified a need for tube feeding via PEG to meet nutritional requirements, and a physician’s order directed that 1700 ml of tube feeding be administered over 20 hours daily. Review of this resident’s Medication Administration Record for an entire month showed that on 28 of 30 days, the resident received less tube feeding volume than ordered, with documented daily totals consistently below 1700 ml and on some days significantly lower. The Administrator and Infection Preventionist/Staff Development acknowledged on review that the resident did not receive the ordered amount of tube feeding, and the DON stated that nursing staff were expected to follow and implement physician tube feeding orders as indicated in the MAR. These findings demonstrated that the facility did not implement the physician’s prescribed tube feeding volume as required by policy and the resident’s care plan. For a second resident with clear speech, memory deficits, cardiac arrest, respiratory failure, and swallowing difficulty, the MDS and nutrition care plan showed a PEG tube remained in place while the resident was on a mechanically altered diet and no longer receiving tube feeding. A nutritional evaluation documented that tube feeding had been discontinued after the resident established good appetite and oral intake. The resident’s representative notified the facility of the need for a physician referral to remove the PEG tube, and a PA progress note recorded that the resident reported discomfort from the PEG and that an order for removal was pending per nursing staff. During observation and interview, the resident stated they could manage nutrition by eating, no longer needed tube feeding, and wanted the PEG removed. However, review of medical records and progress notes over nearly two months showed no documented follow-up by the facility to coordinate PEG removal, and staff confirmed there was no documentation of follow-up after the PA’s visit, indicating a failure to ensure ongoing review and evaluation of PEG discontinuation once adequate oral nutrition was achieved.
Incomplete Wound Care Documentation and Unlabeled Dressings for Venous Leg Ulcer
Penalty
Summary
The deficiency involves the facility’s failure to maintain complete and accurate medical records and documentation of wound care for a resident with a venous leg ulcer. Facility policy on Skin and Wound Monitoring and Management required that wound care be implemented as ordered, with documentation in the Treatment Administration Record (TAR) reflecting the care provided and any wound changes. The resident’s care plan, revised in early June 2025, identified altered skin integrity due to a venous ulcer on the right leg and directed staff to perform treatments as ordered and to assess, record, and monitor wound healing. The resident’s Minimum Data Set showed they were cognitively intact and had multiple medical conditions, including heart and respiratory failure and unstable blood sugar, and that they received skin/wound treatment during the assessment period. During observations, the resident was seen with a white mesh dressing on the right lower leg that was secured with tape and showed scant drainage, but the dressing was unlabeled with no date or staff initials. In a later observation and interview, the dressing remained unlabeled, and the resident reported they were sure the dressing had not been changed that day, though they could not recall the exact date of the last change. A registered nurse stated they changed the dressing every other day as ordered but acknowledged they did not date or initial the dressing after changes. Review of the resident’s February 2026 TAR showed that on three specific dates the ordered right leg wound dressing change was not signed off and the entries were left blank. The administrator and the infection preventionist/staff development nurse confirmed their expectation that nurses date and initial dressings for auditing and that staff follow physician wound treatment orders and document the care provided in the medical record.
Failure to Provide Required Written Transfer/Discharge Notices and LTCO Notifications
Penalty
Summary
The facility failed to provide required written notifications and Long Term Care Ombudsman (LTCO) notifications to residents and/or their representatives at the time of transfer or discharge for six out of seven residents reviewed. Specifically, there was no documentation in the clinical records of written transfer notices describing the reason for transfer for multiple hospitalizations involving residents with significant medical conditions such as stroke, kidney failure, high blood sugars, abdominal pain, and terminal illness. The facility's policy required that written notice be given to the resident or their representative and a copy sent to the State LTCO office prior to transfer or as soon as practicable, but this was not followed in these cases. Interviews with facility staff revealed a lack of awareness and responsibility regarding the requirement to provide written notifications. Staff members reported notifying families by phone and sending an "e-interact" form with residents to the hospital, but were unaware of the need for written notifications. Social services staff also confirmed that the LTCO was not notified of the transfers as required. Additionally, staff interviews indicated that there was no clear assignment of responsibility for providing these written notices during transfers or hospitalizations. For two residents, the facility also failed to communicate a report to the receiving hospital regarding the resident's condition at the time of transfer. Review of transfer forms showed that the necessary information was not provided to the receiving hospitals, and staff confirmed that reports were not called in for these transfers. These failures were observed through record reviews and staff interviews, confirming that the required notifications and communications were not completed as per facility policy and regulatory requirements.
Failure to Update and Revise Care Plans for Multiple Residents
Penalty
Summary
The facility failed to ensure that care plans (CPs) were updated and revised periodically and as needed for several residents, as required by both facility policy and regulatory standards. For one resident who used hearing aids, repeated observations showed the resident was not wearing them, and staff confirmed the care plan did not reflect the resident's current preference not to use hearing aids. Another resident with a mental health diagnosis and an order for antipsychotic medication did not have a care plan addressing the mental health diagnosis itself, only the medication. Staff acknowledged this omission during review. A third resident with a history of kidney and heart failure, who had transitioned from tube feeding to eating soft food without difficulty, still had a care plan indicating dependence on tube feeding, which staff confirmed was outdated. Additionally, a resident dependent on staff for all activities of daily living (ADLs) had a care plan that did not specify the correct bathing schedule or include physical therapy recommendations for daily wheelchair use and positioning, despite these being part of the resident's current care needs. These findings were based on direct observation, interviews with staff, and review of medical records and care plans.
Dietary Manager Lacks Required Certification and Insufficient Dietician Coverage
Penalty
Summary
The facility failed to ensure that the Dietary Manager met the minimum qualifications required in the absence of a full-time Registered Dietician. Review of the facility's Key Personnel list showed that the Dietary Manager had been in the role for thirteen months but was still enrolled in a dietary manager certification class and had not completed the required certification. The facility did not provide documentation to demonstrate that the Dietary Manager's experience or qualifications were sufficient to meet regulatory requirements. Additionally, the Registered Dietician was only on site one day per week and provided remote services two other days, while also working at another facility. The Interim Administrator was unable to confirm whether the Dietary Manager's qualifications met the necessary standards, and no further documentation was provided to support compliance with staffing requirements for food and nutrition services.
