Puyallup Nursing And Rehabilitation Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Puyallup, Washington.
- Location
- 516 23rd Ave Se, Puyallup, Washington 98372
- CMS Provider Number
- 505211
- Inspections on file
- 23
- Latest survey
- February 19, 2026
- Citations (last 12 mo.)
- 39
Citation history
Health deficiencies cited at Puyallup Nursing And Rehabilitation Center during CMS and state inspections, most recent first.
The facility failed to promptly initiate and resolve grievances related to missing personal property for two residents, despite policies requiring timely grievance handling and maintenance of personal property inventories. Family-purchased items, including specialized amplified phones and an Echo device intended to assist with hearing, were delivered to the facility but were not added to the residents’ inventory lists and were later reported missing. Emails and concerns from a resident’s representative about these missing items were not timely documented in the grievance log, and the social services department initially did not receive or process the grievances. One resident’s room was observed without the reported phones or Echo, and another resident’s phone was eventually found at the bedside, but only after a period in which the grievance had not been properly logged or addressed.
Surveyors found that after a change of ownership, the facility shifted toward a short‑term/post‑acute model while continuing to hold Medicaid certification, and began systematically planning discharges for LTC residents whose primary payor was Medicaid. The new admission agreement only allowed month‑to‑month or respite/short‑term stays, and the website omitted LTC services. The Administrator and DON acknowledged that discharge planning began on admission and that residents on former LTC wings were being moved to skilled care, while discharge logs showed that all residents sent to other nursing homes over a recent period were Medicaid. Multiple residents and their representatives reported being told that LTC residents, especially those on Medicaid, could not stay because the facility was now only rehabilitation or short‑term, that “long‑term don’t belong,” and that stable, non‑skilled residents were being transitioned out, leading to fear and distress among remaining Medicaid LTC residents.
Surveyors found that the facility involuntarily discharged multiple LTC residents, many on Medicaid, while transitioning to a skilled-only model, without adequate documentation of a valid discharge reason, sufficient notice, or individualized discharge planning aligned with resident goals. Several residents had care plans or state case records indicating they were LTC with no discharge plan, yet were told they had to move because the facility would no longer keep LTC residents. Multiple residents and their representatives reported they were not given a real choice of receiving facility, were informed of moves on very short notice, did not pack their own belongings, and in some cases believed they were going elsewhere. Staff, including the Social Services Director and administrator, asserted that residents agreed to the moves, but their explanations were vague and conflicted with resident and family accounts. The pattern of discharges and statements from another facility’s administrator indicated that Medicaid LTC residents were being transferred out to make room for Medicare and skilled residents, implicating equal practices and discharge process requirements.
Surveyors found that the facility did not consistently provide required written transfer or discharge notices, including appeal rights and reasons for transfer, to multiple residents and their representatives when moving residents to other SNFs or initiating discharge planning. Several residents reported being told verbally, often the day before or the day of transfer, that they were being moved, with no written documentation in their records. In some cases, a POA was not notified in writing or at all, even when the facility was aware of the POA, and residents described having no choice of discharge location or receiving information only through brief phone calls. One resident with a documented LTC goal and cognitive confusion was approached alone about alternative placements without written notice to the POA, and another non‑English‑speaking resident’s family reported being informed only by phone that the resident would be moved to whichever facility accepted them, without written notice or community placement assessment. The Social Services Director stated that NHTDNs were included in discharge packets and later uploaded, but also acknowledged that notifications to the LTCO were being batched and that no LTCO notices had been sent for about a month.
The facility did not have a system in place to document or address concerns raised by the Resident Council over several months. A resident reported taking personal initiative to resolve issues, and review of meeting minutes showed multiple concerns requiring resolution were not entered into the grievance log. The administrator confirmed that these grievances should have been documented and followed up on, but this did not occur.
The facility did not provide written bed hold notices to four residents or their representatives when they were transferred to the hospital, as required. The affected individuals had various medical conditions, and in each case, there was no documentation in the health record that the necessary notice or transfer form was given at the time of hospitalization.
Several residents with mental health or intellectual disability diagnoses did not receive timely PASARR Level 1 screenings after admission, with delays ranging from over two weeks to several months, and one resident did not receive a required Level 2 evaluation referral. Facility staff confirmed these screenings were not completed as expected.
The facility did not ensure that non-pharmacological interventions were attempted before administering PRN pain medications for several residents with complex medical conditions, and failed to provide clear parameters or pain scales for PRN pain medication use. Staff interviews and record reviews confirmed that required interventions and documentation were not consistently completed as ordered.
A resident with hemiplegia, repeated falls, and diabetes was not provided with a bed that fit their height, resulting in their feet hanging off the end and requiring assistance to reposition. Despite the facility's policy to accommodate residents' needs, staff were unable to provide a longer bed for over three weeks, and the issue was confirmed by both nursing and maintenance staff.
A resident with multiple medical and mental health diagnoses reported being hit by staff and was observed with significant bruising. Staff interviews and medical records confirmed the resident's reports and injuries, but the facility's investigations attributed the injuries to self-harm without witness statements or evidence. Despite policy requirements, law enforcement was not notified, and no environmental interventions were implemented.
Surveyors identified that several residents did not receive care according to physician orders and facility protocols, including missing care plans for anticoagulation therapy, administration of blood pressure medications outside of prescribed parameters, lack of bowel management for chronic constipation, and incomplete documentation of skin injuries. Nursing staff and the DON confirmed these deficiencies in care and documentation.
Two residents with respiratory conditions did not receive oxygen therapy in accordance with provider orders: one received a higher flow rate than ordered with inaccurate documentation, and another received oxygen without a provider order. Staff interviews confirmed that these practices did not meet facility expectations.
A resident with significant dental needs and a history of malnutrition and failure to thrive was not referred for dental services, despite having only two teeth and being on a mechanically altered diet. Staff interviews confirmed that the resident was not offered dental care as required by facility procedures.
Surveyors found multiple environmental deficiencies, including missing closet doors, plastic bags and socks tied to overbed light cords, and peeling baseboard molding in several rooms. Maintenance staff and the administrator were unaware of these issues, despite a system for reporting repairs, and confirmed that such practices did not meet facility expectations.
Several residents exhibiting symptoms of COVID-19 were tested without documented physician orders or proper recording in the MAR/TAR. Staff confirmed that testing was performed based on symptoms, but documentation and standing orders were inconsistent, resulting in incomplete records and lack of PRN orders for COVID-19 testing.
The facility failed to maintain an effective infection prevention and control program, including lapses in contact tracing, exposure testing, and use of Transmission Based Precautions for residents and staff exposed to COVID-19. Staff did not consistently use appropriate PPE or follow posted precautions, and concurrent therapy sessions were conducted without adequate source control, placing multiple residents at risk of infection.
The facility failed to provide adequate supervision during transfers for three residents requiring two-person assistance. A resident sustained a laceration during a transfer when a mechanical lift was improperly used by one staff member. Two other residents reported inconsistent use of two-person assistance, leading to minor injuries. These incidents indicate non-compliance with care plan requirements for mechanical lift transfers.
The facility failed to notify the Ombudsman of hospital transfers for three residents, each with significant medical conditions, including heart failure and diabetes. The Administrator confirmed the lack of documentation for these notifications, which are required to ensure appropriate discharge processes.
The facility failed to provide complete bed hold notices for two residents transferred to the hospital. One resident was not offered a bed hold notice, and another had an incomplete form lacking the daily rate, leading to a rescinded decision after being informed of the cost. Staff interviews confirmed these deficiencies in documentation and communication.
The facility failed to create baseline care plans within 48 hours for three residents, leading to potential delays in essential treatments. A resident with renal disease and respiratory failure lacked care plans for dialysis and oxygen treatment. Another resident, readmitted post-surgery, did not have a care plan for a surgical wound until six days later. A third resident, with a history of falls and recent surgery, lacked a pain management plan. Staff confirmed these omissions did not meet expectations.
The facility failed to develop and implement comprehensive care plans for several residents, leading to potential risks in their care. A resident with vision issues did not have their needs addressed in the care plan, while another with anxiety disorder had an incomplete care plan regarding medication monitoring. Additionally, a resident at risk for falls did not have the prescribed fall mats in place, highlighting lapses in care plan execution.
The facility failed to ensure proper pain management for three residents, leading to deficiencies in documentation and adherence to protocols. One resident received Tylenol without documented non-pharmacological interventions, another was given oxycodone daily without attempts at non-pharmacological approaches, and a third received Tylenol without observed interventions. Staff interviews confirmed the lack of adherence to pain management protocols.
The facility failed to monitor side effects of psychotropic medications for four residents, including those with dementia, anxiety, and depression. Documentation for monitoring side effects was missing or incomplete, and staff were unaware of monitoring requirements. This deficiency highlights a systemic issue in the facility's processes.
The facility failed to implement proper infection control measures, including transmission-based precautions for a resident with MRSA and enhanced barrier precautions for two residents with wounds. Additionally, the medication cart was not maintained in a sanitary condition, with an unlabeled pill cutter and inappropriate items stored within. Staff acknowledged these deficiencies, which placed residents at risk.
The facility failed to obtain complete consents for psychotropic medications for two residents, risking adverse effects. One resident received fluoxetine and memantine without consent forms, while another had incomplete consents for citalopram and Seroquel. Staff interviews confirmed the consents did not meet expectations.
A resident was moved to a new room without receiving written notice or an explanation, and was not given the opportunity to see the new room beforehand. The resident, who was cognitively intact, expressed dissatisfaction with the move, preferring their previous room. Facility staff confirmed that while verbal notice was sometimes given, written documentation was not provided to the resident.
A resident receiving Hospice services did not have a change of condition MDS completed, despite being unable to communicate needs and having significant health issues. Staff interviews confirmed the oversight, which is a deficiency in care.
A facility failed to accurately complete a PASRR assessment for a resident readmitted with anxiety, depression, and psychotic disorder. The assessment omitted the psychotic disorder as a serious mental illness indicator. Staff interviews confirmed the inaccuracy, acknowledging the omission of the diagnosis.
A facility failed to update the care plan for a resident receiving Hospice services, despite the resident's inability to communicate needs and the initiation of Hospice care. The care plan, created earlier, lacked new interventions for Hospice services, as confirmed by staff interviews, placing the resident at risk of unmet care needs.
The facility failed to initiate PT/OT for a resident with hemiplegia and did not monitor pain management for another resident with dementia and chronic pain. The PT/OT order was not received by the Rehabilitation Director, and pain management documentation was missing, despite care plan requirements.
The facility failed to monitor and document bowel movements for two residents, leading to unaddressed diarrhea and constipation. Additionally, a resident with a history of stroke and hemiplegia did not receive proper positioning or therapy, as prescribed. Staff interviews confirmed the lack of adherence to protocols and orders.
