Redmond Care And Rehabilitation Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Redmond, Washington.
- Location
- 7900 Willows Road Northeast, Redmond, Washington 98052
- CMS Provider Number
- 505181
- Inspections on file
- 18
- Latest survey
- February 13, 2026
- Citations (last 12 mo.)
- 1
Citation history
Health deficiencies cited at Redmond Care And Rehabilitation Center during CMS and state inspections, most recent first.
Surveyors found that the facility failed to follow physician orders for pain management and post-surgical staple removal for two residents. One resident admitted after orthopedic surgery with knee osteoarthritis had an order for scheduled acetaminophen and a documented history of pain, but there was no documentation that any pain medication was administered on the day of admission, despite available OTC stock and a process to continue hospital discharge orders. Another resident admitted after a head injury had an order to remove four scalp staples on a specific date; the TAR showed the staples as removed, but a later hospital ED record documented staples still in place. The RN reported only partial removal due to the resident’s refusal and could not recall how many staples were removed, and there was no documentation of additional scheduled treatments or follow-up attempts to complete the ordered staple removal.
A cook was observed handling food items, including fresh parsley, with gloved hands after touching multiple surfaces and without using serving utensils, affecting numerous residents. Both the cook and the dietary supervisor confirmed that this practice did not follow established food safety protocols, as required by facility policy.
A resident indicated they had an advance directive and would provide a copy, but the facility failed to obtain and file this document in the medical record. Only a financial DPOA was on file, and there was no documentation of follow-up to secure the healthcare advance directive as required by facility policy.
Surveyors identified that three residents had inaccurate MDS assessments, including incorrect documentation of discharge status, missing diagnosis of dementia, and unreported use of antianxiety medication. Staff confirmed these errors during interviews and record reviews, acknowledging that the assessments did not accurately reflect the residents' conditions or care provided.
A resident with hearing impairment did not receive the required assistance with hearing aids as outlined in their care plan. Despite recommendations from a hearing clinic and clear care plan instructions for staff to assist with placing and charging the hearing aid, the resident was repeatedly observed without the device, and staff were unaware of its status or location.
A resident with documented hearing difficulty did not receive assistance with the use of a prescribed hearing aid, despite physician orders and facility policy. Multiple observations and staff interviews confirmed the device was not placed or charged for an extended period, and staff were unclear about their responsibilities, resulting in the resident not having access to necessary hearing support for communication.
Surveyors found that drugs and supplements were not properly stored or labeled, including an opened bottle of biotin left unsecured at a resident's bedside and an expired medication in a medication cart. Staff interviews confirmed that medications and supplements should be stored in locked areas or locked drawers if self-administered, and that opened creams should be dated. These failures resulted in improper medication management.
A CNA was observed multiple times transporting soiled materials while wearing gloves in the hallway and touching door handles with soiled gloves, contrary to facility policy and infection prevention protocols. Interviews with the Infection Preventionist and DON confirmed that these actions did not align with expected procedures for handling soiled items and increased the risk of infection transmission.
A resident requiring assistance with ADLs did not receive scheduled showers due to a failure to adjust the shower schedule after a change in the resident's dialysis timing. Staff interviews confirmed the oversight and lack of documentation for any shower refusals, leading to a lapse in care.
The facility failed to label and date stored food in the Kitchen Walk-In Freezer, Kitchen Walk-In Refrigerator, and Residents' Refrigerator, as required by their policy. This included unlabeled vegetable mix, carrots, and broccoli, expired tartar sauce, and a resident's leftover lunch without a use-by date. The Nutrition Service Manager acknowledged these lapses, and the Administrator confirmed the expectation for compliance with food safety guidelines.
The facility failed to employ qualified social workers, as required for a facility with over 120 beds. Two social workers, Staff J and Staff P, did not meet the educational and experience requirements. Staff J had an associate degree in communication, while Staff P had a bachelor's degree in leisure and hospitality management, neither of which met the criteria for a social services position. This deficiency placed residents at risk for unmet social services care needs.
A resident with dementia sustained a closed fracture, facial laceration, and head injury, but the LTC facility failed to report the incident to the State Agency as required. Despite the substantial injuries and the resident's inability to recall the event, the facility did not notify the authorities, citing a belief that abuse was ruled out. This oversight was contrary to the facility's policy and state regulations.
A resident with serious mental illness was not referred for a required Level II PASRR evaluation, despite facility policy mandating such referrals. The resident's diagnoses included depression, anxiety, and a psychotic disorder, necessitating further evaluation. The Social Services Director and Administrator confirmed the lack of referral documentation, highlighting a failure to meet the resident's mental health needs.
The facility failed to implement care plans for two residents, leading to unmet care needs. One resident did not receive consistent range of motion exercises as required, while another did not receive necessary follow-up for hearing issues. Staff interviews confirmed lapses in documentation and execution of care plans.
A resident with a hearing deficit did not receive necessary follow-up for audiology services, despite reporting difficulties and having a care plan in place. Facility staff failed to document follow-up actions, and recommendations from a previous consultant visit were not implemented. The resident expressed frustration over the lack of assistance for about a year.
A resident with impaired cognition and high elopement risk was able to wander outside unsupervised due to a lack of a wanderguard trigger alarm on their room's sliding door and an unsecured gate leading to a parking lot. The facility's failure to implement safety measures as per their policy resulted in a significant safety hazard.
A resident with chronic obstructive pulmonary disease did not have their oxygen nasal cannula properly maintained, labeled, or stored, as required by facility protocol. Observations showed the cannula was often left unlabeled and not stored in a bag. Staff interviews revealed inconsistencies in following procedures for changing and discarding the cannula after therapy sessions, posing a risk for unmet care needs and respiratory infections.
A CNA failed to follow hand hygiene protocols during meal tray pass and resident care, increasing infection risk. The CNA did not perform hand hygiene after assisting a resident with their meal and continued to interact with other residents without sanitizing hands. Interviews confirmed the expectation for hand hygiene between resident interactions.