Deficient Food Storage and Meal Tray Distribution Practices
Penalty
Summary
Surveyors observed that the facility failed to store food under sanitary conditions in both the 200 and 300 unit refrigerators. The 200 unit refrigerator/freezer lacked a temperature log for the freezer, contained unlabeled frozen meals and beverages, and had visible dried liquid stains inside. Food items were not labeled with resident names or use-by dates as required by facility policy, and some containers held unknown substances. The 300 unit refrigerator also contained outside food that was not dated, a lack of documented freezer temperatures for a two-week period, and several items that were either unlabeled or improperly labeled. One container held a moldy substance with spilled liquid, and there was no indication of ownership or discard date. Staff interviews revealed confusion over responsibility for maintaining the cleanliness and labeling of the unit refrigerators, with dietary and nursing staff each indicating the other was responsible. Additionally, on the 300 unit, a Certified Nursing Assistant delivered two lunch trays at once to a shared resident room, resulting in the trays being given to the wrong residents. Both residents immediately called for staff to correct the error. The CNA acknowledged that trays were supposed to be delivered one at a time to prevent such mistakes, as delivering the wrong meal could pose a risk of injury or incorrect diet. The Director of Nursing confirmed the expectation that trays be delivered individually to ensure resident safety and infection prevention.
Failure to Educate and Offer COVID-19 Vaccine to Staff
Penalty
Summary
The facility failed to educate staff on the risks and benefits of the COVID-19 vaccine and did not offer the vaccine to all staff, as required by facility policy. During interviews, the Human Resources staff stated they did not maintain records of staff COVID-19 vaccinations or related education, believing that the Infection Preventionist was responsible for these records. Upon review, the Infection Preventionist confirmed that no education or offers of the COVID-19 vaccine had been provided to staff, and no documentation existed to show that staff were educated or offered the vaccine. This deficiency was identified through interviews and record reviews, and was found to be inconsistent with the facility's own infection prevention and control policy.
Failure to Obtain Required Consents for Medications and Safety Devices
Penalty
Summary
The facility failed to obtain required consents for psychoactive medication administration and the use of safety devices for several residents. One resident, who had memory issues but was able to communicate clearly, received an antianxiety medication on multiple occasions without documented consent from the resident or their representative. Staff confirmed that consent was not obtained prior to administering the medication, despite facility expectations that such consent should be secured before starting any new medications. Additionally, two other residents were observed with safety devices in use—specifically, fall mats on both sides of the bed for one resident with a history of falls and a bed positioned against the wall for another resident. In both cases, there was no documented consent from the residents or their representatives for the use of these safety interventions. Staff interviews confirmed that consents were not obtained as required, even though facility policy and staff expectations dictated that consents should be secured prior to implementing such interventions.
Failure to Provide Advance Directive Information and Assistance
Penalty
Summary
The facility failed to provide information and assistance to formulate an advance directive for two residents reviewed for advanced directives. According to facility policy, staff are required to provide written information about advance directives to all residents or their representatives upon or immediately after admission, and to document this in the resident's record. For one resident with severe cognitive impairment and dependency on staff for all care, records indicated an interest in formulating an advance directive, but there was no documentation that information or assistance was provided. Staff interviews confirmed that the resident did not have an advance directive and that no information had been given. For another resident with severe memory impairment and a diagnosis of non-Alzheimer's dementia, records showed the resident reported having advance directive paperwork but also requested information on how to formulate one. There was no documentation that information or assistance was provided, nor was there a copy of an advance directive in the resident's records. Staff interviews confirmed the absence of documentation regarding the provision of information or assistance for both residents.
Failure to Complete Timely Comprehensive MDS Assessments
Penalty
Summary
The facility failed to complete comprehensive Minimum Data Set (MDS) assessments within the required regulatory timeframes for several residents. Specifically, one resident's admission MDS was completed 15 days past the required timeframe, while two other residents' admission MDS assessments were completed five and 15 days late, respectively. These delays were identified through interviews and record reviews, which showed that the assessments were not finalized within the 14-day period mandated by the Resident Assessment Instrument (RAI) Manual. The manual requires that an admission MDS be completed by the end of day 14, counting the date of admission as day one, and that annual MDS assessments be completed no later than 14 days after the Assessment Reference Date (ARD). The MDS Coordinator confirmed during an interview that timely completion of comprehensive assessments is essential for resident care and facility reimbursement. The Coordinator also stated that when they began working at the facility, there was no MDS Coordinator in place, and the facility was already behind on completing residents' MDS assessments. This lack of timely assessment completion hindered the care planning process necessary to provide appropriate care and services to the residents.
Inaccurate MDS Assessments for Two Residents
Penalty
Summary
The facility failed to ensure the Minimum Data Set (MDS) assessments accurately reflected the clinical status of two residents. For one resident with a neurogenic bladder who used an indwelling catheter, the MDS inaccurately coded the resident as always incontinent of bladder, rather than using the appropriate coding for catheter use. Observation confirmed the presence of the catheter, and the MDS Coordinator acknowledged the error, stating that the incontinence status should not have been marked as always incontinent for a resident with a catheter. For another resident, the MDS assessment recorded a high mood score indicating significant depressive symptoms, including poor appetite, low self-esteem, and difficulty concentrating. The assessment also documented the use of an antidepressant medication but failed to indicate a diagnosis of depression, despite a physician's order for antidepressant treatment specifically for depression. The MDS Coordinator confirmed that the resident should have been identified with a depression diagnosis on the MDS assessment.