A facility failed to maintain an accurate and current smoking assessment for a resident with stroke and hemiparesis, placing them at risk for avoidable accidents. The resident, who smoked off property, had a smoking evaluation that was outdated and incomplete, lacking details on how they managed smoking activities. Staff interviews confirmed that smoking evaluations were expected quarterly, but this was not followed.
A facility failed to include ostomy care instructions in the care plan for a resident with diverticulitis and an ostomy. The resident reported discomfort and doubted staff training. Interviews with staff revealed no documented orders or care plans for ostomy care, despite expectations for such documentation upon admission.
A facility failed to monitor and document fluid restrictions for a resident with a prescribed limit of 2 liters per day. Despite physician orders, the resident had a water pitcher within reach, and staff were unaware of the restriction. The care plan lacked relevant interventions, and the DON confirmed that orders were not followed, risking the resident's health.
A facility failed to ensure proper communication and collaboration with a dialysis provider for a resident with end-stage renal disease. The resident's care plan lacked a focus on dialysis, and communication forms were not consistently completed, leading to inadequate coordination of dialysis care.
A long-term care facility failed to maintain a medication error rate below 5 percent, resulting in a 16 percent error rate. Two residents did not receive their medications as prescribed due to staff errors. An LPN failed to administer a scheduled dose of clonazepam on time and discarded a dose of MiraLax without proper documentation. Another resident received only a partial dose of MiraLax, and eye drops were documented as administered twice but given only once. These actions led to non-compliance with medication administration guidelines.
The facility failed to provide complete and accurate discharge summaries for six residents, leading to potential risks of post-discharge complications and delayed treatment. Discharge summaries lacked essential details such as wound care treatment orders, home health services, scheduled appointments, and medication reconciliations. These deficiencies highlight a systemic issue in the facility's discharge process, potentially compromising the continuity of care for discharged residents.
The facility failed to prevent and monitor pressure ulcers for several residents, including a resident with a Stage 2 PU/PI that was not evaluated or monitored, and another resident discharged without proper care instructions. Weekly wound evaluations were not consistently performed, placing residents at risk for worsening conditions.
Failure to Promptly Address Grievances and Missing Personal Property
Penalty
Summary
The deficiency involves the facility’s failure to promptly initiate, investigate, and resolve resident grievances related to missing personal property, as required by its grievance policy and theft/loss prevention program. The admission agreement stated the facility must listen to and act promptly on grievances from residents and their families, and the theft/loss program required a written inventory of personal property upon admission. Despite these requirements, multiple high-value and functionally important items purchased for residents, including specialized phones and an Echo device, were not inventoried when received and were later reported missing without timely grievance processing. For one resident, the representative reported that two phones and an Echo device purchased to assist with hearing were missing. Invoice receipts showed a white landline phone ordered and shipped to the facility, an Echo with stand ordered and shipped to the facility, and a Clarity amplified cordless phone delivered to the facility’s front desk. The representative emailed the social services aide about the missing Echo but received no response, and the facility was still unable to locate the items weeks later. When the resident’s room was observed, there were no cordless or landline phones and no Echo present. Review of grievance logs for several months showed no entry for this resident’s missing items during the period when the concerns were initially raised, and inventory sheets dated after the items were delivered did not list the two phones or the Echo. For another resident, an amplified cordless landline phone was ordered and delivered to the facility’s front desk, but the resident’s inventory list was blank and did not include the phone. The grievance logs for multiple months did not list a grievance for this resident’s missing phone during the time it was reported missing. Later observation showed the amplified cordless phone at the resident’s bedside, charged and turned on, but this was after the period when the grievance had not been documented or promptly addressed. The social services director later stated that grievances for both residents were resolved but was initially unable to locate or provide the grievance forms, indicating that the grievances were not promptly documented and processed in accordance with the facility’s grievance policy and theft/loss prevention program.
Discriminatory Discharge Practices Targeting Medicaid LTC Residents
Penalty
Summary
The deficiency involves the facility’s failure to ensure residents were treated equally regarding transfer, discharge, and provision of services regardless of Medicaid payment source, and failure to ensure Medicaid residents were not being discharged because of their payor status. A Change of Ownership (CHOW) application dated 07/23/2025 indicated the new owner requested Medicaid certification and a letter to residents and families stated there would be no disruption in care. However, the new, undated admission agreement under the new facility name only offered month‑to‑month or respite/short‑term stay options, and the facility website listed skilled nursing, rehabilitation, activities, and social services but did not list LTC services. The Administrator stated facility practices had not changed but acknowledged they discharged “all kinds of residents,” started discharge planning on admission, and that acceptance and retention of LTC Medicaid residents “depended” on the resident. Interviews and records showed a pattern of targeting Medicaid LTC residents for discharge or transfer. The DON reported that social services sought residents willing to transfer to other SNFs to increase availability to provide services to the community and that residents on the East wings, previously LTC, were being placed on skilled care. Census review showed a high proportion of Medicaid residents on the East wings, and discharge records from 01/01/2026 to 01/21/2026 showed nine residents discharged to other nursing homes, all of whom were Medicaid. An administrator and DNS from a receiving facility stated the discharging facility was referring Medicaid residents because they now only accepted Medicare residents, were making room for more skilled residents, and were trying to transition to skilled‑care‑only operations. Multiple residents and their representatives reported being told that LTC residents, particularly Medicaid‑funded residents, could not remain. One resident’s representative stated they were told the facility was no longer doing LTC, only rehabilitation, and another emergency contact reported being told that the LTC side of the building “had to be discharged.” Several residents and POAs, all with Medicaid as primary payor source, reported being informed that the facility was becoming a short‑term/post‑acute or rehabilitation facility and that LTC residents “don’t belong,” could not stay, or would be transitioned because they were stable and did not need skilled care. A Nursing Facility Case Manager stated the new ownership wanted to run the facility like a rehabilitation place, fill beds, and discharge residents as soon as possible. Residents and representatives described fear and upset as LTC residents were approached about transfers without written notices, and staff interviews confirmed an active process of discharge planning for “everyone” and transitioning stable, non‑skilled residents out of the facility, many of whom were Medicaid LTC residents.
Involuntary Discharge of LTC Residents Without Proper Basis, Notice, or Resident-Centered Planning
Penalty
Summary
The deficiency involves the facility’s failure to permit residents to remain in the facility and its involuntary discharge of multiple LTC residents without proper basis, documentation, or discharge planning focused on resident goals. The facility’s admission agreement allowed involuntary discharge only for specific reasons, such as unmet medical needs, improved health, endangerment, nonpayment, facility closure, or other legal grounds, and required prior consultation with the resident, representative, and attending physician except in emergencies. Surveyors found that 8 of 9 residents reviewed for nursing home transfers were involuntarily discharged or transferred without adequate documentation of the basis for transfer, without sufficient time and orientation, and without an effective discharge planning process reflected in the care plan. The report states this failure placed residents at risk of displacement, discrimination based on ability to pay, and decreased quality of life. One resident who had a care plan goal to remain in the facility for LTC and whose state case management record documented no discharge plan was told by phone that the facility was no longer taking LTC residents and would be transferred to another SNF. The resident reported liking the facility, feeling at home, and wanting to stay near friends and church in the local area, while their representative and emergency contact stated they did not want the resident moved and were simply told the resident was moving. The roommate reported that staff came in late one afternoon and informed the resident they would be moved the next day, which surprised the resident. The facility’s written transfer notice for this resident cited improved health as the reason for transfer, and the discharge plan of care documented discharge to another SNF on the same date as the notice, while the Social Services Director could not clearly explain why the resident did not remain and only stated that this was the discharge plan they “landed on.” Another long-term resident, who had lived in the facility for several years and enjoyed the facility’s programs, stated that moving was not their idea and that they believed they were going to a different state but were instead taken to another SNF. This resident did not pack their own belongings and reported missing items, appearing distressed and fixated on their possessions. Their representative and sister stated the resident likely would not have wanted to move, needed help with decision-making, and was shocked by the move, believing they were going elsewhere; they also reported being told the new facility was closer when it was actually farther away, and that the resident’s social supports were in the original community. The admitting facility’s administrator and DNS reported that the discharging facility’s new company was referring Medicaid residents out because they now only accepted Medicare residents and were transitioning the building to skilled care only, sending LTC residents to other facilities. Additional residents with documented care plan goals to remain for LTC or with no documented discharge care plan were also moved. One resident, whose state case management notes showed no discharge plan and an inactive case due to staying LTC, stated they had lived in the facility for about three years and planned to stay, but were told they were being discharged because “long-term don’t belong,” and that staff chose the receiving facility, presenting it as the only option other than a city the resident did not want. Another resident admitted for nursing and rehab, who had come off skilled services, was discharged to a SNF closer to a visiting friend according to staff, but the resident and friend both stated they were told the resident had to move, were not given a choice of facility, and that the move happened quickly without time to pack belongings. A long-term resident since 2019 with a care plan goal to stay in the facility reported not knowing they were moving until the morning of the move, receiving no written notice, and not being given a choice of discharge location, while the Social Services Director gave vague responses about offering discharge options. Another resident initially admitted for rehab and unable to return to prior living, who wanted to be with their POA in another SNF, stated they were told the facility was short term only and that they had to go to another nursing home for LTC; the POA reported being told by the facility that the building had been sold, it was now short term, and the resident had to leave that morning. A further resident with a care plan discharge goal of returning home with a roommate and then moving to an ALF or AFH was instead transferred to another SNF; this resident stated the facility was moving everybody because they were not going to have LTC residents anymore, that they were not given a choice of options, and that staff picked a facility and moved them the next day after boxing up their belongings. A nurse manager stated residents who did not want to leave were not being discharged, asserting that acceptance of another placement showed agreement, while the administrator stated no one had been discharged without agreeing and that they would not discharge people who were not agreeable, despite multiple resident and family accounts to the contrary. The report cites related deficiencies at F621 (Equal Practices Regardless of Payment Source) and F628 (Discharge Process) and references WAC 388-97-0120(1)(2), in the context of the facility’s pattern of discharging LTC residents, many of whom were Medicaid, while transitioning to a skilled-only model without adequate documentation, notice, or individualized discharge planning aligned with resident goals and preferences.