Failure to Follow Physician Orders for Pain Management and Staple Removal
Penalty
Summary
The deficiency involves the facility’s failure to follow physician orders for pain management and treatment as outlined in its own policy on medication and treatment orders. For one resident admitted with orthopedic aftercare and left knee osteoarthritis, the hospital After Visit Summary listed acetaminophen 500 mg, two capsules by mouth every eight hours. On admission, the facility’s Licensed Nurse Pain Management Review documented that the resident had endorsed pain or discomfort in the left knee in the past five days and recommended initiating a pain plan of care. The facility’s Order Summary Report showed a physician order for acetaminophen 1000 mg by mouth three times a day for pain starting the day after admission, and the MAR reflected scheduled doses beginning that day at 8:00 a.m., 2:00 p.m., and 8:00 p.m. However, there was no documentation that the resident received any pain medication on the day of admission, despite the availability of OTC medications and the expectation that hospital discharge orders would be continued without delay. Nursing progress notes for this resident documented an initial provider visit the day after admission, stating the resident was seen as a new admit and prior to leaving AMA, and that the resident reported being very unhappy with care since admission, including having to wait several hours for pain medication and ice for her knee. The resident, who had documented allergies to codeine and tramadol, stated in interview that she arrived mid-afternoon on the admission date, was on acetaminophen every eight hours due to opioid allergies, and that she had no pain medication available upon arrival despite having a fresh injury. Staff interviews confirmed that staff relied on the MAR for medication administration, that OTC medications were kept on hand so there should not be a lag in providing them, and that hospital discharge orders were to be continued at the facility. A joint record review with the Resident Care Manager showed no documentation of pain medication administration upon admission, and the LPN acknowledged that the acetaminophen should have been given. For a second resident admitted with a diagnosis including head injury due to a fall, the hospital discharge summary specified that four scalp staples required removal on a specified date. The facility’s Order Summary Report contained a physician order to remove four scalp staples starting on that date, and the December Treatment Administration Record showed the staples marked as removed on that date, with a registered nurse documented as having performed the removal. However, a later hospital Emergency Department record documented a right scalp wound with dried blood and staples in place. In interview, the RN stated she remembered attempting staple removal, that the resident refused and they had to reschedule, and that she believed she removed a couple of staples before the resident told her to stop, but she could not recall the total number removed. Joint record review showed no additional scheduled scalp staple removal treatments or nursing notes documenting further attempts after the initial date, despite the discharge summary specifying four staples and the expectation that all staples would be removed. The DON stated they expected staff to assess for pain, assess the site, and ensure everything was removed, but the records contained no further documentation of staple removal after the initial entry.
Improper Food Handling During Meal Service
Penalty
Summary
Staff G, a cook, was observed handling food items in a manner inconsistent with professional food safety standards. While wearing gloves, Staff G touched various surfaces including the meal cart, meal tickets, and preparation table, and then used the same gloves to place fresh parsley on the plates of multiple residents. Later, after washing hands and donning new gloves, Staff G again touched several surfaces, including a bag of bread, before continuing to place fresh parsley on additional residents' plates without using a serving utensil. These actions were directly observed during a meal service and involved a total of 32 residents. Interviews with Staff G and the Dietary Supervisor confirmed that the expected procedure was to use serving utensils for food items and not to handle garnishes like fresh parsley with gloved hands after touching other surfaces. Both staff members acknowledged that the proper protocol was not followed during the observed meal service. The facility's policy required adherence to professional food safety standards, including the use of proper sanitation and food handling practices to prevent foodborne illness.
Failure to Obtain and Document Resident's Advance Directive
Penalty
Summary
The facility failed to obtain and maintain a copy of an advance directive for one resident who indicated at admission that they had such a document and would provide it. Upon review, the resident's electronic health record only contained a financial Durable Power of Attorney (DPOA), not a healthcare advance directive. Multiple staff interviews confirmed that the DPOA on file was for financial matters only, and there was no documentation or progress notes indicating that follow-up was conducted to obtain the resident's advance directive for healthcare prior to a recent inquiry. The facility's policy requires staff to inquire about advance directives at or near admission and to obtain and file a copy in the resident's health record. Despite the resident's indication that they had an advance directive, there was no evidence in the record that the facility followed up to secure the document or documented any attempts to do so until prompted by the survey process. Staff acknowledged that documentation of follow-up was lacking and that the required healthcare advance directive was not present in the resident's file.
Inaccurate MDS Assessments for Discharge Status, Diagnosis, and Medication Use
Penalty
Summary
The facility failed to ensure the accuracy of Minimum Data Set (MDS) assessments for three residents, resulting in incorrect documentation of discharge status, active diagnoses, and medication use. For one resident, the discharge MDS inaccurately indicated a discharge to the hospital, despite nursing progress notes and staff interviews confirming the resident was discharged home. Staff acknowledged the error and confirmed that the MDS should have reflected a discharge to home/community. Another resident's admission MDS did not document a diagnosis of dementia, even though the resident's face sheet and physician progress notes during the look-back period confirmed the diagnosis and corresponding medication use. Staff confirmed that dementia should have been marked on the MDS. Additionally, a third resident's admission MDS failed to indicate the use of antianxiety medication during the look-back period, despite the Medication Administration Record (MAR) showing administration of such medication on multiple dates. Staff interviews and joint record reviews confirmed that the resident received antianxiety medication and that this should have been documented in the MDS. These inaccuracies were identified through interviews, record reviews, and joint reviews with staff, who acknowledged the discrepancies and the expectation for MDS assessments to be completed accurately according to the RAI MDS Manual.
Failure to Implement Communication Care Plan for Resident with Hearing Impairment
Penalty
Summary
The facility failed to implement the care plan for a resident with hearing impairment, as evidenced by multiple observations and interviews. The resident had been recommended hearing aids by a hearing clinic, and the care plan specified that staff were to assist with placing and removing the hearing aid, which was to be kept charged at the bedside. Despite these documented interventions, the resident was repeatedly observed without hearing aids in place over several days. The resident's representative confirmed that the hearing aids had not been used for some time and were not charged, and staff interviews revealed a lack of awareness and adherence to the care plan instructions. Record reviews and staff interviews further confirmed that the care plan was not being followed, with both nursing and CNA staff indicating either a lack of knowledge about the hearing aid's location or stating that the resident had not been using them. The care plan was only updated after these observations to reflect that the resident's representative would be responsible for charging the hearing aid and that either the representative or staff could place it. At the time of the deficiency, the care plan interventions for communication were not implemented, placing the resident at risk for unmet care needs.
Failure to Ensure Use of Hearing Aid for Communication
Penalty
Summary
The facility failed to provide necessary services to maintain a resident's ability to communicate by not ensuring the use of prescribed hearing aids. The resident had a documented history of hearing difficulty, with clinical recommendations and physician orders specifying the use of a left hearing aid to be placed in the morning and removed at night. Despite these orders, multiple observations over several days showed the resident was not wearing the hearing aid, and staff interviews confirmed that the device had not been placed or charged for an extended period. Staff members, including nurses and CNAs, were unclear about the responsibility for ensuring the hearing aid was in place, and there was a lack of verification that the device was being used as ordered. The resident's representative also reported that the hearing aid had not been used or charged for weeks, and staff interviews revealed a lack of consistent follow-through with the physician's orders. The facility's policy required that residents' abilities in activities of daily living, including communication, should not diminish unless unavoidable due to clinical condition. However, the failure to ensure the resident's hearing aid was used as ordered resulted in the resident not having access to necessary hearing assistance, directly impacting their ability to communicate.