Failure to Obtain Timely PASRR Level 2 Evaluations for Residents with Serious Mental Illness
Penalty
Summary
The facility failed to ensure that Pre-admission Screening and Resident Review (PASRR) level 2 comprehensive evaluations were obtained for two residents who were identified as requiring further assessment for serious mental illness (SMI) after their level 1 PASRR screenings. For one resident with a diagnosis of depression who began antidepressant treatment, the facility delayed updating the level 1 PASRR for four months and did not follow up to obtain the required level 2 evaluation. The resident's records showed no evidence of a level 2 PASRR being completed, despite the ongoing use of antidepressant medication and the initial identification of SMI. For another resident with a psychiatric mood disorder, the facility's records indicated that a level 2 PASRR evaluation was required, but there was no documentation of the evaluation being completed. Although a referral for the level 2 evaluation was reportedly sent, there was a delay of over a year and three months before any follow-up occurred. Staff interviews confirmed awareness of these delays and lapses in the PASRR process, with staff citing workload and external factors as reasons for the lack of timely follow-up.
Failure to Follow and Clarify Physician Orders and Document Care Provided
Penalty
Summary
The facility failed to ensure that physician's orders were followed and properly documented for several residents. For three residents at risk of or with existing pressure ulcers, air mattress settings were not maintained as ordered by the physician. In one case, the air mattress was set at 300 pounds instead of the ordered 160-180 pounds, and staff acknowledged the mattress could not be set to the prescribed range and that the order should have been clarified. Another resident's air mattress was set at 200 pounds instead of the ordered 100-110 pounds, despite staff documenting that the mattress was monitored every shift. Additionally, a resident received blood pressure and diuretic medications outside of the ordered parameters, with staff confirming that medications were not held as directed when blood pressure readings were below the specified threshold. The facility also failed to ensure that nurses only signed for treatments after they were provided. In one instance, a nurse did not sign the Medication Administration Record (MAR) immediately after administering morning medications to a resident with complex medical needs, as required. Furthermore, there was a lack of clarification of physician's orders for another resident receiving artificial nutrition via feeding tube; the order specified the rate of administration but did not indicate the type of nutrition to be used, and staff did not seek clarification from the provider. Additionally, the facility did not ensure that physician's orders were in place prior to providing certain types of care. One resident was observed receiving supplemental oxygen without a corresponding physician's order, and staff confirmed that an order should have been obtained but was not. Another resident was found using a low air loss mattress for pressure relief without a specific physician's order for that device, and staff acknowledged the absence of an appropriate order. These failures were identified through observation, interview, and record review, and placed residents at risk for unmet needs and ineffective or delayed treatments.
Failure to Provide Functional Communication System for Non-English Speaking Resident
Penalty
Summary
The facility failed to provide a functional communication system for a resident who did not speak English and required interpreter services to communicate with staff. Despite the resident's care plan indicating a need for staff to use a language line or contact the resident's family for communication, staff were observed not utilizing these resources during care. Instead, staff relied on non-verbal cues such as facial expressions and did not have a communication binder with everyday words and pictures available in the resident's room, as was indicated should be present. The only accommodation observed was a posted language line phone number in the resident's room, which staff did not use during interactions. The resident, who had multiple medical conditions and no memory issues, was observed on several occasions attempting to communicate in their preferred language but was not understood by staff. The resident's representative confirmed that the resident could not speak English and had experienced difficulty communicating symptoms, such as shortness of breath, to staff. Staff interviews revealed an absence of a facility policy for language and communication for residents with English as a second language, and staff acknowledged the lack of appropriate communication tools in the resident's room.
Failure to Provide Assistance with Activities of Daily Living
Penalty
Summary
The facility failed to provide necessary assistance with Activities of Daily Living (ADLs) such as bathing, grooming, dressing, oral hygiene, and getting out of bed for several residents who were dependent on staff for these tasks. Observations and interviews revealed that multiple residents remained in bed in hospital gowns, with unkempt hair and unbrushed teeth, and did not receive scheduled showers or assistance with dressing as outlined in their individualized care plans. Staff interviews confirmed that required morning care, including oral care, hair care, dressing, and assistance to get up, was not consistently provided, and that refusals of care were not documented as required by facility policy. One resident with complex medical conditions was observed multiple times in bed, unshaven, with greasy hair and unbrushed teeth, and reported not receiving help with oral hygiene. Another resident, who required maximal assistance and use of a mechanical lift, was observed in bed during multiple visits and was not assisted to get up for meals or activities as specified in their care instructions. A third resident, dependent for all cares due to stroke and dementia, had no documentation of bathing being offered or provided for several months and was not assisted out of bed except for a medical appointment. Staff confirmed that these residents should have received regular assistance with ADLs but did not, and there was no documentation of refusals. Additional residents also reported or were observed not receiving scheduled showers or assistance with dressing and hygiene. One resident expressed frustration at not receiving showers as scheduled, and documentation confirmed that only half of the scheduled showers were provided, with no refusals documented. Staff interviews further corroborated that expected care was not consistently offered or documented. These failures were in direct violation of the facility's ADL policy and care plans, leaving residents without the necessary support for their daily living needs.
Failure to Provide and Document Individualized Activities for Dependent Residents
Penalty
Summary
The facility failed to provide individualized activity plans and to document activity refusals for two of three residents reviewed for activities. According to the facility's policy, activities should be available to all residents to support their physical, mental, and psychosocial well-being, with assessments conducted at admission to determine preferences, including cultural and spiritual interests. However, for one resident, the Minimum Data Set (MDS) did not show an assessment of activity preferences, and the care plan indicated a need for 1:1 room visits and staff escort to group activities. Despite this, multiple observations showed the resident lying in bed, with no music or television on, and no evidence of activities being provided. Staff interviews confirmed that the resident was dependent on staff for all mobility and care, enjoyed music, and should have been offered activities, but there was no documentation of activities being offered or refused. For the second resident, the MDS indicated complex medical conditions, including depression, and highlighted the importance of music, favorite activities, and religious services. The care plan noted impaired vision and the need for staff assistance to participate in activities. Observations revealed the resident was often awake in bed with no music or television on. The resident expressed a desire to attend activities such as listening to music, going outside, and attending church services but required staff assistance for mobility. Staff interviews indicated that the resident needed help to get out of bed and that activities staff did not consistently offer or document activities, including religious services and fresh air, as outlined in the care plan. The facility's failure to consistently offer and provide meaningful, individualized activities, as well as to document refusals, was confirmed through observation, record review, and staff interviews. Both residents were dependent on staff for mobility and care, and their preferences and needs were not met according to facility policy and care plans. There was a lack of documentation for activities offered or refused, and staff did not ensure that residents were provided with opportunities for engagement as required.