Failure to Provide Required Written Transfer/Discharge Notices and Ombudsman Notification
Penalty
Summary
The deficiency involves the facility’s failure to provide required written transfer or discharge notices to residents and/or their representatives, and to notify the State Long-Term Care Ombudsman (LTCO), when residents were transferred to other SNFs or when discharge planning was initiated. The facility’s own SNF Admission Agreement stated that, except in emergencies, no resident would be transferred or discharged without prior consultation with the resident, family/representative, and attending physician, and that a 30‑day advance written notice would be provided for involuntary transfers or discharges. The agreement also specified that written notice must state the reason for transfer or discharge and the resident’s right to appeal. Despite these requirements, surveyors found that multiple residents did not receive written notices, did not receive 30‑day notice, and were not informed in writing of their appeal rights. For one resident, the representative reported being called and told the resident would be moved because the facility would no longer provide LTC, only rehabilitation services, and that the move would occur the next day. Another emergency contact stated the resident was told late in the day that they would be moved the following day, leaving no time to adjust. The Nursing Home Transfer or Discharge Notice (NHTDN) for this resident showed the transfer date and indicated the notice was given only one day prior. For another resident, the admitting facility DNS acknowledged that the resident’s POA was not notified of the move. The resident’s representative stated they only learned of the move when contacted by the admitting facility to sign papers, and the resident’s sister reported being called in the evening and told the resident would be moved the next day, despite the facility being aware of the POA. Progress notes documented a call to the sister about an accepting LTC facility and agreement to transfer, but there was no indication of written notice to the POA. Several other residents reported not receiving written notices of transfer or discharge and having little or no advance notice. One resident stated they were not given a discharge notice or informed of appeal rights, and their EHR lacked documentation of written notification prior to discharge to another SNF. Another resident’s nurse’s note documented discharge to a SNF, but the resident and a friend reported only vague or sudden notice and no written transfer notice, and the EHR contained no written notification. Additional residents stated they did not know they were moving until the day of transfer, received no written notice, and were not given a choice of discharge location; their EHRs similarly lacked written notifications. One resident’s POA reported only verbal notice on the day of discharge and no written documentation. Further, a resident with a care plan goal of LTC at the current facility reported wanting to return home and said staff had recently approached them about discharge planning without providing anything in writing. The resident’s POA stated the social worker had spoken to the resident alone, offered other placements, and that the resident chose one despite being highly confused and unable to make such decisions; the POA confirmed receiving no written notice, even though the resident had been in the facility for about three years and had a spouse/partner also residing there. Another resident who did not speak English had a POA who reported being told by phone that the facility would apply to three nursing homes and move the resident to whichever accepted them, without offering a choice and without written notice or assessment for community placement, and that the resident’s care needs had not changed. The Social Services Director stated that NHTDNs were given to residents at discharge as part of a packet and then uploaded into the EHR, but acknowledged that notices to the LTCO were being sent only at the end of the month, that they were working on an audit and binder system, and that no notices had been sent to the LTCO since they started working at the facility a month earlier. These findings showed that written transfer/discharge notifications and timely LTCO notifications were not consistently provided as required.
Failure to Document and Address Resident Council Grievances
Penalty
Summary
The facility failed to establish and implement a system to address grievances and concerns raised by the Resident Council for four of eight months reviewed. During interviews, a resident reported that when concerns were brought up in Resident Council meetings, they personally took the initiative to resolve the issues and were unaware if these concerns were documented as grievances. Review of Resident Council meeting minutes for January, March, April, and September 2025 revealed eight concerns requiring resolution, but none of these were recorded in the facility's Resident/Family Grievance Log. The administrator confirmed that grievances should have been documented by the meeting facilitator, logged, and followed up on, but this process was not followed for the concerns raised during the specified months.
Failure to Provide Bed Hold Notices During Hospital Transfers
Penalty
Summary
The facility failed to provide written bed hold notices to residents or their representatives at the time of transfer to the hospital for four sampled residents. Record review showed that each of these residents was hospitalized, but there was no documentation in their electronic health records indicating that the required bed hold notice or transfer form was given. The residents involved had various diagnoses, including dementia, diabetes, rheumatoid arthritis, COPD, hip pain, depression, and degenerative disc disease. Some residents were unable to make their needs known, while others were able to communicate. During an interview, the facility administrator confirmed that the expectation was for bed hold and transfer forms to be provided to residents upon transfer to the hospital. However, for all four residents reviewed, this documentation was missing at the time of their respective hospitalizations.
Delayed and Incomplete PASARR Screenings for Residents with Mental Health Diagnoses
Penalty
Summary
The facility failed to promptly complete the Preadmission Screening and Resident Review (PASARR) for four out of seven sampled residents with mental health diagnoses or intellectual disabilities. For these residents, the PASARR Level 1 screenings were not conducted within the expected timeframe after admission, with delays ranging from 15 days to over four months. The residents involved had diagnoses such as dementia, depression, psychotic disorder, hemiplegia, diabetes, arthritis, bipolar disorder, and heart failure, and were able to communicate their needs. The records showed that the PASARR screenings were either significantly delayed or, in one case, a required Level 2 evaluation referral for mental illness was not made. Interviews with facility staff, including the Social Services Director and the Administrator, confirmed that the PASARR screenings for these residents were not completed in a timely manner and did not meet facility expectations. The Director of Nursing Services also acknowledged that the lack of a Level 2 evaluation referral for a resident with mental illness was not in accordance with expectations. These findings were based on review of electronic health records and staff interviews, as referenced under WAC 388-97-1915(1)(2)(a-c).
Failure to Implement Non-Pharmacological Interventions and PRN Pain Medication Parameters
Penalty
Summary
The facility failed to implement non-pharmacological interventions (NPI) prior to administering as needed (PRN) pain medications for four out of five residents reviewed, and did not provide clear parameters for the use of pain medications for one resident. For multiple residents with complex medical histories, including stroke, diabetes, COPD, fractures, hypertension, anxiety, depression, hemiplegia, and end-stage renal disease, provider orders required staff to attempt NPI such as repositioning before giving PRN pain medications. However, medication administration records (MAR) showed that NPI were not attempted or documented prior to the administration of PRN narcotic and non-narcotic pain medications. Interviews with staff confirmed that NPI were not consistently provided or documented as required by provider orders and facility expectations. Additionally, for one resident, provider orders for multiple PRN pain medications did not specify which medication should be used for different levels of pain, and there was no pain scale included to guide nursing staff in medication selection. This resulted in the resident receiving PRN pain medications without the use of NPI and without clear instructions for medication choice based on pain severity. Staff interviews further confirmed that the lack of NPI and absence of a pain scale for PRN medications did not meet facility expectations. These findings were based on record reviews, MAR audits, and staff interviews, and were cited under WAC 388-97-1060(3)(k)(i).
Failure to Provide Appropriately Sized Bed for Resident
Penalty
Summary
A deficiency occurred when the facility failed to provide a bed that properly accommodated a resident who was 6'3" tall and had limited mobility due to hemiplegia, repeated falls, and diabetes. The resident was observed with their feet hanging off the end of the bed after the footboard was removed, and their representative reported that the resident would slide down in bed and required assistance to reposition. The issue persisted for at least three weeks, during which time the facility was unable to provide a longer bed, citing limited availability and prioritization of bariatric beds for other patients. Staff interviews confirmed that the facility's expectation was for all residents to have beds that fit their needs, and that additional beds could be rented if necessary. However, in this case, the resident's needs were not met, as acknowledged by both the Resident Care Manager and the Director of Nursing Services. The failure to provide an appropriately sized bed was directly observed and reported by both staff and the resident's representative.
Failure to Investigate and Notify Law Enforcement of Physical Abuse Allegation
Penalty
Summary
The facility failed to thoroughly investigate and notify law enforcement regarding an allegation of physical abuse with injuries for one resident. The resident, who had diagnoses including acute respiratory failure, malnutrition, depression, anxiety, and seizure disorder, was able to communicate needs and reported pain and bruising after alleging that a staff member had hit them. Observations confirmed visible bruising on the resident's right knee and thigh, and staff interviews corroborated that the resident reported being hit and was observed with new bruises. Despite these reports and visible injuries, the facility's investigations attributed the injuries to the resident's own actions without obtaining witness statements or evidence to support this conclusion. The incident logs showed that both occurrences of injury were reported to the state hotline, but the facility's internal investigations ruled out abuse and neglect, citing the resident's cognition and diagnoses as the root cause. The investigations lacked documentation of staff witnessing the resident's alleged self-harm. Additionally, law enforcement was not notified, contrary to facility policy, which was acknowledged by the nurse manager upon review. The DON stated that law enforcement notification was only required when abuse was confirmed, and no environmental interventions were implemented despite claims of self-injury.
Failure to Provide Quality of Care in Medication, Skin, Bowel, and Anticoagulation Management
Penalty
Summary
The facility failed to provide quality of care in several areas for five residents, as evidenced by observations, interviews, and record reviews. For one resident with a history of stroke and unable to communicate needs, there was an active order for anticoagulation therapy (coumadin), but no corresponding care plan was in place. Both the LPN/Resident Care Manager and the Director of Nursing Services confirmed that a care plan should have been present but was not. Another resident with multiple diagnoses, including a leg fracture and hypertension, received blood pressure medications (metoprolol tartrate and furosemide) outside of the prescribed blood pressure parameters on multiple occasions, as documented in the medication administration records for August and September. Nursing staff and the Director of Nursing Services acknowledged that medication parameters were not followed as required. Additionally, a resident with chronic constipation and end-stage renal disease experienced multiple episodes of no bowel movements for several consecutive days, with no evidence of laxatives being administered or the facility's bowel protocol being initiated, contrary to facility policy. Two residents with various medical conditions, including arthritis, depression, and malnutrition, had multiple skin injuries such as bruises and skin tears. Documentation of these injuries was incomplete, lacking clear descriptions, sizes, and measurements in the weekly skin checks. Nursing staff and the Director of Nursing Services confirmed that the documentation did not meet expectations, as injuries were not properly described or monitored according to facility procedures.
Failure to Provide and Document Oxygen Therapy per Provider Orders
Penalty
Summary
The facility failed to provide oxygen services according to provider orders for two residents. For one resident with heart failure, COPD, and diabetes, provider orders specified oxygen at 2 liters per minute (L/m) with nursing staff required to verify the flow rate three times daily. However, observations on multiple occasions showed the resident was receiving oxygen at 5 L/m, while nursing documentation inaccurately indicated the resident was receiving oxygen at 2 L/m. Interviews with staff confirmed that the oxygen was not being administered as ordered and that documentation did not reflect the actual flow rate provided. For another resident with respiratory failure, COPD, and asthma, observations showed the resident was receiving oxygen at 2 L/m via nasal cannula, and the resident reported ongoing use of oxygen since hospital readmission. However, a review of provider orders for the relevant period revealed there was no order for oxygen use. Staff interviews confirmed that oxygen administration should be based on provider orders and that documentation for this resident did not meet expectations.