Improper Storage and Labeling of Medications and Supplements
Penalty
Summary
Surveyors observed that drugs and biologicals, including supplements, were not consistently stored in accordance with accepted professional standards. An opened bottle of biotin, a vitamin supplement, was repeatedly found on a resident's nightstand during multiple observations. The resident reported self-administering the supplement daily. Staff interviews confirmed that supplements are considered medications and should be stored in a locked medication room or cart, or, if self-administered, in a locked drawer at the bedside. However, the supplement remained unsecured on the nightstand, and staff expressed uncertainty about the proper storage requirements in this situation. Additional deficiencies were identified in the storage and labeling of medications on treatment and medication carts. An opened urea cream on a treatment cart lacked an open date, despite labeling indicating it should be used within 24 months of opening. Staff confirmed that an open date was expected. Furthermore, an expired medication (Gabapentin) was found in a medication cart, and staff acknowledged that expired medications should not be stored and should have been discarded. These findings demonstrate failures in proper medication storage, labeling, and removal of expired drugs.
Failure to Follow Hand Hygiene and Glove Use Protocols During Soiled Material Transport
Penalty
Summary
Staff J, a Certified Nursing Assistant, failed to follow proper hand hygiene and glove use practices while handling soiled materials. On multiple occasions, Staff J was observed carrying soiled material in a plastic bag through the hallway to the soiled utility room while wearing gloves. During these instances, Staff J touched the soiled utility room door handle with soiled gloves, disposed of the gloves in a hallway garbage container, and then performed hand hygiene. Staff J stated that their process was to wear gloves while carrying soiled materials in the hallway and acknowledged touching the door handle with soiled gloves. Interviews with the facility's Infection Preventionist and Director of Nursing confirmed that staff are expected to bag soiled items, remove gloves, perform hand hygiene, and then transport the bagged items to the soiled utility room without wearing gloves in the hallway. Both staff members stated that wearing gloves in the hallway and touching door handles with soiled gloves is not permitted and poses a risk for spreading infection. The facility's policy requires effective methods for handling, storing, and transporting linens and waste to prevent the spread of infection, which was not followed in these observed instances.
Failure to Provide Scheduled Showers for a Resident
Penalty
Summary
The facility failed to ensure that showers or bathing were consistently provided for a resident who required partial/moderate assistance with activities of daily living (ADLs). According to the facility's policy, nursing assistants are expected to provide assistance with ADLs based on the resident's individualized plan of care. The resident was scheduled for showers on Thursday evenings, but records showed that the resident did not receive showers on two scheduled dates, and there was no documentation indicating that the resident refused showers. The last recorded shower was almost a month prior to the surveyor's observation. Interviews with staff revealed that the resident's shower schedule was not adjusted when the resident's dialysis schedule changed to evenings, which contributed to the missed showers. Staff members confirmed that the resident did not receive showers as scheduled and acknowledged the lack of documentation for any shower refusals. This oversight placed the resident at risk for poor hygiene, decreased self-esteem, and a diminished quality of life.
Failure to Label and Date Stored Food
Penalty
Summary
The facility failed to adhere to professional standards for food safety by not labeling and dating stored food items in the Kitchen Walk-In Freezer, Kitchen Walk-In Refrigerator, and Residents' Refrigerator. During an observation and interview, it was found that 10 bags of vegetable mix, three bags of carrots, and 10 bags of broccoli in the Kitchen Walk-In Freezer were not labeled with delivery and use-by dates, contrary to the facility's policy. Additionally, in the Kitchen Walk-In Refrigerator, 20 packets of tartar sauce were found with a use-by date that had already passed, and a package of roast beef lacked a use-by date. In the Residents' Refrigerator, a resident's leftover lunch was not labeled with a use-by date, although it was dated with the day it was stored. Staff H, the Nutrition Service Manager, acknowledged these lapses, stating that the facility's policy required labeling with delivery and use-by dates upon arrival. The tartar sauce should have been discarded after its use-by date, and the leftover food should have been labeled with a use-by date. The Administrator, Staff A, confirmed that the expectation was for kitchen staff to maintain food safety according to State and Federal guidelines. These oversights in food labeling and dating placed residents at risk for foodborne illnesses.
Facility Lacks Qualified Social Workers
Penalty
Summary
The facility failed to employ a qualified social worker who met the educational and experience requirements for a facility with more than 120 beds. The facility's job description for a Social Services Manager required a minimum of a bachelor's degree in social work or a related human services field and at least one year of experience in a healthcare setting. However, the facility employed two social workers who did not meet these qualifications. Staff J, hired as the Social Services Director, only held an associate degree in communication, which did not meet the bachelor's degree requirement. Staff P, also a Social Services Director, had a bachelor's degree in leisure and hospitality management, which was not in a human services field, and lacked the required one year of experience as a social worker in a healthcare setting. The facility's failure to employ qualified social workers placed residents at risk for unmet social services care needs and a diminished quality of life. The facility was licensed to provide care for 139 residents, necessitating the employment of a qualified full-time social worker. Interviews with Staff J and Staff P confirmed their lack of qualifications, and the facility administrator acknowledged that neither staff member met the educational and experience requirements outlined in the job description. This deficiency was identified during a review of the facility's staff list and interviews with the involved staff and the administrator.
Failure to Report Abuse Allegation to State Agency
Penalty
Summary
The facility failed to report an allegation of abuse to the State Agency for a resident who was reviewed for abuse allegations. This failure involved Resident 237, who was admitted with a diagnosis that included dementia. On a specific date, Resident 237 was found lying on their back with a head injury and complained of shoulder and back pain. The resident was sent to the emergency room and returned with a diagnosis of a closed fracture of the left upper arm, facial laceration, and head injury. Despite the substantial injuries and the resident's inability to recall the incident, the facility did not notify the State Agency as required by their policy and state regulations. The facility's policy, as outlined in their Abuse Prevention & Investigation document, mandates that all suspected, alleged, or actual cases of resident abuse, including injuries of unknown origin, be thoroughly investigated and reported according to State and Federal regulations. However, the facility's incident log indicated that the hotline was not notified about Resident 237's incident. Staff interviews revealed a misunderstanding of the reporting requirements, with the Assistant Director of Nursing stating that they did not report the incident because they believed they had ruled out abuse. This oversight placed the resident at risk for potential unidentified abuse and lack of protection.
