Regency Coupeville Rehab And Nursing Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Coupeville, Washington.
- Location
- 311 Northeast 3rd Street, Coupeville, Washington 98239
- CMS Provider Number
- 505309
- Inspections on file
- 36
- Latest survey
- February 26, 2026
- Citations (last 12 mo.)
- 31
Citation history
Health deficiencies cited at Regency Coupeville Rehab And Nursing Center during CMS and state inspections, most recent first.
Two residents did not have their bathing preferences consistently honored or documented, resulting in infrequent showers despite stated preferences and facility practice of scheduling two showers per week. One resident with dementia and severe cognitive impairment went long intervals between showers, with multiple refusals recorded but no clear care plan guidance or documentation of her preferred method of bathing. Another cognitively intact resident with hemiplegia, who preferred twice-weekly showers, was also showered infrequently, with several refusals and non-applicable entries and no nursing progress note documentation of refusals. NACs reported re-approaching residents, documenting refusals, and notifying nurses, and a regional RN confirmed there was no facility shower policy.
Surveyors found that clinical records were not consistently complete, accurate, or timely for several residents. NAC documentation in the EMR for daily care, skin observations, behavioral symptoms, bowel monitoring, ADLs, and intake was missing on multiple days and shifts for more than one resident, and a fall risk assessment for a resident was not finalized until several days after it was dated. In addition, interdisciplinary care conference documentation for three residents was either not completed as of the survey or was entered several days after the conferences, despite facility expectations that NAC entries be done by end of shift and care conference documentation be locked within a day.
A resident with dementia and anxiety had only one documented care plan conference in the EMR despite facility policy requiring an initial and quarterly interdisciplinary care conference with resident and/or representative participation. The resident’s representative reported attending only one conference and stated that a more recent conference, which they could not attend, was not rescheduled despite their request and desire to be involved in the resident’s care. Social services staff confirmed that only one conference was documented for this resident, indicating that required ongoing care conferences with resident/representative involvement were not consistently conducted or documented.
A resident with severe cognitive impairment and dementia with anxiety had physician orders to increase acetaminophen dosing and start a daily lidocaine patch for back pain, but the responsible party was not notified of the resident’s pain or these new and changed medications. The responsible party later reported they were not kept informed of medication changes, and review of the EMR confirmed no documentation of notification, despite staff stating that responsible parties are to be notified of such changes. This failure prevented the designated decision-maker from participating in care planning and knowing what medications the resident was receiving.
A resident with intellectual disabilities and disorders of psychological development was admitted without the required PASRR Level 2 process being completed. The Level 1 PASRR form indicated the need to forward the case to the Regional DDA ID/RC PASRR team for review before admission, but the EMR contained no evidence that this contact occurred. The SSD reported being unaware that the Level 1 PASRR had to be sent to the Regional DDA ID/RC PASRR team prior to admission and stated that Admissions staff handled PASRR review. The Admissions staff member confirmed they reviewed Level 1 PASRR forms but did not know that this resident’s PASRR needed to be forwarded for a Level 2 determination based on the intellectual disability diagnosis.
Three residents with complex medical conditions were transferred to the hospital without proper documentation or notification of bed hold and transfer/discharge rights. Staff interviews confirmed that required forms were missing from transfer packets, and there was no follow-up or record to show that residents or their representatives were informed of their rights.
The facility did not ensure timely review and implementation of monthly pharmacist Medication Regimen Reviews (MRRs) for several months. MRR reports were often reviewed by the provider and acted upon weeks to months after the pharmacist's initial review, due to process changes following a pharmacy switch. The DON acknowledged that the facility had not adjusted to the new process, resulting in ongoing delays.
Multiple residents received antihypertensive and cardiac medications outside of physician-ordered parameters, or without required documentation of vital signs before and after administration. Nursing staff did not consistently document reasons for holding medications or record vital signs as ordered, and the facility did not identify these medication errors in its reporting log.
Surveyors found expired medications and medical supplies on two medication carts and in the medication storage room. Staff confirmed the items were expired and had not been removed as required. Interviews revealed uncertainty among staff about the facility's procedures for checking and discarding expired drugs and biologicals.
The facility did not complete or document ordered laboratory tests for multiple residents, including those with sepsis, urinary incontinence, and recent infections. There were missed or undocumented lab collections, lack of timely follow-up on critical results, and gaps in communication and documentation among nursing staff and providers. Staff interviews revealed confusion about lab processes and the absence of a formal lab policy.