Failure to Provide Dental Services for Resident with Nutritional Risk
Penalty
Summary
A deficiency occurred when the facility failed to provide dental services to a resident who was admitted with diagnoses including enterocolitis, malnutrition, and adult failure to thrive. The resident, who was able to communicate needs, was observed to have only two teeth and reported that no dental services had been offered. Review of the resident's care plan showed no focus area related to dental care, despite the resident being at risk for nutritional problems and having a mechanically altered diet. The dietitian's assessment noted no dental or mouth problems affecting chewing or swallowing, but the resident expressed a desire for an upgraded diet. Interviews with facility staff revealed that oral exams were conducted on admission to determine the need for dental services, and residents with missing teeth were supposed to be referred to a dentist or denturist. However, staff confirmed that the resident had not been referred for dental services, which did not meet facility expectations. The DON also stated that the resident should have been referred for dental care, confirming the lapse in following established procedures.
Environmental Deficiencies Impact Homelike Setting
Penalty
Summary
Surveyors observed multiple environmental deficiencies across two facility halls, including missing closet doors, plastic bags tied to overbed light cords, socks tied to cords, and peeling baseboard molding. These issues were noted in several resident rooms over multiple days, with plastic bags and other items being used to extend or modify overbed light cords, and a plastic bag braided into a cord affixed to a bathroom door. Additionally, some overbed light cords were found to be less than three inches long, and maintenance issues such as missing closet doors and peeling molding were not addressed. Interviews with the Maintenance Director and Administrator revealed that maintenance concerns were to be reported via books at each nursing station, but both staff members were unaware of several of the observed deficiencies. Both staff confirmed that plastic bags should not be tied to overbed light cords and acknowledged that the observed maintenance issues did not meet facility expectations. The report references WAC 388-97-0880 regarding the requirement to maintain a safe, clean, comfortable, and homelike environment for residents.
Failure to Obtain and Document Physician Orders for COVID-19 Testing
Penalty
Summary
The facility failed to obtain and document physician orders for COVID-19 testing for six residents who exhibited symptoms consistent with COVID-19. In multiple cases, residents presented with symptoms such as fever, cough, malaise, and other respiratory issues, and were tested for COVID-19 without corresponding physician orders or proper documentation in the Medication Administration Record (MAR) or Treatment Administration Record (TAR). For example, one resident tested positive for COVID-19 after exhibiting a fever and cough, but there was no documentation of when the test was performed or by whom, and no physician order was present. Other residents were similarly tested for COVID-19 due to symptoms, but the tests and results were not documented in the appropriate records, and there were no PRN orders for COVID-19 testing in the event of symptoms. Staff interviews confirmed that COVID-19 testing was performed based on the presence of symptoms, but documentation practices were inconsistent, and standing orders for testing had previously lapsed. The lack of physician orders and incomplete documentation for COVID-19 testing did not align with professional standards of practice and placed residents at risk of delayed identification or diagnosis of COVID-19. The deficiency was identified through review of progress notes, MAR/TAR, and staff interviews, which revealed gaps in both ordering and recording of COVID-19 tests for symptomatic residents.
Failure to Implement Effective Infection Control and COVID-19 Precautions
Penalty
Summary
The facility failed to establish and maintain an effective infection prevention and control program, resulting in multiple lapses in COVID-19 management for 18 out of 32 residents reviewed. The facility did not conduct proper contact tracing or identify all individuals exposed to COVID-19, nor did it initiate exposure testing or implement Transmission Based Precautions (TBPs) for those exposed. In several cases, residents who were exposed to COVID-19 positive individuals were not monitored, tested, or placed on appropriate precautions, and documentation of testing and monitoring was inconsistent or absent. For example, after a resident tested positive for COVID-19, their roommate was not identified as exposed, nor were they placed on precautions or scheduled for follow-up testing. Other residents who were exposed to COVID-19 positive staff were only monitored for symptoms, without TBPs or exposure testing, and staff interviews confirmed that asymptomatic residents were not routinely tested. The facility also failed to implement universal source control and enforce the use of appropriate personal protective equipment (PPE) for both staff and residents. Observations revealed that staff did not consistently wear N95 respirators or eye protection as required, and some staff wore non-approved masks such as KN95s. Fit testing and training for N95 use were not consistently verified, and staff were observed entering and exiting COVID-19 units without donning or doffing PPE as posted. Additionally, signage and instructions for PPE use were either missing or not followed, and staff entered COVID-19 units through unmarked doors without being alerted to the need for PPE. In the therapy gym, concurrent therapy sessions were conducted with multiple residents and staff present, some of whom were not masked or were coughing, increasing the risk of transmission. Residents on Enhanced Barrier Precautions did not have PPE readily available for staff, and staff failed to use gloves and gowns during high-contact activities. Several residents who tested positive for COVID-19 were observed outside their rooms or in common areas without masks, and staff did not consistently follow posted precautions. These failures were documented through direct observation, interviews, and record reviews, demonstrating a systemic breakdown in infection control practices.
Failure to Provide Adequate Supervision During Transfers
Penalty
Summary
The facility failed to provide the required care-planned supervision to prevent accidents and falls for three residents who required two-person assistance with transfers. Resident 1, who was alert and oriented but dependent on staff for transfers, was involved in an incident where a mechanical lift was used improperly by a single staff member. During a transfer from bed to shower chair, the lift's leg got caught under the bed, causing it to tip and resulting in a controlled fall. The resident sustained a superficial laceration on the forehead from the overhead bar of the lift. Resident 3, with moderate cognitive impairment, and Resident 4, who was cognitively intact, both reported that staff did not consistently use two-person assistance during transfers. Resident 3 mentioned being hit in the nose twice in the past year, while Resident 4 reported being hit in the head a couple of times, though neither sustained severe injuries. These incidents highlight the facility's failure to adhere to the care plan requirements for mechanical lift transfers, placing residents at risk for injury.
Failure to Notify Ombudsman of Resident Hospital Transfers
Penalty
Summary
The facility failed to properly notify the Office of State Long-Term Care Ombudsmen regarding the discharges of three residents who were transferred to the hospital. This deficiency was identified during interviews and record reviews for Residents 54, 76, and 36. Resident 54, who had diagnoses including heart failure and chronic obstructive pulmonary disease, was transferred to the hospital via 911 on August 1, 2024, but there was no documentation of notification to the Ombudsman. Similarly, Resident 76, with conditions such as acute pyelonephritis and diabetes, was transferred to the hospital on June 26, 2024, without the required notification. Resident 36, who had chronic obstructive pulmonary disease and diabetes, was also transferred to the hospital on July 14, 2024, without any notification to the Ombudsman. The deficiency was confirmed during interviews with Staff A, the Administrator, who acknowledged the lack of documentation for notifying the Ombudsman for each of these cases. The expectation was that such notifications should be sent and documented, but this was not done for the residents in question. The failure to notify the Ombudsman placed the residents at risk for inappropriate discharge and diminished quality of life, as per the findings of the surveyors.
Failure to Provide Complete Bed Hold Notices
Penalty
Summary
The facility failed to provide or thoroughly complete a bed hold notice in writing at the time of transfer to the hospital or within 24 hours of transfer for two residents. Resident 54, who had diagnoses including heart failure and chronic obstructive pulmonary disease, was transferred to the hospital via 911. Upon return, the resident stated they were not offered a bed hold notice. Staff interviews confirmed that there was no documentation of a bed hold for this transfer in the resident's electronic health record (EHR). Resident 36, with diagnoses including chronic obstructive pulmonary disease and diabetes, was transferred to the hospital and had a bed hold document signed. However, the document was incomplete as it did not include the daily rate for holding the bed. The resident rescinded the bed hold after being informed of the cost, but this conversation was not documented. Staff interviews revealed that the bed hold form should have been fully completed and explained to the resident within 24 hours to allow for an informed decision.
Failure to Formulate Timely Baseline Care Plans
Penalty
Summary
The facility failed to formulate baseline care plans within 48 hours of admission or readmission for three residents, leading to potential delays in necessary services and treatments. Resident 28, admitted with end-stage renal disease and respiratory failure, required dialysis and continuous oxygen treatment. However, the care plan initiated on the admission date did not include focus areas for these critical treatments. Staff interviews confirmed that the absence of these care plan elements did not meet the facility's expectations. Resident 54, readmitted after surgery for a right lower leg wound, did not have a care plan addressing the surgical wound until six days post-readmission, despite provider orders for daily wound treatment. Similarly, Resident 379, admitted with a history of falls and recent hip surgery, required therapy and experienced pain, yet lacked a care plan for pain management. Staff acknowledged that baseline care plans should have been created within 48 hours, indicating a lapse in meeting the expected standards of care planning.
Deficiencies in Care Planning and Implementation
Penalty
Summary
The facility failed to develop and implement comprehensive care plans for four residents, leading to potential risks in their care. Resident 24, who was admitted with kidney failure and a urinary tract infection, reported poor vision and the use of corrective lenses. However, the care plan did not address vision needs or the use of glasses, despite staff acknowledging the importance of including such information. Similarly, Resident 44, who was readmitted with anxiety disorder, depression, and psychotic disorder, had a care plan that failed to address the anxiety disorder and did not document behaviors or side effects to monitor for the antipsychotic medication prescribed. Resident 26, admitted with dementia, malnutrition, and depression, was at risk for falls. After a fall, a new intervention was added to the care plan to use fall mats, but observations showed the mats were not in place, and staff were unaware of their location. These deficiencies in care planning and implementation placed residents at risk of inadequate services and diminished quality of life.
Deficiencies in Pain Management and Documentation
Penalty
Summary
The facility failed to ensure freedom from unnecessary pain medication for three residents, leading to deficiencies in pain management and documentation. Resident 44, who was readmitted with diagnoses including a stroke and insomnia, had an order for Tylenol as needed for pain. However, there was no documentation of non-pharmacological interventions being attempted before administering the medication, and the resident's sleep and pain management records were incomplete. Staff interviews confirmed the lack of documentation and adherence to the facility's pain management protocols. Resident 36, diagnosed with chronic obstructive pulmonary disease and diabetes, was prescribed oxycodone for moderate pain with instructions to attempt non-pharmacological interventions first. Despite this, the resident received oxycodone daily without any documented attempts of non-pharmacological approaches. The Director of Nursing Services acknowledged that the expected protocol was not followed, as non-pharmacological interventions should have been completed and documented prior to administering the narcotic. Resident 379, who had multiple falls and a recent hip fracture surgery, was prescribed Tylenol as needed for pain, along with non-pharmacological interventions. On one occasion, Tylenol was administered without any documented or observed non-pharmacological interventions. Staff interviews revealed that non-pharmacological interventions were expected to be attempted and documented before administering medication, but this was not done for Resident 379. The lack of documentation and adherence to pain management protocols was confirmed by the Director of Nursing Services.