Failure to Complete Level II PASRR Evaluation
Penalty
Summary
The facility failed to ensure that a Level II PASRR evaluation was completed for a resident with a positive Level I PASRR indicating the presence of serious mental illness (SMI). The resident, who was readmitted to the facility, had diagnoses of depression, anxiety, and a psychotic disorder, which necessitated a Level II PASRR evaluation. However, there was no documentation in the resident's electronic health record to indicate that a referral for the Level II PASRR evaluation had been made, as confirmed by the Social Services Director during an interview and joint record review. The facility's policy, revised in September 2018, mandates that a PASRR be completed for every resident upon admission and that appropriate referrals be made for specialized services for residents with mental illness. Despite this policy, the Social Services Director acknowledged the absence of evidence for a referral, and the Administrator confirmed that residents requiring a Level II PASRR evaluation should be referred appropriately, with documentation of the referral. This oversight placed the resident at risk for unmet care and mental health needs, as well as a decreased quality of life.
Failure to Implement Care Plans for Residents
Penalty
Summary
The facility failed to implement care plans for two residents, leading to unmet care needs and a diminished quality of life. Resident 5, who was admitted with range of motion impairments, had a care plan that required active range of motion exercises to be performed three times a week. However, documentation showed that these exercises were not consistently performed, with significant gaps in the schedule. Staff interviews revealed that the exercises were not documented properly, and the care plan was only followed about 50% of the time, which did not meet the facility's expectations. Resident 42, who had a communication care plan due to a hearing deficit, did not receive the necessary follow-up for audiology referrals and hearing aid management. Despite the resident's repeated requests for assistance with hearing checkups and hearing aids, there was no documentation of the care plan being implemented. Staff interviews confirmed that there was a lack of follow-up on the resident's hearing needs, and the care plan was not executed as required.
Failure to Follow Up on Hearing Services for a Resident
Penalty
Summary
The facility failed to follow up on hearing services for a resident, identified as Resident 42, who was at risk for communication problems due to a hearing deficit. The resident's communication care plan included a referral to audiology for a hearing consult and follow-up with hearing aids. Despite the resident reporting difficulty hearing on multiple occasions, there was no documentation of follow-up actions by the facility staff from April 23, 2024, to June 7, 2024. The resident expressed that they were supposed to have an annual hearing checkup and had been requesting assistance for about a year without receiving help. Interviews with facility staff revealed that the Nurse Practitioner was notified of the resident's hearing difficulty but did not complete an assessment or make an audiology referral until June 7, 2024. Additionally, recommendations from a previous speech and hearing consultant visit in March 2023 were not implemented. The Social Services Director acknowledged the lack of follow-up on the resident's audiology appointment, and the Assistant Director of Nursing confirmed that the facility's process was to notify the Nurse Practitioner and ensure referrals were made when residents reported hearing issues.
Failure to Prevent Elopement Risk for Resident with Impaired Cognition
Penalty
Summary
The facility failed to maintain an environment free of accident hazards for a resident identified as being at high risk for elopement. The resident, who had impaired cognition and was ambulatory with an assistive device, was observed wandering outside the facility without adequate supervision. The facility's policy on elopement and unsafe wandering was not effectively implemented, as evidenced by the lack of a wanderguard trigger alarm on the sliding door of the resident's room, which allowed the resident to exit the building without staff being alerted. Observations revealed that the sliding door in the resident's room was left wide open, with only a screen door in place, and there was no wanderguard trigger alarm installed. Additionally, the gate leading from the resident's room to a parking lot and busy road was found unsecured and open, further increasing the risk of elopement and potential injury. Staff interviews confirmed that the absence of the alarm system and the open gate posed significant safety risks to the resident, who was known to follow visitors to exit doors due to impaired safety awareness and impulsive behavior. The facility's failure to assess and monitor the sliding door as an exit, along with the unsecured gate, directly contributed to the deficiency. Despite the resident's high risk for elopement, as documented in their care plan and evaluations, the necessary safety measures were not in place to prevent unsupervised wandering. Staff acknowledged the importance of the wanderguard system in alerting them to potential elopement risks, yet the system was not fully operational, compromising the resident's safety.
Improper Storage and Labeling of Oxygen Nasal Cannula
Penalty
Summary
The facility failed to maintain, label, date, and properly store the oxygen nasal cannula for Resident 47, who was diagnosed with chronic obstructive pulmonary disease and required continuous oxygen therapy. Observations over several days revealed that the nasal cannula was repeatedly found unlabeled and not stored in a bag when not in use, despite the facility's protocol to change, label, and store it weekly. Staff interviews confirmed that the nasal cannula should have been labeled and stored properly, but this was not consistently done. Additionally, there was a lack of coordination between the therapy and nursing staff regarding the use and disposal of the nasal cannula. The physical therapist and the Director of Rehabilitation stated that a new nasal cannula should be used and discarded after each therapy session, but this practice was not followed. The Assistant Director of Nursing also confirmed that the nasal cannula should have been discarded after therapy sessions. These lapses in protocol placed Resident 47 at risk for unmet care needs and potential respiratory infections.
Failure in Hand Hygiene Practices
Penalty
Summary
The facility failed to ensure proper hand hygiene practices were followed by a Certified Nursing Assistant (CNA), identified as Staff I, during meal tray pass and resident care. Observations revealed that Staff I did not perform hand hygiene after assisting Resident 1 with their meal, which involved touching utensils and food. Subsequently, Staff I left Resident 1's room, touched various surfaces, and returned with a new fork without performing hand hygiene. This pattern continued as Staff I assisted Resident 5, touching items on their bedside table, and then proceeded to Resident 46's room, again without performing hand hygiene. Interviews with Staff I, the Infection Preventionist (Staff S), and the Assistant Director of Nursing (Staff K) confirmed the expectation for staff to perform hand hygiene between resident interactions and after touching resident items. Staff I acknowledged the lapse in hand hygiene practices, and both Staff S and Staff K reiterated the facility's policy requiring hand hygiene before and after resident contact and when moving between resident rooms. This failure to adhere to hand hygiene protocols increased the risk of infection transmission among residents, staff, and visitors.
Latest citations in Washington
A resident with cerebral palsy and a court-appointed guardian experienced multiple episodes of nausea, vomiting, loose stools, abdominal discomfort, fatigue, and later refusal of meals and medications, leading to changes in the care plan including close monitoring, lab testing, and IV fluid administration. Despite a facility policy recognizing court-appointed guardians as resident representatives with decision-making authority, staff did not document any notification to the guardian during these changes in condition or treatment decisions. The guardian reported not being contacted when the resident stopped eating or developed stomach issues and felt the facility did not respect the guardianship, while the DON acknowledged there were multiple missed opportunities to notify the guardian of the resident’s change from baseline.