Failure to Perform and Document Weekly Skin Assessments and Notify Providers
Penalty
Summary
The facility failed to ensure that weekly skin assessments were performed, documented, and acted upon as required for two residents reviewed for non-pressure skin issues. For one resident, multiple bruises on both arms were observed on several occasions, but there were no physician orders to monitor the bruising, and weekly skin assessments either were not completed as ordered or failed to identify the bruises. The care plan instructed staff to perform weekly head-to-toe skin assessments and to notify the nurse supervisor of any skin breakdown, including bruises, but this was not followed. Staff interviews confirmed that weekly skin checks were missed and that new skin issues were not documented or reported as required. For another resident, a scab with bloody drainage was observed on the left cheek during multiple observations, but there was no treatment order in the record and weekly skin assessments had not been completed after a certain date. The resident's care plan and physician orders required weekly skin checks, but staff failed to perform and document these assessments, and did not notify the physician about the new skin issue. Staff interviews confirmed that the required assessments and notifications were not completed according to facility policy and physician orders.
Failure to Assess and Attempt Removal of Indwelling Catheter
Penalty
Summary
The facility failed to ensure that a resident admitted with an indwelling catheter (I/C) was properly assessed for the continued need for the catheter and that attempts were made to remove it as soon as possible. Upon admission from the hospital, the resident had an I/C in place, but there was no documentation in the medical record indicating an assessment of the reason for the catheter, nor evidence that staff consulted with a provider regarding its necessity. The resident's bowel and bladder assessment indicated incontinence, but no further evaluation or trial removal of the catheter was documented. Staff interviews confirmed that the required assessment and trial removal were not performed, and there was no documentation of post void residual (PVR) measurements or provider consultation as per facility protocol. Observations showed the resident with the I/C in various positions, including lying in bed and sitting in a wheelchair, with the catheter bag sometimes resting on the floor. The care plan and physician orders directed staff to provide catheter care every shift, but the critical step of reassessing the need for the catheter and attempting its removal was omitted. The lack of assessment and documentation regarding the ongoing need for the I/C constituted a failure to follow established protocols and placed the resident at risk for complications associated with prolonged catheter use.
Failure to Complete Safety Assessments and Documentation for Safety Devices and Positioning
Penalty
Summary
The facility failed to complete required safety assessments and obtain necessary documentation for the use of certain safety devices and positioning interventions for multiple residents. For one resident with no memory impairment, the care plan included placing the bed against the wall, but there was no documented safety assessment to justify this intervention. Observation confirmed the bed was positioned against the wall, and staff interviews revealed an expectation for safety assessments in such cases, but none could be provided. Another resident with impaired memory and a history of falls was observed with fall mats on both sides of the bed. The care plan indicated the resident was at risk for falls, but there was no physician’s order, informed consent, or safety device assessment for the use of the floor mats. Staff confirmed that these steps were expected but had not been completed or documented for this resident. A third resident with multiple diagnoses, including stroke, impaired memory, and a history of falls, was using a tilt-in-space wheelchair. Although a safety device evaluation recommended the wheelchair for support and comfort, there was no therapy evaluation or safety assessment to determine the necessity and safety of the device. Observations showed the resident was unable to unlock the wheelchair brakes independently and expressed frustration at being unable to return to their room. Staff interviews confirmed the lack of required assessments and documentation for the use of the tilt-in-space wheelchair.
Medication Error Rate Exceeds Acceptable Threshold
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, as required by policy and regulation. During medication administration observations, two of four nurses did not properly administer two of thirty-two medications to one resident. Specifically, one nurse administered an enteric-coated blood thinner instead of the prescribed chewable form for a resident with heart issues, contrary to the physician's order. The nurse acknowledged not checking the physician order before administering the medication. On a separate occasion, another nurse administered artificial tear eye drops to the same resident for dry eyes, despite the physician's order specifying medicated eye drops for eye irritation. The nurse admitted to misinterpreting the order and not following the physician's instructions. These errors resulted in a medication error rate of 6.25%, exceeding the acceptable threshold and not aligning with the facility's medication administration policy.
Failure to Properly Label and Secure Medications
Penalty
Summary
Drugs and biologicals in the facility were not labeled in accordance with currently accepted professional principles. Additionally, all drugs and biologicals were not stored in locked compartments, and controlled drugs were not kept in separately locked compartments as required. These actions resulted in a failure to meet regulatory requirements for the labeling and secure storage of medications and biologicals within the facility.
Failure to Document Supporting Labs for Antibiotic Stewardship
Penalty
Summary
The facility failed to complete antibiotic stewardship for two of four residents reviewed for unnecessary antibiotic use. According to facility policy, the Infection Preventionist (IP) is responsible for infection surveillance, tracking multidrug resistant organisms, and collecting and reviewing all supporting labs and tests for antibiotic usage. For both residents in question, one admitted with sepsis and the other with a bone infection, there were no supporting laboratory results or test documentation in their records to justify the prescribed antibiotic treatments. Interviews with the Resource Infection Preventionist confirmed that staff are expected to obtain appropriate diagnoses, start and stop dates for antibiotics, lab results, and other supporting data at the time of admission, especially for residents admitted with infections. However, a thorough review of the records for these two residents revealed that staff did not obtain the required lab results at admission, and the Infection Preventionist was unable to provide documentation to support the antibiotic treatments administered.