Failure to Monitor Psychotropic Medication Side Effects
Penalty
Summary
The facility failed to monitor potential side effects related to the use of psychoactive medications for four residents, leading to a deficiency in care. Resident 9, who was admitted with dementia, anxiety, and depression, was prescribed fluoxetine and memantine. However, the care plan did not document behaviors or adverse side effects to monitor for these medications. Additionally, there was no monitoring documentation for memantine's side effects, and staff were unaware of the monitoring requirements in the electronic health record. Resident 44, who had anxiety disorder, depression, and psychotic disorder, was prescribed citalopram. The order required close observation for significant antidepressant side effects, but the monitoring record for August 2024 was blank, indicating a lack of documentation. Similarly, Resident 36, with chronic obstructive pulmonary disease and diabetes, was prescribed sertraline for depression. There was no behavior monitoring documented for this medication, and staff were unable to locate any consistent monitoring records. Resident 26, diagnosed with anxiety and depression, was taking buspirone and Remeron. The facility failed to document monitoring for adverse side effects for these medications. Staff interviews revealed that there was missing documentation for monitoring side effects, and orders were not visible to staff for proper monitoring. These deficiencies indicate a systemic issue in the facility's monitoring and documentation processes for residents on psychotropic medications.
Infection Control and Sanitation Deficiencies
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by the improper application of transmission-based precautions (TBP) for Resident 23, who had a methicillin-resistant staphylococcus aureus (MRSA) infection. Despite the resident's condition, there was no TBP sign on the door or a personal protective equipment (PPE) supply container available for staff use. The Director of Nursing Services (DNS) acknowledged that the expectation was to have these measures in place for residents with active MRSA infections. Additionally, the facility did not follow Enhanced Barrier Precautions (EBP) for Residents 1 and 54, who required such measures due to chronic wounds and a surgical incision, respectively. Observations revealed that there were no EBP signs or PPE supply carts at the entrances to their rooms. Staff interviews confirmed that these precautions were expected but not implemented, and Resident 54's care plan did not document the need for EBP. The facility also failed to maintain sanitary conditions in the East Long Hall medication cart. An unlabeled pill cutter with medication residue was used without being cleaned, and inappropriate items such as dermal wound spray and a urine sample were stored in the medication cart. Staff interviews indicated that these practices did not meet the facility's expectations for medication storage and cleanliness.
Failure to Obtain Complete Psychotropic Medication Consents
Penalty
Summary
The facility failed to obtain signed consents for psychotropic medications before administration to two residents, placing them at risk for adverse side effects and diminished quality of life. Resident 9, admitted with dementia, anxiety, and depression, was prescribed fluoxetine and memantine without completed consent forms in their electronic health record. Interviews with staff revealed that the expectation was to obtain consent forms prior to administering these medications, which was not met in this case. Resident 44, with diagnoses including anxiety disorder, depression, and psychotic disorder, was prescribed citalopram and Seroquel. However, the informed consent forms for these medications were incomplete, missing critical information such as the indication for use, related diagnosis, and target behaviors. Staff interviews confirmed that the consents did not meet the facility's expectations, as they were not fully filled out, failing to ensure residents were fully informed about their treatments.
Failure to Provide Written Notice and Explanation for Room Change
Penalty
Summary
The facility failed to honor a resident's right to receive written notice and explanation before a room change, as well as the opportunity to see the new room and meet new roommates. This deficiency was identified for Resident 14, who was cognitively intact and able to express their needs. Resident 14 was admitted with diagnoses including Diabetes and Depression. During an interview, Resident 14 expressed dissatisfaction with the room change, stating they preferred their previous room near the window and with familiar staff. They reported not receiving advance notice or the chance to view the new room before the move, suspecting the change was due to the other hall being full. The facility's electronic health record showed a Room Transfer/New Roommate Change form dated after the move, with no prior documentation regarding the room change. Interviews with facility staff revealed that while verbal notice was given when possible, written notice and explanation were not provided to the resident or their representative. Staff G, the Social Services Director, confirmed that the facility's practice was to document room moves but not to provide this documentation to residents. Staff H, the Social Services Assistant, mentioned showing the new room to Resident 14 but could not recall the date and did not document the event. The Administrator acknowledged that the expectation was for advance notice and a written explanation to be provided, and that residents should be offered the opportunity to see the new room before moving.
Failure to Complete Change of Condition MDS for Hospice Resident
Penalty
Summary
The facility failed to identify a significant change in condition for a resident receiving Hospice services, which is a deficiency in care. The resident, who was admitted with diagnoses including dementia, malnutrition, and adult failure to thrive, was unable to communicate their needs. Despite the initiation of Hospice services, the facility did not complete a change of condition Minimum Data Set (MDS) assessment, which is required to address the resident's evolving care needs. Interviews with staff, including a Licensed Practical Nurse responsible for MDS and the Director of Nursing Services, confirmed that a change of condition MDS should have been completed following the start of Hospice services, but it was not done.
Inaccurate PASRR Assessment for Resident with Psychotic Disorder
Penalty
Summary
The facility failed to ensure the Pre-Admission Screening and Resident Review (PASRR) assessment was accurately completed for one resident, who was readmitted with diagnoses including anxiety disorder, depression, and psychotic disorder. The quarterly minimum data set assessment indicated the resident was able to make needs known. However, the PASRR assessment did not document the psychotic disorder as a serious mental illness indicator. Interviews with the Social Service Assistant and the Director of Nursing Services confirmed the inaccuracy of the PASRR assessment, acknowledging that it should have included the psychotic disorder diagnosis.
Failure to Update Care Plan for Hospice Services
Penalty
Summary
The facility failed to review and revise the care plan for Resident 55 after a change in condition, specifically the initiation of Hospice services. Resident 55, who was admitted with diagnoses including dementia, malnutrition, and adult failure to thrive, was unable to communicate their needs. Despite the initiation of Hospice services on 06/14/2024, the care plan, which was initially created on 03/23/2023, did not reflect any new interventions or approaches for these services. Interviews with staff revealed that the care plan should have been updated to include Hospice services, but no updates were found. This oversight placed the resident at risk of unmet care needs and a diminished quality of life.
Deficiencies in Therapy Initiation and Pain Management Monitoring
Penalty
Summary
The facility failed to ensure the initiation of a provider order for Physical and Occupational Therapy (PT/OT) for Resident 19, who was readmitted with diagnoses including heart disease, stroke with hemiplegia, and pneumonia. Despite an order dated 07/03/2024 for PT/OT evaluation and treatment, the Rehabilitation Director stated they had not received the order. A Registered Nurse claimed to have delivered a paper copy of the order to the PT/OT department, but could not confirm who received it. Observations showed Resident 19 with a contracted right hand and no brace, and the family expressed concerns about the lack of PT/OT and use of a splint. The facility also failed to monitor and evaluate the effectiveness of pain management for Resident 26, who was admitted with aphasia, dementia, and chronic pain. The care plan required staff to document pain management effectiveness every shift, but a Licensed Practical Nurse reported no place to document this on the medication or treatment administration records. The Director of Nursing Services acknowledged the monitoring issues and stated that pain assessment should occur every shift, but documentation was lacking.
Failure to Implement Bowel Program and Therapy
Penalty
Summary
The facility failed to consistently monitor and document bowel movements and implement the bowel program for two residents, leading to potential health risks. Resident 3, who was admitted with multiple diagnoses including lung and heart disease, diabetes, depression, and malnutrition, reported having diarrhea every day. Despite frequent documentation of loose stools in the resident's electronic health record, the staff did not contact the provider to obtain medication for the diarrhea. Interviews with staff confirmed that the issue was known but not addressed according to the facility's bowel program policy. Resident 9, admitted with diagnoses including dementia, anxiety, depression, GERD, muscle weakness, and malnutrition, experienced periods without bowel movements. The facility's medication administration record showed that the bowel protocol was not followed correctly, as Milk of Magnesia was administered but documented as ineffective, and no further action was taken. A suppository was administered without prior Milk of Magnesia administration, contrary to the protocol. Staff interviews revealed a lack of adherence to the bowel protocol, which was expected to be initiated for constipation. Additionally, the facility failed to initiate proper positioning and restart physical and occupational therapy for Resident 19, who had a history of heart disease, stroke with hemiplegia, and pneumonia. The resident was observed with a contracted right arm and hand, without the prescribed brace or sling. The resident's family expressed concern about the lack of therapy and brace application. Despite a provider order for PT/OT evaluation and treatment, the facility did not act on it, and staff interviews confirmed the absence of orders to apply the brace or restart therapy.
Failure to Maintain Current Smoking Assessment for Resident
Penalty
Summary
The facility failed to maintain an accurate and current smoking assessment for a resident, identified as Resident 4, which placed the resident at risk for avoidable accidents and diminished quality of life. Resident 4, who was admitted with diagnoses including stroke and hemiparesis affecting both sides of the body, was observed in an electric wheelchair and indicated through gestures and writing that they smoked off the facility property. A cigarette odor was noted on their clothing. The Electronic Health Record showed a Smoking Safety Evaluation dated approximately five months prior, which did not address how the resident managed smoking activities such as holding, lighting, and extinguishing a cigarette. Interviews with staff revealed that smoking evaluations were expected to be completed quarterly and upon any change in condition, but this was not adhered to in Resident 4's case.
Failure to Provide Ostomy Care Instructions in Care Plan
Penalty
Summary
The facility failed to provide appropriate ostomy care and treatment instructions in the care plan for a resident with an ostomy, identified as Resident 129. The resident was admitted with a diagnosis of diverticulitis and had an ostomy, but the electronic health record (EHR) lacked any provider orders or care directives related to ostomy care. During an interview, Resident 129 expressed discomfort around the ostomy bag and doubted the staff's training in managing the ostomy. The Medication Administration Record (MAR) and Treatment Administration Record (TAR) for August 2024 also showed no ostomy care directives. Interviews with staff revealed a lack of documented orders and care plans for the resident's ostomy care. Staff F, an LPN, mentioned that nurses were responsible for changing and emptying the ostomy bag every other day but could not find any provider's order or care plan in the EHR. Staff C, another LPN and Residential Care Manager, confirmed the absence of orders and care plans related to the ostomy bag, stating that there should have been orders for changing the bag and assessing the stoma site. The Director of Nursing Services, Staff B, acknowledged that the expectation was for ostomy orders to be entered in the EHR and care planned upon admission.
Failure to Monitor and Document Fluid Restrictions
Penalty
Summary
The facility failed to monitor and accurately document fluid restrictions for a resident, identified as Resident 36, who was on a prescribed fluid restriction of 2 liters per day. The resident's electronic health record indicated a fluid restriction order, with specific allocations for dietary and nursing staff. However, observations revealed that the resident had a water pitcher within reach on multiple occasions, contrary to the physician's orders and facility policy. Interviews with staff members, including CNAs and an LPN, showed a lack of awareness regarding the resident's fluid restriction, indicating a communication breakdown within the facility. The care plan for Resident 36 did not include any goals or interventions related to the fluid restriction, which was acknowledged as an oversight by the Residential Care Manager. The Director of Nursing Services confirmed that it was expected for provider's orders to be care planned and followed, and that residents on fluid restrictions should not have water pitchers at their bedside. This deficiency placed the resident at risk for medical complications and a diminished quality of life, as the facility did not adhere to its policy or the physician's orders regarding fluid restrictions.