A resident with depression, anxiety, moderate cognitive impairment, and urinary incontinence, care-planned for q2h checks and assistance with toileting, was found by a visitor to be soaking wet, unusually agitated, and reporting they had been told to wait to be changed and referred to with a derogatory remark. The visitor filed a written grievance alleging abuse/neglect related to delayed incontinence care and removal of the resident’s tablet as a consequence. Although an incident report noted that the matter was reported to the state and that the resident was not soaking wet, a CNA who actually changed the resident later reported the resident’s brief, pants, wheelchair, and socks were soaked and that the resident was acting timid and repeatedly saying they had to sit for five minutes, but this CNA was never interviewed. The DON acknowledged not investigating the resident’s behavior or interviewing this CNA, and the grievance official acknowledged the facility did not fully investigate or communicate findings and resolution to the complainant, resulting in a failure to follow the facility’s grievance policy.
A resident with dementia, respiratory failure, and heart failure developed new shortness of breath with an O2 sat of 90%, and a physician ordered transfer to the ED for tx and eval. An RN completed an SBAR, notified the MD and family, and reported to the oncoming nurse that the resident needed ED transfer and that paramedics should be contacted, then left the facility. Instead of calling 911 for this emergent respiratory distress, staff arranged non-emergent transport through a contracted ambulance service, resulting in the resident remaining at the facility for several hours without pickup until the dispatcher later instructed staff to call 911. The DON stated that 911 is expected to be used for emergent conditions and the contracted service only for non-emergent transport.
A resident with anoxic brain injury, dysarthria, and documented lack of decisional capacity alleged physical abuse and expressed fear of their identified representative, yet social services only reported the allegation to the state and did not complete an incident report, revise the care plan, or implement protective interventions. The same representative continued to be treated as the resident’s decision-maker and visited frequently, with staff noting suspicious odors of foreign substances and concerns about possible illicit substance use. Psychiatry later documented concern that the representative was providing illicit substances, and the resident was subsequently hospitalized for altered mental status and overdose, after which the representative was banned. Key staff, including the DON, unit manager, and administrator/abuse coordinator, were unaware of the initial abuse allegation, and social services did not timely explore or clarify legal decision-making authority or alternative representation for the resident.
A resident with severe cognitive impairment, osteoarthritis, and spinal spondylosis, care planned for 2-person Hoyer transfers, was being moved by two CNAs using a mechanical lift when one corner loop of the sling became disengaged, causing the resident to fall about four feet, strike the floor and the lift, and sustain head abrasion, multiple rib fractures, and lumbar vertebral fractures. Facility policy required staff to verify secure sling attachment, examine hooks, clips, fasteners, and strap stability, and ensure the sling bar was sound before lifting, but during this transfer the sling loop detached despite staff believing it was properly fastened and hearing it click into place; post-incident assessment showed the loop had come loose, the sling appeared in good condition, and a CNA later reported thinking one of the round metal disks on the lift might have been slightly loose, while maintenance logs documented no prior concerns with the lifts or slings.
The facility failed to revise and individualize care plans to reflect current needs and preferences for multiple residents, including one cognitively intact resident with hemiplegia, hemiparesis, and mononeuropathy who had bilateral shoulder surgery and could not tolerate BP measurements on the upper arms but preferred forearm readings. Despite repeatedly informing staff, this preference was not documented in the care plan or Kardex, and direct care staff and the RN/UM were unaware of it. Another cognitively intact resident with hemiplegia, contractures, and weakness reported they were supposed to get out of bed for two hours daily, but some NACs did not know this, even though the MAR/TAR contained an order to document times up and back to bed. The surveyors concluded that care plans were not accurately revised for several residents, placing them at risk for unidentified and unmet care needs and diminished quality of life.
Surveyors found that two residents with hemiplegia, hemiparesis, weakness, and contractures did not receive restorative nursing services, including ROM exercises and splint/brace or orthotic assistance, after therapy discharge. Although PT and OT discharge summaries documented established restorative ROM and transfer programs, recommended PROM to affected extremities, and recommended splint/brace use and assistance with orthotic wear, these recommendations were not entered as restorative referrals in the EHR. As a result, the residents’ care plans and records showed no restorative programs, and both residents reported that therapy and restorative exercises had stopped, while the DON, rehab director, and MDS coordinator confirmed they were unaware of and had not implemented the recommended restorative services.
A resident with cancer, cognitive impairment, and declining strength experienced multiple unwitnessed falls, most occurring while attempting to toilet or move toward the bathroom, culminating in a fractured ankle requiring ED treatment. Although assessments identified fall and incontinence risks and the facility’s policy required individualized interventions, the comprehensive care plan lacked a toileting plan and did not include several interventions that were discussed in incident investigations, such as consistent wheelchair placement and frequent rounding for bathroom assistance. Staff reported relying on verbal reminders and education to use the call light, despite acknowledging the resident’s impulsivity and failure to call for help, and the resident’s bed remained furthest from the bathroom while repeated bathroom-related falls occurred without the trend being recognized or addressed in the care plan.
A resident with a history of acute urinary retention and acute kidney injury had a Foley catheter deemed permanent by the hospital, with instructions that it not be removed in the SNF. At a later urology visit, the catheter was removed, and the resident returned with no new orders documented. Facility staff did not document bladder assessments, post-void residuals, or urine output, and CNA documentation showed the resident did not void that evening. Over the next day, the resident had vomiting, poor intake, altered level of consciousness, tachycardia, hypotension, and no documented wet briefs. A bladder scan eventually showed more than 2000–2500 mL of retained urine, and a new catheter drained a large volume. The resident and a roommate reported moaning, crying out in pain, and repeatedly alerting staff that the resident was not urinating and that the catheter was not draining, while nurses documented catheter care when no catheter was in place and later had to flush and replace the catheter due to continued complaints.
Surveyors found that nurses and nurse aides did not consistently administer medications according to professional standards and facility policy. Multiple residents reported that agency nurses were slow with medications, did not fully follow instructions, and often gave routine meds late. Observations showed an LPN administering expired Humalog/Lispro insulin well past the scheduled time, an LPN giving several scheduled meds (including Tizanidine) late and all at once, and an RN attempting to give sliding-scale insulin nearly two hours late, which a resident refused after already eating. Another resident received Methocarbamol two hours late after questioning the RN, and a resident on scheduled Tramadol had doses given without timely documentation, with a discrepancy between the narcotic count and pills remaining. These events demonstrated failures in timely administration, use of non-expired medications, and immediate, accurate MAR and narcotic documentation.