Failure to Maintain Functional Toilets and Call Lights
Penalty
Summary
Surveyors identified that the facility failed to maintain essential equipment, specifically toilets and call lights, in safe and functional condition on multiple floors. Observations over several days revealed that toilets in the second-floor family room, sensory room, and a shared resident bathroom were not flushing adequately, often remaining filled with waste despite repeated attempts to clear them. Staff interviews confirmed that these issues were longstanding, with maintenance either unaware of the problems or not addressing them effectively. In one instance, a resident reported having to use a commode due to the persistent unclean state of the shared toilet, and staff noted that maintenance performed only cosmetic repairs rather than fixing the underlying plumbing issues. Additionally, a bathroom sink faucet was found to have a large crack with jagged metal, posing a risk of injury, and staff acknowledged the bathroom was unsafe for resident use. Further deficiencies were observed with the call light systems in shared bathrooms on the third floor. Call light cords were found to be out of reach or missing entirely, making it impossible for residents to alert staff if they needed assistance or had fallen. Staff confirmed that these issues had been reported multiple times, but maintenance logs showed no record of repairs for the affected call lights. The lack of accessible call light cords was acknowledged by staff as a safety risk, and no documentation was provided to show that repairs had been made. These findings were in direct violation of the facility's policy ensuring a safe, clean, and homelike environment for residents.
Failure to Initiate CPR and Activate EMS for Full Code Resident
Penalty
Summary
The facility failed to ensure that Basic Life Support (BLS), including Cardio-Pulmonary Resuscitation (CPR), was initiated immediately for a resident who was found unresponsive, not breathing, and without a pulse, despite the resident having a current physician order and POLST form indicating Full Code status. The facility's policy required staff to activate Emergency Medical Services (EMS) and begin CPR without delay unless a Do Not Resuscitate order was in place or there were obvious signs of irreversible death. However, when the resident was discovered in this condition, the first licensed staff member on the scene did not initiate CPR or call EMS, instead leaving the resident to notify the Director of Nursing (DON). The staff member who found the resident admitted to panicking and failing to assess for signs of irreversible death or to start CPR as required. Two certified nursing assistants were also present in the room but did not initiate CPR. Review of staff credentials revealed that the registered nurse on the scene had a current CPR certification, but both certified nursing assistants had expired CPR cards at the time of the incident. The facility did not have a process in place to ensure that staff CPR certifications were current and reviewed before expiration. As a result of these actions and inactions, CPR was not performed, and EMS was not called for the resident, who was subsequently pronounced deceased by a physician assistant. The deficiency was identified as placing additional residents with Full Code status at serious risk, as the facility had 48 other residents with current physician orders to receive CPR according to policy.
Failure to Ensure Staff Competency in CPR and Emergency Response Procedures
Penalty
Summary
The facility failed to ensure that nursing staff, including RNs, LPNs, and CNAs, maintained appropriate competencies and current certifications necessary to provide emergency care, specifically Cardio-Pulmonary Resuscitation (CPR). Review of staff records revealed that several staff members, including Staff C, D, and E, lacked current CPR certification and had not completed required training on the facility's Emergency Response procedures. Staff C, who encountered a resident found unresponsive, without a pulse, and not breathing, did not initiate CPR due to panic and lack of knowledge. Staff D and E, both present during the same incident, also did not perform CPR; Staff D's and E's CPR certifications were expired, and neither had received recent emergency response training. Staff E indicated an expectation that the nurse would perform CPR, while Staff D did not act as required. Additionally, the facility did not ensure that all staff were aware of the location of emergency equipment. Staff F, an LPN, was unaware of the location of the facility's Automated External Defibrillator (AED) on their assigned floor, and it was observed that the AED was missing from the third floor nurse's station due to being out for repair, leaving only one functioning AED on the second floor. The Resident Care Manager confirmed that all staff were expected to know the AED's location. These failures were contrary to the facility's own assessment, which required all licensed nurses and CNAs to maintain current CPR certification and be competent in emergency response procedures.
Failure to Report Unexpected Resident Death as Required
Penalty
Summary
The facility failed to implement its abuse prohibition policy by not reporting an unexpected resident death to the State Survey Agency (SSA) as required by both facility policy and state and federal regulations. The policy mandates that any allegation or suspicion of abuse, neglect, or unexpected death be reported immediately, no later than two hours from the incident, and that the results of the investigation be submitted within five working days. In this case, the incident log and interviews confirmed that the unexpected death was neither reported to the SSA nor investigated by the facility. The resident involved had been admitted for short-term rehabilitation following a heart procedure and was found dead unexpectedly. The administrator was unaware that the death had not been reported, as the responsibility was delegated to the DON, who stated they did not recognize the death as unexpected and therefore did not report it. A corporate clinical resource confirmed that facility guidelines require reporting such incidents to the SSA, police, and coroner or medical examiner. Despite these requirements, the facility did not fulfill its reporting obligations for this incident.
Failure to Investigate Unexpected Resident Death per Abuse Policy
Penalty
Summary
The facility failed to implement its abuse prohibition policy by not conducting a complete and thorough investigation into the unexpected death of a resident who was admitted for short-term rehabilitation following a heart procedure. The resident, who had a goal of returning home, was found deceased unexpectedly, and the facility did not complete an incident investigation as required by their policy. The policy mandates that all allegations of abuse, neglect, or unexpected incidents be promptly and thoroughly investigated, including interviews with relevant parties and a review of medical records, with documentation of the findings. Despite the policy requirements, the facility only provided a one-page, undated timeline of events and did not document staff interviews or a comprehensive review of the circumstances surrounding the death. The Administrator was unaware that an investigation had not been conducted, and the DON stated they did not realize the death was considered unexpected and therefore did not initiate an investigation. The lack of a documented and thorough investigation into the resident's unexpected death constituted a failure to follow the facility's abuse prevention and reporting protocols.
Deficiencies in Kitchen Sanitation and Food Handling
Penalty
Summary
The facility failed to maintain a clean and sanitary kitchen environment, as observed during a survey. The kitchen floor had peeling surfaces and exposed, cracked cement filled with dirt and debris, which had been in that condition for years. The stove tops were dirty and full of grime and burnt debris, and the wire racks inside the walk-in refrigerator were dirty and rusted, making them uncleanable and unsanitary for food storage. The facility's Executive Director confirmed these environmental issues during a kitchen walk-through and acknowledged the need for immediate attention. The facility also failed to ensure proper food handling and storage practices. During breakfast tray line service, a dietary aide was observed handling raw eggs without changing gloves or performing hand hygiene before touching ready-to-eat food, risking cross-contamination. Additionally, the facility had issues with food labeling and storage, with undated and expired food items found in the walk-in freezer and dry food storage. Dented cans and expired food items were present, and some food items were stored beyond the facility's posted guidelines, such as ham, cheese, and thawed chicken parts. The facility's sanitizing solution was found to be ineffective, as testing showed a reading of zero parts per million, indicating it could not effectively sanitize kitchen surfaces. This failure to maintain potent sanitizing solutions further contributed to the unsanitary conditions in the kitchen. The dietary supervisor acknowledged the importance of maintaining effective sanitizing solutions to prevent food-borne illnesses. Overall, these deficiencies in kitchen cleanliness, food handling, and storage practices placed residents at risk for food-borne illnesses and decreased quality of life.