Failure in Dialysis Care Coordination
Penalty
Summary
The facility failed to provide ongoing collaboration and communication with a dialysis provider for a resident with end-stage renal disease who was dependent on renal dialysis. The resident was admitted to the facility with a diagnosis of end-stage renal disease and had orders to undergo dialysis on Monday, Wednesday, and Friday. However, the resident's care plan did not include a focus area for dialysis, indicating a lack of comprehensive planning for the resident's dialysis needs. Interviews and record reviews revealed that the facility did not maintain proper communication with the dialysis provider. The resident was transported to dialysis by family members and did not consistently take communication forms to the dialysis sessions. The communication binder lacked completed forms for several dates, and the facility staff did not ensure that the top portion of the forms was filled out by the dialysis staff. Staff members acknowledged that the lack of completed communication forms did not meet the facility's expectations for dialysis care coordination.
Medication Administration Errors in LTC Facility
Penalty
Summary
The facility failed to maintain a medication error rate of less than 5 percent, as evidenced by a 16 percent error rate observed during 25 medication administration observations. This deficiency involved two residents, Resident 1 and Resident 8, who did not receive their medications as prescribed. For Resident 1, a dose of clonazepam was not administered within the scheduled time frame due to the unavailability of the narcotic book, and a dose of MiraLax was discarded without being administered, with incorrect documentation in the electronic health record (EHR). Staff U, an LPN, failed to administer the clonazepam dose on time and did not document the discarded MiraLax dose accurately. Resident 8 also experienced medication administration errors. The resident was given only a partial dose of MiraLax, which was discarded without proper documentation of the incomplete administration. Additionally, Resident 8 was prescribed systane ophthalmic solution to be administered four times a day, but Staff U documented two administrations while only administering one. These actions and inactions by the staff led to the medication errors, which were not in compliance with the facility's guidelines for medication administration and documentation.
Incomplete Discharge Summaries Compromise Resident Care
Penalty
Summary
The facility failed to provide complete and accurate discharge summaries for six residents, leading to potential risks of post-discharge complications and delayed treatment. For Resident 3, the discharge summary was incomplete, lacking details on wound care treatment orders, home health nursing services, and necessary information for foley catheter maintenance. The Licensed Practical Nurse (LPN) responsible for the discharge was unaware of the resident's pressure ulcers and did not include necessary treatments in the medication reconciliation. Resident 9's discharge summary was also incomplete and inaccurate, missing scheduled appointments and contact information for follow-up care, including blood thinner management and home health services. The resident's collateral contact confirmed that the discharge nurse did not provide necessary information, and the home health agency did not receive a referral for the resident. Similarly, Resident 8's discharge summary lacked essential details such as the reason for discharge, discharge destination, and scheduled appointments with oncology and primary care providers. The medication reconciliation was outdated, and the home health referrals were not documented. Other residents, including Residents 7, 10, and 11, experienced similar issues with their discharge summaries. Resident 7's summary did not include vital information such as daily weight monitoring instructions and scheduled follow-up appointments. Resident 10's discharge documentation was missing entirely from the clinical record, and Resident 11's summary was incomplete with outdated vital signs and missing signatures. These deficiencies highlight a systemic issue in the facility's discharge process, potentially compromising the continuity of care for discharged residents.
Failure to Prevent and Monitor Pressure Ulcers
Penalty
Summary
The facility failed to provide necessary care and services to prevent the occurrence and/or worsening of avoidable pressure ulcers/pressure injuries (PU/PIs) for several residents. For Resident 3, the facility did not implement new interventions for a newly identified Stage 2 PU/PI on the right buttock, which was not present upon admission. The wound was not evaluated or monitored between its identification and a later evaluation by a wound specialist, and there was no notification to the responsible party or physician. Additionally, the resident was discharged without proper instructions or treatment orders for the care of the PU/PIs at home. Resident 1 was admitted with a Stage 3 PU/PI, and the care plan directed weekly documentation of wound evaluations. However, there was no wound assessment or progress note for a specific week, indicating a lapse in the required weekly monitoring and documentation. Similarly, Resident 4, who was at risk for PU/PI, had a Stage 1 PU/PI on admission, but there was no documentation of wound evaluations for certain weeks, and the first measurement was only provided weeks after admission. Resident 6 had an unhealed Stage 3 PU/PI, and the facility failed to evaluate, measure, or document the status of the wounds when the wound specialist was unavailable for weekly rounds. The facility's lack of a consistent system for timely and accurate evaluation of PU/PIs and failure to perform weekly wound evaluations placed residents at risk for worsening conditions and unmet care needs.
Latest citations in Washington
A resident with cerebral palsy and a court-appointed guardian experienced multiple episodes of nausea, vomiting, loose stools, abdominal discomfort, fatigue, and later refusal of meals and medications, leading to changes in the care plan including close monitoring, lab testing, and IV fluid administration. Despite a facility policy recognizing court-appointed guardians as resident representatives with decision-making authority, staff did not document any notification to the guardian during these changes in condition or treatment decisions. The guardian reported not being contacted when the resident stopped eating or developed stomach issues and felt the facility did not respect the guardianship, while the DON acknowledged there were multiple missed opportunities to notify the guardian of the resident’s change from baseline.
A resident with depression, anxiety, moderate cognitive impairment, and urinary incontinence, care-planned for q2h checks and assistance with toileting, was found by a visitor to be soaking wet, unusually agitated, and reporting they had been told to wait to be changed and referred to with a derogatory remark. The visitor filed a written grievance alleging abuse/neglect related to delayed incontinence care and removal of the resident’s tablet as a consequence. Although an incident report noted that the matter was reported to the state and that the resident was not soaking wet, a CNA who actually changed the resident later reported the resident’s brief, pants, wheelchair, and socks were soaked and that the resident was acting timid and repeatedly saying they had to sit for five minutes, but this CNA was never interviewed. The DON acknowledged not investigating the resident’s behavior or interviewing this CNA, and the grievance official acknowledged the facility did not fully investigate or communicate findings and resolution to the complainant, resulting in a failure to follow the facility’s grievance policy.
A resident with dementia, respiratory failure, and heart failure developed new shortness of breath with an O2 sat of 90%, and a physician ordered transfer to the ED for tx and eval. An RN completed an SBAR, notified the MD and family, and reported to the oncoming nurse that the resident needed ED transfer and that paramedics should be contacted, then left the facility. Instead of calling 911 for this emergent respiratory distress, staff arranged non-emergent transport through a contracted ambulance service, resulting in the resident remaining at the facility for several hours without pickup until the dispatcher later instructed staff to call 911. The DON stated that 911 is expected to be used for emergent conditions and the contracted service only for non-emergent transport.
A resident with anoxic brain injury, dysarthria, and documented lack of decisional capacity alleged physical abuse and expressed fear of their identified representative, yet social services only reported the allegation to the state and did not complete an incident report, revise the care plan, or implement protective interventions. The same representative continued to be treated as the resident’s decision-maker and visited frequently, with staff noting suspicious odors of foreign substances and concerns about possible illicit substance use. Psychiatry later documented concern that the representative was providing illicit substances, and the resident was subsequently hospitalized for altered mental status and overdose, after which the representative was banned. Key staff, including the DON, unit manager, and administrator/abuse coordinator, were unaware of the initial abuse allegation, and social services did not timely explore or clarify legal decision-making authority or alternative representation for the resident.
A resident with severe cognitive impairment, osteoarthritis, and spinal spondylosis, care planned for 2-person Hoyer transfers, was being moved by two CNAs using a mechanical lift when one corner loop of the sling became disengaged, causing the resident to fall about four feet, strike the floor and the lift, and sustain head abrasion, multiple rib fractures, and lumbar vertebral fractures. Facility policy required staff to verify secure sling attachment, examine hooks, clips, fasteners, and strap stability, and ensure the sling bar was sound before lifting, but during this transfer the sling loop detached despite staff believing it was properly fastened and hearing it click into place; post-incident assessment showed the loop had come loose, the sling appeared in good condition, and a CNA later reported thinking one of the round metal disks on the lift might have been slightly loose, while maintenance logs documented no prior concerns with the lifts or slings.
The facility failed to revise and individualize care plans to reflect current needs and preferences for multiple residents, including one cognitively intact resident with hemiplegia, hemiparesis, and mononeuropathy who had bilateral shoulder surgery and could not tolerate BP measurements on the upper arms but preferred forearm readings. Despite repeatedly informing staff, this preference was not documented in the care plan or Kardex, and direct care staff and the RN/UM were unaware of it. Another cognitively intact resident with hemiplegia, contractures, and weakness reported they were supposed to get out of bed for two hours daily, but some NACs did not know this, even though the MAR/TAR contained an order to document times up and back to bed. The surveyors concluded that care plans were not accurately revised for several residents, placing them at risk for unidentified and unmet care needs and diminished quality of life.
Surveyors found that two residents with hemiplegia, hemiparesis, weakness, and contractures did not receive restorative nursing services, including ROM exercises and splint/brace or orthotic assistance, after therapy discharge. Although PT and OT discharge summaries documented established restorative ROM and transfer programs, recommended PROM to affected extremities, and recommended splint/brace use and assistance with orthotic wear, these recommendations were not entered as restorative referrals in the EHR. As a result, the residents’ care plans and records showed no restorative programs, and both residents reported that therapy and restorative exercises had stopped, while the DON, rehab director, and MDS coordinator confirmed they were unaware of and had not implemented the recommended restorative services.
A resident with cancer, cognitive impairment, and declining strength experienced multiple unwitnessed falls, most occurring while attempting to toilet or move toward the bathroom, culminating in a fractured ankle requiring ED treatment. Although assessments identified fall and incontinence risks and the facility’s policy required individualized interventions, the comprehensive care plan lacked a toileting plan and did not include several interventions that were discussed in incident investigations, such as consistent wheelchair placement and frequent rounding for bathroom assistance. Staff reported relying on verbal reminders and education to use the call light, despite acknowledging the resident’s impulsivity and failure to call for help, and the resident’s bed remained furthest from the bathroom while repeated bathroom-related falls occurred without the trend being recognized or addressed in the care plan.
A resident with a history of acute urinary retention and acute kidney injury had a Foley catheter deemed permanent by the hospital, with instructions that it not be removed in the SNF. At a later urology visit, the catheter was removed, and the resident returned with no new orders documented. Facility staff did not document bladder assessments, post-void residuals, or urine output, and CNA documentation showed the resident did not void that evening. Over the next day, the resident had vomiting, poor intake, altered level of consciousness, tachycardia, hypotension, and no documented wet briefs. A bladder scan eventually showed more than 2000–2500 mL of retained urine, and a new catheter drained a large volume. The resident and a roommate reported moaning, crying out in pain, and repeatedly alerting staff that the resident was not urinating and that the catheter was not draining, while nurses documented catheter care when no catheter was in place and later had to flush and replace the catheter due to continued complaints.