Failure to Notify Court-Appointed Guardian of Resident’s Clinical Changes
Penalty
Summary
The deficiency involves the facility’s failure to notify a resident’s court-appointed guardian of significant clinical changes and care decisions, contrary to its own policy and state requirements. The facility’s policy on Resident Representatives, revised 02/2021, states that a resident representative includes a court-appointed guardian or conservator and that the facility treats the representative’s decisions as those of the resident to the extent delegated or required by the court. Resident 1, admitted with cerebral palsy, had a Superior Court guardianship letter dated 02/07/2025 indicating a guardian of person and conservator of the estate with full authority, identifying Collateral Contact 1 (CC1) as the guardian. Despite this, multiple clinical events and changes in condition were documented without any corresponding documentation that CC1 was notified. Progress notes and provider notes show that Resident 1 experienced an episode of nausea and vomiting, frequent loose stools, abdominal discomfort, bloating, worsening fatigue, generalized weakness, and later refusal of meals and medications over at least a 24-hour period, with observations that the resident appeared frailer, more fatigued, and had no energy or interest to talk. The provider developed care plans including close monitoring for deterioration, sending stool to the lab, and later initiating IV fluids for rehydration, with a plan to call family/POA for discussion. However, there was no documentation that the guardian was notified at any of these points, including when IV fluids were started. CC1 reported that they were not contacted when the resident stopped eating or developed stomach issues, and expressed that the facility did not respect their guardianship and that involvement in care planning took too long. The DON confirmed on record review that there were many opportunities to notify the guardian when the resident’s condition changed from baseline and that there was no evidence staff did so.
Failure to Thoroughly Investigate and Resolve Resident Grievance Regarding Incontinence Care and Staff Conduct
Penalty
Summary
The deficiency involves the facility’s failure to thoroughly investigate and resolve a grievance alleging neglect and disrespect toward a resident, as required by its grievance policy. The resident had depression, anxiety, moderate cognitive impairment, occasional urinary incontinence, and required moderate assistance with toileting, with a care plan directing staff to check the resident every two hours, ask about toileting needs, and ensure they were clean and dry. A collateral contact reported arriving to visit the resident and finding them soaking wet and agitated, with behavior that was not typical for the resident. The collateral contact documented in a written grievance that the resident’s tablet was off, the resident appeared upset, and the resident reported being told they had to wait five minutes to be changed and that staff would change their “nasty *ss” in five minutes, leading the collateral contact to believe the resident had been given a consequence of no tablet and sitting in wet clothes, which they characterized as abuse/neglect and requested immediate removal of the responsible staff and a report filed. The facility documented receipt of the grievance and created an incident report indicating the matter was reported to the state agency, and that the unit manager interviewed the collateral contact and the resident, with the resident described as confused and denying being soaking wet. The incident report stated that a different nursing assistant was assigned to assist with the brief change and that the unit manager believed the resident was not soaking wet, and that the resident and collateral contact were satisfied when they left the room. However, a CNA who actually changed the resident reported that the resident’s brief was soaked through their pants onto the wheelchair and their socks were soaked, and that the resident was timid, repeatedly saying they had to sit for five minutes, and not acting like themselves; this CNA stated they were never interviewed or asked about the grievance or the resident’s condition. The DON acknowledged not interviewing this CNA or investigating the resident’s behavior and why they were upset, and the unit manager did not recall whether the collateral contact was present during follow-up and did not believe they followed up with the collateral contact regarding the grievance. The administrator, identified as the Grievance Official, stated the facility should have thoroughly investigated the grievance and discussed findings and resolution with the collateral contact, indicating the grievance process was not fully carried out in accordance with policy and WAC 388-97-0460.
Failure to Obtain Timely Emergency Transport for Resident in Respiratory Distress
Penalty
Summary
The deficiency involves the facility’s failure to obtain timely emergency medical services for a resident experiencing new-onset respiratory distress. The resident had dementia, respiratory failure, and heart failure, with severe cognitive impairment and a need for substantial assistance with activities of daily living. On the day the resident was sent to the hospital, a collateral contact observed the resident having difficulty breathing, appearing unable to get enough air, and looking as if they were sleeping or unconscious, and reported this to staff with a request to contact the doctor. An SBAR Communication Form documented that the resident was experiencing shortness of breath that had not occurred before, with an oxygen saturation of 90%. The physician was notified and ordered the resident sent to the emergency department for treatment and evaluation, and the collateral contact was notified shortly thereafter. Progress notes later documented that, despite the order for emergency department transfer, the resident was still awaiting pickup by Olympic transportation several hours later, with no estimated time of arrival. At approximately 3:30 AM, the dispatcher informed the facility that they could not provide transportation and instructed that 911 be called; only then was 911 contacted and the resident transported to the hospital via ambulance for respiratory distress. The RN caring for the resident stated they completed the SBAR, notified the physician and family, and at the end of their shift reported to the oncoming nurse that the resident needed to be sent to the emergency department for respiratory distress and that paramedics should be contacted, then left assuming 911 would be called. The DON stated that staff are expected to contact 911 for emergent conditions such as shortness of breath or respiratory distress, and that Olympic Ambulance is used only for non-emergent transport.
Failure to Provide Social Service Advocacy After Abuse Allegation and Questionable Representative
Penalty
Summary
The deficiency involves the facility’s failure to provide appropriate medically-related social services and advocacy for a resident following an allegation of abuse and concerns about the resident’s representative. The resident had an anoxic brain injury, dysarthria, moderate cognitive impairment, and was dependent on staff for activities of daily living. A hospital palliative care note documented that the resident lacked decisional capacity, had no DPOA, that the legal next of kin (CC4) did not want to be part of care decisions, and that care decisions were being deferred to another contact (CC5). CC5 accompanied the resident on admission, signed admission forms, and was listed as the primary contact in the medical record profile. On a date in February, during communication therapy, the resident reported that CC5 had done something to them, pounded their hands on their chest, recalled being hit in the back of the head by an unknown person, and stated they were sometimes afraid of CC5. A social services staff member reported this allegation to the state agency but did not complete a facility incident report, did not initiate care plan changes or interventions, and took no further action. CC5 continued to be treated as the resident’s representative, and progress notes documented CC5 at the bedside on multiple dates, including an entry noting the room smelled like foreign substances and that CC5 was seen waking the resident and then asking the nurse to administer pain medications. A psychiatry note later documented concern that CC5 was providing the resident with illicit substances and stated it would be prudent for the resident to identify a POA. Subsequently, the resident was found unresponsive, transported to the hospital, and later readmitted after altered mental status and overdose, with a provider note stating that CC5 posed a significant danger to the resident and was banned from visiting. After readmission, staff attempted to contact CC4 for consent to treat but initially reached someone who stated they were not CC4. The social service director acknowledged that, beyond reporting the initial allegation, no additional interventions were implemented, that CC5 continued to be used as the resident’s representative after the allegation, and that they had not explored legal authority for decision making following the abuse allegation or concerns about substances. The social service assistant reported they did not speak with the resident about the hospital stay or CC5 and did not complete an incident report or care plan changes after the allegation. The unit manager and DON were unaware of the initial abuse allegation, and the administrator, who served as abuse coordinator, also stated they were unaware of the allegation and that an investigation should have been initiated and a representative for the resident investigated at a minimum.