Failure to Assist Residents in Formulating Advance Directives
Penalty
Summary
The facility failed to obtain and/or offer assistance to residents and/or their representatives to formulate Advance Directives (AD) for 8 of 17 residents reviewed. This deficiency was identified through interviews and record reviews, revealing that the facility did not follow its policy to inform and provide residents with written information to formulate an AD. The policy required the Admission Nurse or Social Service staff to inquire about the existence of any AD and ensure a copy was included in the medical record if one existed. However, for several residents, there was no documentation of follow-up or assistance provided to establish their AD status. Resident 11, who had multiple medical conditions including heart, respiratory, and kidney failure, had an incomplete AD Acknowledgement form, and there was no documentation of follow-up regarding their AD status. Similarly, Resident 59, who had conditions such as kidney failure and schizophrenia, was unsure about having an AD, and no AD paperwork was found in their records. Staff interviews confirmed the lack of documentation and follow-up for these residents, indicating a failure to establish their AD status as required. Other residents, including Residents 65, 80, 24, 77, 48, and 62, also had incomplete or missing AD Acknowledgement forms, with no evidence of assistance or education provided by the facility. Interviews with staff members confirmed these deficiencies, highlighting the facility's failure to ensure that residents' healthcare wishes were documented and accessible. The lack of follow-up and incomplete documentation placed residents at risk of not having their medical treatment preferences honored.
Failure to Conduct Care Conferences for Residents
Penalty
Summary
The facility failed to ensure that residents were provided an opportunity to participate in Care Conferences (CCs), which are essential for care planning and addressing residents' needs. This deficiency was identified for five residents, each with complex medical conditions. Resident 44, who had heart failure, end-stage kidney disease, and depression, reported not remembering any CCs, and their medical records lacked documentation of such meetings. Similarly, Resident 46, with heart failure and bipolar disorder, also could not recall any CCs for over a year, and their records showed no evidence of quarterly CCs. Resident 2, who had severe memory impairment and a Durable Power of Attorney, had no documented CCs, and their representative confirmed the absence of such meetings. Resident 37, with moderate memory impairment and multiple medical conditions, also lacked documentation of CCs. Staff F, the Social Services Director, acknowledged that these residents did not receive the required CCs, which should occur within 72 hours of admission and quarterly thereafter. The failure to conduct these conferences left residents at risk for unmet care needs and diminished participation in their care planning.
Deficiencies in Implementing Physician's Orders
Penalty
Summary
The facility failed to ensure proper implementation and documentation of physician's orders for several residents, leading to potential negative health outcomes. Resident 67, who was admitted with a pressure ulcer, was observed lying on an air mattress set incorrectly for their weight, which was significantly lower than the setting. The facility did not have a physician's order for the air mattress settings, and staff were not instructed to monitor the mattress settings every shift, as confirmed by the Director of Nursing. Resident 64, diagnosed with kidney and liver failure, was observed with swelling in the lower legs and feet but was not consistently provided with the prescribed elastic tubular bandages for compression. The bandages were either missing or applied incorrectly on different days. Staff interviews revealed that the physician's orders were not followed, and there was no documentation of resident refusal or notification to the provider. Resident 24, who experienced chronic pain, was administered narcotic medication despite reporting no pain, contrary to the physician's order. Resident 44 had an incomplete catheter order lacking specifications for catheter size and balloon saline amount, increasing the risk of injury and infection. Resident 46's CPAP machine was broken for several months, and despite notifications, a replacement was not ordered, leaving the resident at risk for respiratory distress.
Deficiencies in ADL Assistance and Personal Hygiene Care
Penalty
Summary
The facility failed to provide adequate assistance with Activities of Daily Living (ADL) for several residents, specifically in the areas of bathing, shaving, and nail care. Resident 15, who was on hospice care and required staff assistance for bathing, reported not receiving a shower or bed bath for an extended period. The facility's records confirmed that Resident 15 had not been offered or received bathing assistance for the previous 30 days. Staff L, a Certified Nursing Assistant (CNA), incorrectly assumed that hospice care relieved them of the responsibility to provide bathing assistance, which was contradicted by the Director of Nursing (DON), who expected the shower aide to ensure bathing was provided as per the care plan. Resident 44, who required maximum staff assistance for bathing, was observed multiple times over several days without receiving the showers they preferred twice weekly. The shower schedule indicated that Resident 44 had not received a shower or bath for eight days. Staff L admitted that due to understaffing, they could not provide showers to all residents as ordered, and the documentation was incorrect, suggesting a sponge bath instead of a full body bath. The DON was not informed of the missed showers, which was against the facility's protocol. Residents 24 and 80 also experienced deficiencies in personal hygiene care. Resident 24 was observed with matted hair, long facial hair, and dirty fingernails, indicating a lack of grooming assistance. Staff C confirmed that the staff failed to provide the necessary personal hygiene care. Similarly, Resident 80, who required assistance with grooming, was observed with long facial hair and reported not receiving a razor despite requesting one. Staff B stated that razors were available, and staff were expected to assist residents with shaving for safety reasons, but this assistance was not provided.