Surveyors found that nurses and nurse aides did not consistently administer medications according to professional standards and facility policy. Multiple residents reported that agency nurses were slow with medications, did not fully follow instructions, and often gave routine meds late. Observations showed an LPN administering expired Humalog/Lispro insulin well past the scheduled time, an LPN giving several scheduled meds (including Tizanidine) late and all at once, and an RN attempting to give sliding-scale insulin nearly two hours late, which a resident refused after already eating. Another resident received Methocarbamol two hours late after questioning the RN, and a resident on scheduled Tramadol had doses given without timely documentation, with a discrepancy between the narcotic count and pills remaining. These events demonstrated failures in timely administration, use of non-expired medications, and immediate, accurate MAR and narcotic documentation.
Failure to Notify Court-Appointed Guardian of Resident’s Clinical Changes
Penalty
Summary
The deficiency involves the facility’s failure to notify a resident’s court-appointed guardian of significant clinical changes and care decisions, contrary to its own policy and state requirements. The facility’s policy on Resident Representatives, revised 02/2021, states that a resident representative includes a court-appointed guardian or conservator and that the facility treats the representative’s decisions as those of the resident to the extent delegated or required by the court. Resident 1, admitted with cerebral palsy, had a Superior Court guardianship letter dated 02/07/2025 indicating a guardian of person and conservator of the estate with full authority, identifying Collateral Contact 1 (CC1) as the guardian. Despite this, multiple clinical events and changes in condition were documented without any corresponding documentation that CC1 was notified. Progress notes and provider notes show that Resident 1 experienced an episode of nausea and vomiting, frequent loose stools, abdominal discomfort, bloating, worsening fatigue, generalized weakness, and later refusal of meals and medications over at least a 24-hour period, with observations that the resident appeared frailer, more fatigued, and had no energy or interest to talk. The provider developed care plans including close monitoring for deterioration, sending stool to the lab, and later initiating IV fluids for rehydration, with a plan to call family/POA for discussion. However, there was no documentation that the guardian was notified at any of these points, including when IV fluids were started. CC1 reported that they were not contacted when the resident stopped eating or developed stomach issues, and expressed that the facility did not respect their guardianship and that involvement in care planning took too long. The DON confirmed on record review that there were many opportunities to notify the guardian when the resident’s condition changed from baseline and that there was no evidence staff did so.
Failure to Thoroughly Investigate and Resolve Resident Grievance Regarding Incontinence Care and Staff Conduct
Penalty
Summary
The deficiency involves the facility’s failure to thoroughly investigate and resolve a grievance alleging neglect and disrespect toward a resident, as required by its grievance policy. The resident had depression, anxiety, moderate cognitive impairment, occasional urinary incontinence, and required moderate assistance with toileting, with a care plan directing staff to check the resident every two hours, ask about toileting needs, and ensure they were clean and dry. A collateral contact reported arriving to visit the resident and finding them soaking wet and agitated, with behavior that was not typical for the resident. The collateral contact documented in a written grievance that the resident’s tablet was off, the resident appeared upset, and the resident reported being told they had to wait five minutes to be changed and that staff would change their “nasty *ss” in five minutes, leading the collateral contact to believe the resident had been given a consequence of no tablet and sitting in wet clothes, which they characterized as abuse/neglect and requested immediate removal of the responsible staff and a report filed. The facility documented receipt of the grievance and created an incident report indicating the matter was reported to the state agency, and that the unit manager interviewed the collateral contact and the resident, with the resident described as confused and denying being soaking wet. The incident report stated that a different nursing assistant was assigned to assist with the brief change and that the unit manager believed the resident was not soaking wet, and that the resident and collateral contact were satisfied when they left the room. However, a CNA who actually changed the resident reported that the resident’s brief was soaked through their pants onto the wheelchair and their socks were soaked, and that the resident was timid, repeatedly saying they had to sit for five minutes, and not acting like themselves; this CNA stated they were never interviewed or asked about the grievance or the resident’s condition. The DON acknowledged not interviewing this CNA or investigating the resident’s behavior and why they were upset, and the unit manager did not recall whether the collateral contact was present during follow-up and did not believe they followed up with the collateral contact regarding the grievance. The administrator, identified as the Grievance Official, stated the facility should have thoroughly investigated the grievance and discussed findings and resolution with the collateral contact, indicating the grievance process was not fully carried out in accordance with policy and WAC 388-97-0460.
Failure to Obtain Timely Emergency Transport for Resident in Respiratory Distress
Penalty
Summary
The deficiency involves the facility’s failure to obtain timely emergency medical services for a resident experiencing new-onset respiratory distress. The resident had dementia, respiratory failure, and heart failure, with severe cognitive impairment and a need for substantial assistance with activities of daily living. On the day the resident was sent to the hospital, a collateral contact observed the resident having difficulty breathing, appearing unable to get enough air, and looking as if they were sleeping or unconscious, and reported this to staff with a request to contact the doctor. An SBAR Communication Form documented that the resident was experiencing shortness of breath that had not occurred before, with an oxygen saturation of 90%. The physician was notified and ordered the resident sent to the emergency department for treatment and evaluation, and the collateral contact was notified shortly thereafter. Progress notes later documented that, despite the order for emergency department transfer, the resident was still awaiting pickup by Olympic transportation several hours later, with no estimated time of arrival. At approximately 3:30 AM, the dispatcher informed the facility that they could not provide transportation and instructed that 911 be called; only then was 911 contacted and the resident transported to the hospital via ambulance for respiratory distress. The RN caring for the resident stated they completed the SBAR, notified the physician and family, and at the end of their shift reported to the oncoming nurse that the resident needed to be sent to the emergency department for respiratory distress and that paramedics should be contacted, then left assuming 911 would be called. The DON stated that staff are expected to contact 911 for emergent conditions such as shortness of breath or respiratory distress, and that Olympic Ambulance is used only for non-emergent transport.
Failure to Provide Social Service Advocacy After Abuse Allegation and Questionable Representative
Penalty
Summary
The deficiency involves the facility’s failure to provide appropriate medically-related social services and advocacy for a resident following an allegation of abuse and concerns about the resident’s representative. The resident had an anoxic brain injury, dysarthria, moderate cognitive impairment, and was dependent on staff for activities of daily living. A hospital palliative care note documented that the resident lacked decisional capacity, had no DPOA, that the legal next of kin (CC4) did not want to be part of care decisions, and that care decisions were being deferred to another contact (CC5). CC5 accompanied the resident on admission, signed admission forms, and was listed as the primary contact in the medical record profile. On a date in February, during communication therapy, the resident reported that CC5 had done something to them, pounded their hands on their chest, recalled being hit in the back of the head by an unknown person, and stated they were sometimes afraid of CC5. A social services staff member reported this allegation to the state agency but did not complete a facility incident report, did not initiate care plan changes or interventions, and took no further action. CC5 continued to be treated as the resident’s representative, and progress notes documented CC5 at the bedside on multiple dates, including an entry noting the room smelled like foreign substances and that CC5 was seen waking the resident and then asking the nurse to administer pain medications. A psychiatry note later documented concern that CC5 was providing the resident with illicit substances and stated it would be prudent for the resident to identify a POA. Subsequently, the resident was found unresponsive, transported to the hospital, and later readmitted after altered mental status and overdose, with a provider note stating that CC5 posed a significant danger to the resident and was banned from visiting. After readmission, staff attempted to contact CC4 for consent to treat but initially reached someone who stated they were not CC4. The social service director acknowledged that, beyond reporting the initial allegation, no additional interventions were implemented, that CC5 continued to be used as the resident’s representative after the allegation, and that they had not explored legal authority for decision making following the abuse allegation or concerns about substances. The social service assistant reported they did not speak with the resident about the hospital stay or CC5 and did not complete an incident report or care plan changes after the allegation. The unit manager and DON were unaware of the initial abuse allegation, and the administrator, who served as abuse coordinator, also stated they were unaware of the allegation and that an investigation should have been initiated and a representative for the resident investigated at a minimum.
Injury from Mechanical Lift Sling Detachment During Transfer
Penalty
Summary
The facility failed to ensure a safe mechanical lift transfer when a resident was being moved with a Hoyer lift and sling, resulting in a fall and injury. Facility policy for using a mechanical lifting machine required staff to securely attach sling straps to the sling bar according to manufacturer’s instructions, double-check the security of the sling attachment before lifting, examine all hooks, clips, or fasteners, check strap stability, and ensure the sling bar was securely attached and sound. Despite these requirements, during a transfer for dinner, two CNAs placed the sling under the resident, attached the loops at each corner of the sling to the lift, and raised the resident off the bed into the space between the bed and wheelchair when the bottom left corner of the sling became disengaged from the lift. The resident involved had multiple diagnoses including osteoarthritis, cervical and thoracic spondylosis, and Alzheimer’s disease, with the Minimum Data Set documenting severely impaired cognitive skills for daily decision-making. The resident’s care plan required the assistance of two staff during Hoyer lift transfers. During the transfer, the resident fell approximately four feet, landing on her buttocks, bouncing, and then falling backward and striking her head on the leg of the Hoyer lift. Hospital records documented that the resident sustained an abrasion to the back of the head, fractures of the 6th, 7th, 8th, and 10th ribs, and fractures of the 1st and 2nd lumbar vertebra. Staff interviews and observations showed that staff believed the sling loops had been securely fastened and reported hearing the loops click into place before lifting. One CNA stated that they had barely lifted the resident off the bed when the bottom left loop became disconnected and the resident fell. Another CNA reported being shocked and unable to figure out what had happened. A nurse who assessed the resident and then examined the equipment after the fall noted that one of the loops of the sling had become disengaged but stated the sling appeared to be in good condition. During a later demonstration, a CNA indicated she thought one of the round metal disks on the lift might have been a little loose. Maintenance logs for Hoyer slings and lifts for the preceding months documented no concerns with the slings or lifts, and the DON acknowledged expecting a citation due to the resident’s injury from the fall.