Injury from Mechanical Lift Sling Detachment During Transfer
Penalty
Summary
The facility failed to ensure a safe mechanical lift transfer when a resident was being moved with a Hoyer lift and sling, resulting in a fall and injury. Facility policy for using a mechanical lifting machine required staff to securely attach sling straps to the sling bar according to manufacturer’s instructions, double-check the security of the sling attachment before lifting, examine all hooks, clips, or fasteners, check strap stability, and ensure the sling bar was securely attached and sound. Despite these requirements, during a transfer for dinner, two CNAs placed the sling under the resident, attached the loops at each corner of the sling to the lift, and raised the resident off the bed into the space between the bed and wheelchair when the bottom left corner of the sling became disengaged from the lift. The resident involved had multiple diagnoses including osteoarthritis, cervical and thoracic spondylosis, and Alzheimer’s disease, with the Minimum Data Set documenting severely impaired cognitive skills for daily decision-making. The resident’s care plan required the assistance of two staff during Hoyer lift transfers. During the transfer, the resident fell approximately four feet, landing on her buttocks, bouncing, and then falling backward and striking her head on the leg of the Hoyer lift. Hospital records documented that the resident sustained an abrasion to the back of the head, fractures of the 6th, 7th, 8th, and 10th ribs, and fractures of the 1st and 2nd lumbar vertebra. Staff interviews and observations showed that staff believed the sling loops had been securely fastened and reported hearing the loops click into place before lifting. One CNA stated that they had barely lifted the resident off the bed when the bottom left loop became disconnected and the resident fell. Another CNA reported being shocked and unable to figure out what had happened. A nurse who assessed the resident and then examined the equipment after the fall noted that one of the loops of the sling had become disengaged but stated the sling appeared to be in good condition. During a later demonstration, a CNA indicated she thought one of the round metal disks on the lift might have been a little loose. Maintenance logs for Hoyer slings and lifts for the preceding months documented no concerns with the slings or lifts, and the DON acknowledged expecting a citation due to the resident’s injury from the fall.
Failure to Revise Care Plans to Reflect Resident Needs and Preferences
Penalty
Summary
The deficiency involves the facility’s failure to revise and individualize comprehensive care plans to reflect residents’ current needs and preferences, as required by its own care planning policy. For one resident with hemiplegia, hemiparesis following cerebrovascular disease, and mononeuropathy of the upper limb, the admission MDS showed intact cognition and upper extremity impairment. This resident reported having bilateral shoulder surgery and an inability to tolerate blood pressure measurements on the upper arms due to pain, and stated a preference for BP measurements on the forearms. The resident reported having informed multiple nursing staff of this preference, but staff continued to place the cuff on the upper arms. Review of the resident’s care plan and Kardex showed no interventions or instructions regarding forearm BP cuff placement. A NAC confirmed they were unaware of the preference until the resident told them directly and that this instruction was not documented in the Kardex. The RN/Unit Manager, who stated they were responsible for revising and reviewing care plans when there were changes, also confirmed they were not aware of the resident’s preference and that it should have been updated in the care plan. Another resident, readmitted with hemiplegia and hemiparesis following a nontraumatic subarachnoid hemorrhage, contracture of the left hand, and weakness, was cognitively intact and required maximum assistance for bed mobility per a quarterly MDS. This resident stated they were supposed to get out of bed for two hours every day, but some NACs were not aware of this care requirement. Review of the resident’s March 2026 MAR/TAR showed an order to document the time the resident got up and the time they returned to bed daily. The report states that, overall, the facility failed to revise care plans accurately to reflect residents’ needs for three of four residents reviewed for care plan revision, placing them at risk for unidentified and unmet care needs and a diminished quality of life.
Failure to Implement Restorative Nursing and Splint/Brace Programs After Therapy Discharge
Penalty
Summary
The deficiency involves the facility’s failure to provide restorative nursing services, including range of motion (ROM) exercises and splint/brace assistance, to maintain or prevent decline in mobility and contractures for two residents with significant motor impairments. The facility’s undated Restorative Nursing Services policy stated that residents would receive restorative care as needed to achieve and maintain optimal functioning and that residents may initiate a restorative program upon discharge from rehabilitative care. Despite this, surveyors found that residents with documented hemiplegia, hemiparesis, weakness, and contractures were not placed on restorative programs and had no restorative interventions documented in their electronic health records (EHRs). Resident 1 was admitted with hemiplegia and hemiparesis following cerebrovascular disease, a left lower leg fracture, and weakness, and the admission MDS showed intact cognition, moderate assistance needs for bed mobility and transfers, and one-sided upper and lower extremity impairment. During observation, the resident was seen lying in bed with a bent inward left forearm and hand and reported no longer receiving therapy or nursing-assisted exercises. The care plan initiated in January showed no restorative services, and the care plan history and EHR contained no restorative nursing interventions. However, the PT discharge summary from February documented that restorative ROM and transfer programs had been established and trained, including PROM to the left upper and lower extremities and stand-by assist with transfers, and the OT discharge summary recommended a splint/brace to prevent contracture. The OT stated that the splint/brace was not tried due to lack of time before insurance was discontinued, and both the Director of Rehab and the MDS coordinator confirmed there was no restorative referral in the EHR and they were unaware of the recommendations. Resident 2 was readmitted with hemiplegia and hemiparesis following a nontraumatic subarachnoid hemorrhage, a left-hand contracture, and weakness, and the quarterly MDS showed intact cognition, maximum assistance needs for bed mobility, total assistance for transfers, bilateral upper and lower extremity impairment, and no therapy or restorative programs. The resident reported that therapy had been discontinued months earlier and that no restorative staff were assisting with exercises. The care plan and EHR showed no restorative services. OT evaluation documented left upper extremity ROM impairment, a left-hand contracture, and prior use of a left orthotic to manage flexion tone, and the OT discharge summary recommended restorative care and assistance with donning/doffing the orthotic. The PT discharge summary recommended restorative programs if Medicaid Part B services did not continue. The Director of Rehab confirmed therapy was discontinued and that restorative nursing programs were recommended, but both the Director of Rehab and the MDS coordinator stated there were no restorative referrals in the EHR after readmission, and the MDS coordinator confirmed the resident had no restorative programs since readmission.