Failure in Dialysis Care Coordination
Penalty
Summary
The facility failed to implement ongoing communication and care coordination with the dialysis facility for two residents requiring dialysis care. For Resident 24, the care plan did not include directions or interventions for nursing staff on how to collaborate with the dialysis facility. On one occasion, Resident 24 expressed abdominal pain before a dialysis appointment, but there was no transfer communication to the dialysis center about this condition, nor was it documented in the nursing progress notes. The Director of Nursing stated that the nursing staff was expected to complete a transfer communication form for residents going to dialysis treatments to ensure continuity of care. Similarly, for Resident 11, the care plan lacked a coordinated plan for dialysis treatment, and the facility's process for dialysis care coordination was not followed. Although the facility's process involved sending a packet with necessary documents to the dialysis center, Resident 11 returned from a dialysis session without a transfer communication form. Staff K acknowledged that the nurses should have completed the form but did not. This lack of documentation and communication with the dialysis center was a failure in the facility's dialysis care coordination process.
Medication Administration Errors Lead to High Error Rate
Penalty
Summary
The facility failed to maintain a medication error rate of less than 5%, resulting in a significant error rate of 61.54% during a medication pass observation. This deficiency involved two residents, Resident 28 and Resident 15, where 16 out of 26 medications were improperly administered. For Resident 28, 7 out of 12 medications were given outside the prescribed time window, and an eye drop medication was administered without proper clarification of the dosage, as the order was inaccurate and immeasurable. Staff M, the LPN responsible, acknowledged the error and admitted to assuming the dosage instead of confirming with the physician. Similarly, for Resident 15, 8 out of 11 medications were administered too early, and an inhalation medication was given without clarifying the inaccurate dosage order. Staff M admitted to administering these medications outside the scheduled time and failing to verify the correct dosage with the physician. The Director of Nursing, Staff B, confirmed the expectation for medications to be administered within one hour before or after the scheduled time and emphasized the importance of this practice to prevent medications from being given too close together.
Failure to Inform Residents of Arbitration Agreement Details
Penalty
Summary
The facility failed to ensure that residents and/or their representatives were adequately informed about the nature and implications of entering into a binding Arbitration Agreement (AA). For Resident 37, the Durable Power of Attorney for Financial (DPOA-F) signed the AA without a full understanding of its details, as the admissions staff did not provide sufficient education on the matter. The representative of Resident 37 expressed that they were overwhelmed by the number of documents during the admission process and were not aware that signing the AA would waive the resident's rights to a jury or court. Upon realizing the implications, the representative expressed a desire to revoke the contract. For Resident 67, the AA was signed by a representative who was not designated as the DPOA-F, as there was no Advance Directive in place to authorize this action. The Admissions Director acknowledged that the representative should not have signed the AA on behalf of Resident 67 and admitted to not adequately explaining the AA to Resident 37's representative. The Executive Director emphasized the importance of educating residents and their representatives about the AA process to ensure they understand the legalities before signing.
Failure to Develop Comprehensive Care Plans for Residents
Penalty
Summary
The facility failed to develop comprehensive care plans for two residents, leading to unmet care needs. Resident 37, who had a right hip fracture requiring surgical repair, did not have a care plan addressing pain management despite experiencing daily pain that affected their sleep and activities. The Director of Nursing acknowledged the absence of a pain management care plan, which was necessary to ensure effective pain management for the resident. Resident 65, who had a left below-the-knee amputation and a left leg fracture requiring surgical repair, did not have a care plan that included instructions for the use of a leg immobilizer. The care plan failed to provide guidance on when to apply or remove the immobilizer and did not include monitoring for skin breakdown. Staff confirmed the lack of written instructions for the immobilizer's use, which was crucial for proper wound healing and safety. The absence of these care plans was identified through observations, interviews, and record reviews.
Failure to Implement Fall Prevention Interventions
Penalty
Summary
The facility failed to implement fall prevention interventions for a resident identified as high risk for falls. The resident, who had a history of falls and a recent hip fracture requiring surgical repair, was observed multiple times without the necessary safety measures in place. These measures, as outlined in the resident's care plan, included keeping the bed in the lowest position and placing bilateral floor mats by the bed. Despite these requirements, observations over several days showed that the bed was not in the lowest position and the floor mats were absent. Interviews with facility staff revealed that the necessary interventions were not reinstated after the resident returned from the hospital following their fall and fracture. A registered nurse acknowledged that the floor mats were likely removed when the resident was hospitalized and were not replaced upon their return. The Director of Nursing confirmed that the interventions were crucial to reducing the risk of further injury and expected the nursing staff to adhere to the care plan. This oversight placed the resident at risk for additional falls and potential injuries.
Facility Fails to Maintain Safe and Homelike Environment
Penalty
Summary
The facility failed to provide a safe, clean, and comfortable environment for its residents, as evidenced by multiple observations of physical damage and inadequate maintenance in resident rooms. Several rooms had gouges on the walls, missing paint, and sharp edges on sink trims, which were inadequately covered with paper tape. Additionally, some rooms had incomplete blinds, missing slats, and curtains barely hanging, compromising residents' privacy. Staff interviews confirmed the need for repairs and maintenance to ensure a homelike environment. Further deficiencies were noted in the cleanliness and odor management of the facility. Observations revealed soiled garbage bags left in a resident's room, which staff acknowledged should have been removed promptly to prevent infection and maintain a clutter-free environment. A strong urine smell was detected in another room, with empty urinals left on a nightstand, and the resident reported frequent incontinence issues. Staff confirmed the importance of maintaining clean and odor-free rooms, especially for residents in the short-stay unit.
Failure to Provide Required Transfer/Discharge Notifications
Penalty
Summary
The facility failed to ensure that residents and the Long-Term Care Ombudsman Office (LTCO) received the required written notices at the time of transfer or discharge, or as soon as practicable, for three residents reviewed for hospitalization. Specifically, Residents 48, 64, and 59 were transferred to acute care hospitals without the facility providing written notifications to the residents, their representatives, or the LTCO. This lack of documentation and notification was contrary to the facility's policy, which mandates that such notices be provided in a language and manner the resident understands, including the reason for, date of, and destination of the transfer or discharge. Interviews with Staff F revealed a lack of awareness regarding the process of sending written notifications to residents or their representatives and the LTCO. Staff F, who had recently started working at the facility, was unable to locate any records of LTCO notifications for the transfers or discharges of the residents in question. The absence of documentation and failure to notify the LTCO prevented the opportunity for residents to be educated and advocated for regarding the discharge process, as required by the Washington Administrative Code.