Failure to Revise Care Plans to Reflect Resident Needs and Preferences
Penalty
Summary
The deficiency involves the facility’s failure to revise and individualize comprehensive care plans to reflect residents’ current needs and preferences, as required by its own care planning policy. For one resident with hemiplegia, hemiparesis following cerebrovascular disease, and mononeuropathy of the upper limb, the admission MDS showed intact cognition and upper extremity impairment. This resident reported having bilateral shoulder surgery and an inability to tolerate blood pressure measurements on the upper arms due to pain, and stated a preference for BP measurements on the forearms. The resident reported having informed multiple nursing staff of this preference, but staff continued to place the cuff on the upper arms. Review of the resident’s care plan and Kardex showed no interventions or instructions regarding forearm BP cuff placement. A NAC confirmed they were unaware of the preference until the resident told them directly and that this instruction was not documented in the Kardex. The RN/Unit Manager, who stated they were responsible for revising and reviewing care plans when there were changes, also confirmed they were not aware of the resident’s preference and that it should have been updated in the care plan. Another resident, readmitted with hemiplegia and hemiparesis following a nontraumatic subarachnoid hemorrhage, contracture of the left hand, and weakness, was cognitively intact and required maximum assistance for bed mobility per a quarterly MDS. This resident stated they were supposed to get out of bed for two hours every day, but some NACs were not aware of this care requirement. Review of the resident’s March 2026 MAR/TAR showed an order to document the time the resident got up and the time they returned to bed daily. The report states that, overall, the facility failed to revise care plans accurately to reflect residents’ needs for three of four residents reviewed for care plan revision, placing them at risk for unidentified and unmet care needs and a diminished quality of life.
Failure to Implement Restorative Nursing and Splint/Brace Programs After Therapy Discharge
Penalty
Summary
The deficiency involves the facility’s failure to provide restorative nursing services, including range of motion (ROM) exercises and splint/brace assistance, to maintain or prevent decline in mobility and contractures for two residents with significant motor impairments. The facility’s undated Restorative Nursing Services policy stated that residents would receive restorative care as needed to achieve and maintain optimal functioning and that residents may initiate a restorative program upon discharge from rehabilitative care. Despite this, surveyors found that residents with documented hemiplegia, hemiparesis, weakness, and contractures were not placed on restorative programs and had no restorative interventions documented in their electronic health records (EHRs). Resident 1 was admitted with hemiplegia and hemiparesis following cerebrovascular disease, a left lower leg fracture, and weakness, and the admission MDS showed intact cognition, moderate assistance needs for bed mobility and transfers, and one-sided upper and lower extremity impairment. During observation, the resident was seen lying in bed with a bent inward left forearm and hand and reported no longer receiving therapy or nursing-assisted exercises. The care plan initiated in January showed no restorative services, and the care plan history and EHR contained no restorative nursing interventions. However, the PT discharge summary from February documented that restorative ROM and transfer programs had been established and trained, including PROM to the left upper and lower extremities and stand-by assist with transfers, and the OT discharge summary recommended a splint/brace to prevent contracture. The OT stated that the splint/brace was not tried due to lack of time before insurance was discontinued, and both the Director of Rehab and the MDS coordinator confirmed there was no restorative referral in the EHR and they were unaware of the recommendations. Resident 2 was readmitted with hemiplegia and hemiparesis following a nontraumatic subarachnoid hemorrhage, a left-hand contracture, and weakness, and the quarterly MDS showed intact cognition, maximum assistance needs for bed mobility, total assistance for transfers, bilateral upper and lower extremity impairment, and no therapy or restorative programs. The resident reported that therapy had been discontinued months earlier and that no restorative staff were assisting with exercises. The care plan and EHR showed no restorative services. OT evaluation documented left upper extremity ROM impairment, a left-hand contracture, and prior use of a left orthotic to manage flexion tone, and the OT discharge summary recommended restorative care and assistance with donning/doffing the orthotic. The PT discharge summary recommended restorative programs if Medicaid Part B services did not continue. The Director of Rehab confirmed therapy was discontinued and that restorative nursing programs were recommended, but both the Director of Rehab and the MDS coordinator stated there were no restorative referrals in the EHR after readmission, and the MDS coordinator confirmed the resident had no restorative programs since readmission.
Failure to Implement Effective Fall and Toileting Interventions for High-Risk Resident
Penalty
Summary
The deficiency involves the facility’s failure to provide adequate supervision, identify fall trends, and implement progressive, resident-centered interventions for a resident with multiple falls and declining strength. The facility’s own Falls and Fall Risk Management policy required staff to identify interventions related to residents’ specific risks and causes to prevent falls and minimize complications. The resident’s Care Area Assessment identified cancer-related risks for pain, falls, and ADL decline, and stated that falls and urinary incontinence would be addressed in the care plan with an objective of improvement and risk minimization. However, the comprehensive care plan did not include a urinary or ADL care plan and contained no toileting plan, despite the resident’s identified risks and prior fall history. Over a series of falls, the resident repeatedly fell while attempting to toilet or move toward the bathroom, yet the facility did not recognize or address this pattern in its investigations or care planning. The resident had multiple unwitnessed falls: next to the bed while getting up to use the restroom, in the bathroom while standing to use the toilet, and near or in the bathroom on several occasions. Incident investigations and post-fall assessments documented environmental factors such as clutter, items on the floor, water on the floor, and issues with footwear, as well as the resident’s increasing weakness, impulsivity, poor safety awareness, and poor insight into limitations. Interventions documented in investigations and risk reviews included encouraging use of the front-wheeled walker, keeping the wheelchair and walker accessible, ensuring proper footwear and non-skid socks, and providing resident education on safe transfers, ambulation, and assistive device use. However, several of these planned interventions, including placement of the wheelchair and frequent rounding/toileting assistance, were not added to or reflected in the care plan as stated. Staff interviews further showed that the resident frequently fell while trying to go to the bathroom and that staff relied on verbal education and reminders to use the call light, even though the resident often did not use it. Staff acknowledged the resident’s impulsivity and tendency to get up independently despite instructions, and one staff member stated that nursing assistants were verbally instructed to offer bathroom assistance, but this intervention was not documented in the care plan. The resident’s bed remained the one furthest from the bathroom throughout the stay, and none of the facility’s investigations identified the trend of bathroom-related falls or addressed toileting options in the care plan. Ultimately, the resident sustained a left ankle fracture after another bathroom-related fall, requiring transfer to the emergency department for evaluation and treatment, and later records documented additional fractures and a decline in condition. The surveyors concluded that the facility’s failures placed residents at risk of repeated falls and injuries.
Failure to Monitor Urinary Retention After Foley Removal Leading to Prolonged Pain
Penalty
Summary
The deficiency involves the facility’s failure to adequately assess and monitor a resident for complications associated with an indwelling urinary catheter and urinary retention, particularly after catheter removal. The resident had a history of acute kidney injury due to urinary retention, which improved after Foley catheter placement in the hospital. Hospital discharge documentation indicated the catheter was placed for acute urinary retention, was deemed permanent, and included instructions that, given the resident’s significant retention and acute renal failure, staff at the skilled nursing facility should not attempt Foley removal. The facility’s catheter care plan directed staff to empty the catheter as needed and record output in milliliters, but review of the last 30 days of documentation showed continence was not rated due to the indwelling catheter and there was no documented urinary output in milliliters on the treatment administration records. The resident had a scheduled urology appointment at which the urinary catheter was discontinued. Upon return from this appointment, nursing documentation initially indicated no new orders, and an alert note later stated the catheter was discontinued and staff were monitoring for retention or pain. However, there was no documented bladder assessment or urinary output following catheter removal. Nursing assistant documentation showed that the resident did not void on the evening shift that same day. Despite the catheter having been removed, the treatment administration record showed staff continued to document provision of catheter care on subsequent shifts when no catheter was in place. Over the next day, the resident experienced vomiting, decreased oral intake, and an altered level of consciousness, with vital signs showing tachycardia and low blood pressure, and staff documented decreased urine output. A bladder scan performed later revealed more than 2000–2500 milliliters of urine in the bladder, and an indwelling catheter was reinserted, initially draining a large volume of urine. The provider note indicated the resident had not eaten since the prior night, was unable to hold down fluids, and staff were unsure whether the resident had urinated in incontinence briefs, with no wet briefs reported since the resident’s return from the hospital after catheter removal. The provider expressed concern that the documented early-morning wet brief might not be accurate given the large bladder volume on scan and stated this should require further investigation. Subsequent notes described the resident moaning and complaining of pain, with limited urine output in the catheter bag and staff flushing and then replacing the catheter due to continued complaints. Interviews with the resident, the roommate, and staff indicated the resident was crying out and moaning in pain, the roommate repeatedly alerted staff that the resident was not urinating and that the catheter was not draining, and staff had to seek assistance to replace the catheter. Facility leadership and clinical staff later acknowledged that typical practice after catheter removal would include contacting the provider, placing the resident on alert, performing post-void residuals with bladder scans, and documenting monitoring, which was not done in this case.
Medication Administration Delays, Documentation Errors, and Use of Expired Insulin
Penalty
Summary
The deficiency involves the facility’s failure to ensure sufficient nursing staff with appropriate competencies and skill sets to administer medications according to professional standards of practice, facility policy, and prescriber orders. The facility’s medication administration policy required medications to be given as prescribed, in accordance with manufacturers’ specifications and good nursing principles, with no expired medications used, and doses administered within 60 minutes of the scheduled time and documented immediately after administration. Multiple residents reported that agency nurses often gave medications late, did not read full instructions, or were slow in bringing medications, and that routinely scheduled medications were not consistently provided without residents having to ask. Surveyors observed several specific medication administration failures. For a resident with diabetes, an LPN drew up and administered Humalog/Lispro insulin from a multi-dose vial that had been opened and dated “02/16” with no year, making it expired per policy, and administered the dose nearly 1 hour and 45 minutes after it was due. Another resident with care plan instructions to receive medications as ordered had multiple scheduled medications (Gabapentin, Oxybutynin, Baclofen, and Tizanidine) that were ordered at specific times throughout the day; the LPN was observed administering all four together and acknowledged that at least one (Tizanidine) was late, while the resident reported that receiving them together at that time was typical and not at their request. For another diabetic resident, an RN checked blood sugar and prepared sliding scale Humalog/Lispro insulin almost two hours after the scheduled time; the resident refused the insulin, stating they had already finished lunch. Additional deficiencies were identified with other residents’ pain and scheduled medications. One resident with a pain care plan and an order for Methocarbamol four times daily at set times approached the cart requesting Methocarbamol and Tylenol; the RN initially stated the Methocarbamol had already been given, but then administered it two hours after it was due when the resident pointed out the scheduled timing. For another resident with a risk for pain care plan and Tramadol ordered three times daily at specific times, an LPN retrieved a PRN pain medication while the electronic record showed no 8:00 AM medications documented; the LPN stated they had given them but had not yet documented. Later, an RN prepared the 2:00 PM Tramadol dose, and review of the narcotic count showed a discrepancy between the number of pills documented and the number remaining in the card. The RN stated they had given the 8:00 AM Tramadol but had not signed it out, then signed out both the 8:00 AM and 2:00 PM doses at that time. Residents interviewed consistently reported that medications were sometimes or frequently late, that agency nurses did not always follow instructions, and that they often had to request medications that were routinely scheduled.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release May 27, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