Failure to Implement Effective Fall and Toileting Interventions for High-Risk Resident
Penalty
Summary
The deficiency involves the facility’s failure to provide adequate supervision, identify fall trends, and implement progressive, resident-centered interventions for a resident with multiple falls and declining strength. The facility’s own Falls and Fall Risk Management policy required staff to identify interventions related to residents’ specific risks and causes to prevent falls and minimize complications. The resident’s Care Area Assessment identified cancer-related risks for pain, falls, and ADL decline, and stated that falls and urinary incontinence would be addressed in the care plan with an objective of improvement and risk minimization. However, the comprehensive care plan did not include a urinary or ADL care plan and contained no toileting plan, despite the resident’s identified risks and prior fall history. Over a series of falls, the resident repeatedly fell while attempting to toilet or move toward the bathroom, yet the facility did not recognize or address this pattern in its investigations or care planning. The resident had multiple unwitnessed falls: next to the bed while getting up to use the restroom, in the bathroom while standing to use the toilet, and near or in the bathroom on several occasions. Incident investigations and post-fall assessments documented environmental factors such as clutter, items on the floor, water on the floor, and issues with footwear, as well as the resident’s increasing weakness, impulsivity, poor safety awareness, and poor insight into limitations. Interventions documented in investigations and risk reviews included encouraging use of the front-wheeled walker, keeping the wheelchair and walker accessible, ensuring proper footwear and non-skid socks, and providing resident education on safe transfers, ambulation, and assistive device use. However, several of these planned interventions, including placement of the wheelchair and frequent rounding/toileting assistance, were not added to or reflected in the care plan as stated. Staff interviews further showed that the resident frequently fell while trying to go to the bathroom and that staff relied on verbal education and reminders to use the call light, even though the resident often did not use it. Staff acknowledged the resident’s impulsivity and tendency to get up independently despite instructions, and one staff member stated that nursing assistants were verbally instructed to offer bathroom assistance, but this intervention was not documented in the care plan. The resident’s bed remained the one furthest from the bathroom throughout the stay, and none of the facility’s investigations identified the trend of bathroom-related falls or addressed toileting options in the care plan. Ultimately, the resident sustained a left ankle fracture after another bathroom-related fall, requiring transfer to the emergency department for evaluation and treatment, and later records documented additional fractures and a decline in condition. The surveyors concluded that the facility’s failures placed residents at risk of repeated falls and injuries.
Failure to Monitor Urinary Retention After Foley Removal Leading to Prolonged Pain
Penalty
Summary
The deficiency involves the facility’s failure to adequately assess and monitor a resident for complications associated with an indwelling urinary catheter and urinary retention, particularly after catheter removal. The resident had a history of acute kidney injury due to urinary retention, which improved after Foley catheter placement in the hospital. Hospital discharge documentation indicated the catheter was placed for acute urinary retention, was deemed permanent, and included instructions that, given the resident’s significant retention and acute renal failure, staff at the skilled nursing facility should not attempt Foley removal. The facility’s catheter care plan directed staff to empty the catheter as needed and record output in milliliters, but review of the last 30 days of documentation showed continence was not rated due to the indwelling catheter and there was no documented urinary output in milliliters on the treatment administration records. The resident had a scheduled urology appointment at which the urinary catheter was discontinued. Upon return from this appointment, nursing documentation initially indicated no new orders, and an alert note later stated the catheter was discontinued and staff were monitoring for retention or pain. However, there was no documented bladder assessment or urinary output following catheter removal. Nursing assistant documentation showed that the resident did not void on the evening shift that same day. Despite the catheter having been removed, the treatment administration record showed staff continued to document provision of catheter care on subsequent shifts when no catheter was in place. Over the next day, the resident experienced vomiting, decreased oral intake, and an altered level of consciousness, with vital signs showing tachycardia and low blood pressure, and staff documented decreased urine output. A bladder scan performed later revealed more than 2000–2500 milliliters of urine in the bladder, and an indwelling catheter was reinserted, initially draining a large volume of urine. The provider note indicated the resident had not eaten since the prior night, was unable to hold down fluids, and staff were unsure whether the resident had urinated in incontinence briefs, with no wet briefs reported since the resident’s return from the hospital after catheter removal. The provider expressed concern that the documented early-morning wet brief might not be accurate given the large bladder volume on scan and stated this should require further investigation. Subsequent notes described the resident moaning and complaining of pain, with limited urine output in the catheter bag and staff flushing and then replacing the catheter due to continued complaints. Interviews with the resident, the roommate, and staff indicated the resident was crying out and moaning in pain, the roommate repeatedly alerted staff that the resident was not urinating and that the catheter was not draining, and staff had to seek assistance to replace the catheter. Facility leadership and clinical staff later acknowledged that typical practice after catheter removal would include contacting the provider, placing the resident on alert, performing post-void residuals with bladder scans, and documenting monitoring, which was not done in this case.
Medication Administration Delays, Documentation Errors, and Use of Expired Insulin
Penalty
Summary
The deficiency involves the facility’s failure to ensure sufficient nursing staff with appropriate competencies and skill sets to administer medications according to professional standards of practice, facility policy, and prescriber orders. The facility’s medication administration policy required medications to be given as prescribed, in accordance with manufacturers’ specifications and good nursing principles, with no expired medications used, and doses administered within 60 minutes of the scheduled time and documented immediately after administration. Multiple residents reported that agency nurses often gave medications late, did not read full instructions, or were slow in bringing medications, and that routinely scheduled medications were not consistently provided without residents having to ask. Surveyors observed several specific medication administration failures. For a resident with diabetes, an LPN drew up and administered Humalog/Lispro insulin from a multi-dose vial that had been opened and dated “02/16” with no year, making it expired per policy, and administered the dose nearly 1 hour and 45 minutes after it was due. Another resident with care plan instructions to receive medications as ordered had multiple scheduled medications (Gabapentin, Oxybutynin, Baclofen, and Tizanidine) that were ordered at specific times throughout the day; the LPN was observed administering all four together and acknowledged that at least one (Tizanidine) was late, while the resident reported that receiving them together at that time was typical and not at their request. For another diabetic resident, an RN checked blood sugar and prepared sliding scale Humalog/Lispro insulin almost two hours after the scheduled time; the resident refused the insulin, stating they had already finished lunch. Additional deficiencies were identified with other residents’ pain and scheduled medications. One resident with a pain care plan and an order for Methocarbamol four times daily at set times approached the cart requesting Methocarbamol and Tylenol; the RN initially stated the Methocarbamol had already been given, but then administered it two hours after it was due when the resident pointed out the scheduled timing. For another resident with a risk for pain care plan and Tramadol ordered three times daily at specific times, an LPN retrieved a PRN pain medication while the electronic record showed no 8:00 AM medications documented; the LPN stated they had given them but had not yet documented. Later, an RN prepared the 2:00 PM Tramadol dose, and review of the narcotic count showed a discrepancy between the number of pills documented and the number remaining in the card. The RN stated they had given the 8:00 AM Tramadol but had not signed it out, then signed out both the 8:00 AM and 2:00 PM doses at that time. Residents interviewed consistently reported that medications were sometimes or frequently late, that agency nurses did not always follow instructions, and that they often had to request medications that were routinely scheduled.
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