Failure to Timely Encode and Transmit MDS Assessments
Penalty
Summary
The facility failed to encode and transmit resident assessment data to the Centers for Medicare & Medicaid Services (CMS) within the required timeframe for two residents. For Resident 6, the Death in Facility Minimum Data Set (MDS) assessment was completed more than two months after the resident's death, which was past the seven-day encoding requirement. The assessment remained export-ready in the facility's software system but was not transmitted timely. Staff D, the MDS Coordinator, acknowledged the delay and confirmed it was an oversight. For Resident 68, the facility did not initiate or complete a discharge assessment after the resident was discharged to the hospital for a scheduled procedure. The discharge date recorded on the facility census was incorrect, and the MDS record showed the discharge assessment was overdue. Staff B, the Director of Nursing, confirmed that the MDS coordinator should have completed and transmitted the discharge MDS as required but did not.
Inaccurate MDS Assessments for Three Residents
Penalty
Summary
The facility failed to ensure the Minimum Data Set (MDS) assessments for three residents were completed accurately, reflecting their current health conditions. Resident 80's MDS did not document the presence of loose upper dentures, despite a dental visit note identifying this issue, which was confirmed through observation and interview. This oversight could impact the resident's risk for aspiration and nutritional monitoring. Resident 48's MDS inaccurately reported no falls during the assessment period, although the resident experienced a fall in their room, leading to a hospital transfer. This discrepancy was acknowledged by the MDS Coordinator, who confirmed the fall should have been recorded. Resident 67's MDS failed to capture a functional limitation in range of motion (ROM) due to a stroke, despite observations showing the resident's right leg was deformed and immobile. The MDS Coordinator admitted this inaccuracy, acknowledging that the resident's limited ROM should have been documented. The Director of Nursing also confirmed that the MDS assessments were expected to be accurate to ensure all resident needs were identified and addressed in their care plans.
Failure to Provide Activities for Resident with Cognitive Impairment
Penalty
Summary
The facility failed to ensure that activity programs met the needs of a resident with severe cognitive impairment and multiple diagnoses, including dementia, stroke with paralysis, and schizophrenia. The resident's Minimum Data Set (MDS) indicated a preference for listening to music, attending group activities, and participating in religious activities. Despite these preferences, the resident was not offered any activities over a 30-day period, as documented in the activity records. Observations over several days showed the resident sitting in their room without any form of entertainment, such as a TV or radio, and without being engaged in any activities. Interviews with the resident's representative revealed that they had provided a radio and a computer tablet for the resident, but staff did not assist the resident in using these devices. The Activities Supervisor acknowledged that the resident was dependent on staff for all activities due to their mental and physical disabilities and admitted to not documenting or offering activities as required by the care plan. The Executive Director stated that staff were expected to offer and document activities for all residents, but this was not done for the resident in question.
Deficiencies in Skin and Bowel Care
Penalty
Summary
The facility failed to provide adequate care for two residents with non-pressure skin alterations and one resident with constipation. Resident 64 had multiple bruises on their right forearm, which were not documented in the weekly skin assessments, and there were no physician orders to monitor these bruises. Staff D, a licensed nurse, was unaware of the bruises and acknowledged that there should have been orders to monitor them. The Director of Nursing confirmed that the bruises should have been documented and monitored. Resident 59, who was at risk for skin breakdown, had a rash on their left forearm that was not documented or monitored as per the care plan. The weekly skin assessment for Resident 59 was overdue, and the Treatment Administration Record did not reflect any monitoring of the rash. Staff U, an LPN, was aware of the rash but did not document it, and Staff K, the Resident Care Manager, confirmed the lack of documentation and monitoring. Resident 2, who had severe cognitive impairment and was dependent on staff for toileting, experienced constipation without receiving appropriate intervention. The resident did not have a bowel movement for five days, yet no laxatives were administered as per the facility's bowel care protocol. Staff B stated that the protocol required administering a laxative after three days without a bowel movement, but this was not done for Resident 2.
Failure to Provide Restorative Nursing Program Services
Penalty
Summary
The facility failed to provide appropriate restorative nursing program (RNP) services to three residents, leading to a deficiency in maintaining or improving their range of motion (ROM) and mobility. Resident 44, who had diagnoses including depression and generalized muscle weakness, was supposed to receive ROM exercises for both arms and legs and bed mobility three to six times a week. However, documentation showed that these services were offered only a fraction of the time. Resident 46, with similar diagnoses and additional needs for assistance with personal care, also did not receive the prescribed RNP services consistently. The resident reported that the restorative aide was no longer available, which contributed to the lack of services. Resident 67, who had a history of stroke and weakness on one side of the body, was supposed to receive passive ROM exercises to both legs three to six times a week. However, the resident received these services only seven times in 30 days. Interviews with staff revealed that the sole Restorative Nursing Aide (RNA) was overwhelmed with too many programs to complete, leading to the failure to provide RNP as ordered. The facility's policy required documentation of RNP services, but this was not consistently done, contributing to the deficiency.
Infection Control Lapses in PPE Use and Catheter Bag Handling
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by staff not adhering to Transmission Based Precautions (TBP) in rooms designated for contact precautions. Observations revealed that multiple staff members, including a receptionist, MDS Coordinator, CNA, and Business Office Manager, entered rooms with contact precaution signs without donning the required Personal Protective Equipment (PPE) such as gowns, gloves, and masks. Despite the signage clearly instructing staff to apply PPE before entering, some staff members were under the impression that PPE was only necessary when directly working with the resident, leading to non-compliance with the established protocols. Additionally, the facility did not ensure proper handling and securing of indwelling catheter bags for residents requiring them. Observations showed that catheter bags for two residents were improperly placed, either hanging on trash cans or dragging on the floor, which poses a risk of contamination and infection. Interviews with the Infection Preventionist confirmed that catheter bags should be secured on the bed frame and not placed on the floor or trash cans, highlighting a lapse in staff adherence to infection control practices.
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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