The facility did not ensure medical records were complete, accurate, or timely, with issues such as late documentation, missing required information for TB testing, and the use of unauthorized stamped signatures by an LPN. Several residents' care plans and assessments were entered late or with future dates, and required entries like weekly weights and immunization details were missing. Staff reported technical barriers to timely documentation and acknowledged the lack of an auditing process.
A resident with a history of depression and dementia was not provided with care plan interventions based on Level II PASRR recommendations, which included specific behavioral and activity supports. Staff interviews and record review confirmed that PASRR guidance was not integrated into the resident's care plan, and the resident was frequently observed without activity engagement.
The facility did not complete or update PASRR assessments in a timely manner after two residents experienced significant changes in mental health status, including new hallucinations and delusions. Staff interviews revealed a lack of understanding about the need to notify the PASRR evaluator for symptoms beyond depression or anxiety, resulting in missed referrals and incomplete documentation.
A resident used a personal Therma Zone pain management device in their room without a physician order, documentation, or monitoring. Facility staff, including nursing and therapy, were unaware of the device, and it was not included in the care plan or Treatment Administration Record. Facility policy requires a doctor's order and assessment for resident-owned medical equipment, but these procedures were not followed.
Two residents did not receive ordered medications upon admission due to pharmacy delays and lack of available stock, with staff documenting repeated missed doses and no evidence of resident notification or assessment for adverse effects. LPN and DON interviews confirmed gaps in medication administration and follow-up.
Staff failed to initiate CPR for a resident found unresponsive, despite clear physician orders and a POLST form indicating full code status. Multiple nurses did not check the resident's code status or start CPR, assuming the resident was on hospice. There was a significant delay in contacting EMS, and no CPR was performed by facility staff prior to EMS arrival, who then initiated resuscitation efforts.
A resident with full code status was found unresponsive and did not receive CPR or a timely EMS call from facility staff, despite clear physician orders and policy requirements. Multiple LPNs failed to check the resident's POLST form or initiate life-saving measures, resulting in a significant delay before EMS arrived and began resuscitation.
Staff failed to timely recognize and report allegations of abuse, neglect, and unexpected death for two residents. One resident, not on hospice or end-of-life care, died unexpectedly and the incident was not reported or investigated as required. Another resident, dependent on staff and legally blind, had their call light repeatedly found out of reach, with concerns about intentional neglect not being reported to authorities. Key staff were unaware of reporting requirements, leading to a deficiency.
The facility did not complete thorough investigations into multiple abuse and neglect allegations involving three residents with complex medical conditions. Investigations lacked staff and witness statements, did not include required monitoring for psychosocial harm, and failed to update care plans or implement interventions to prevent recurrence, as confirmed by staff interviews and record review.
The facility failed to conduct thorough investigations for allegations of abuse/neglect involving two residents. One resident's family reported concerns about care, but the investigation lacked statements from involved parties. Another resident experienced an unwitnessed fall, but no statements were obtained. The RN Director of Nursing Services and Administrator acknowledged the lack of documentation and statements in both cases.
The facility administration failed to maintain compliance with regulatory requirements, leading to deficiencies in care plan timing, professional standards, nursing staff competency, and more. The administrator admitted no quality assurance projects were conducted to address these issues, placing residents at risk.
The facility failed to assess and document yearly competencies for five nursing assistants, impacting their ability to provide quality care. Despite requirements for staff competencies in daily living activities, no performance improvement plan was in place, and this was a repeat deficiency.
The facility failed to conduct annual performance reviews for five NAC employees who had been employed for over a year. Interviews and record reviews revealed that the employee files for these staff members lacked current evaluations, despite the facility's handbook outlining a performance management system. The absence of evaluations was confirmed by staff and administration, and this issue was noted as a repeat deficiency.
The facility failed to maintain sanitary conditions in two nourishment rooms and the kitchen, with soiled refrigerator/freezer units, microwave ovens, and toasters observed. Additionally, overhead light fixtures in the kitchen were soiled with debris and dead insects. Staff K, the Dietary Manager, was unaware of any cleaning schedule for these fixtures.
The facility failed to ensure a clean and sanitary environment by not laundering or replacing soiled privacy curtains in the rooms of two residents. Observations showed that the curtains were heavily stained and remained unchanged over several days. Interviews with staff revealed no established schedule or policy for curtain maintenance, contributing to the unsanitary conditions.
The facility failed to resolve and document grievances for two residents, leading to delays and dissatisfaction. One resident reported missing clothing, which was not documented or resolved promptly, while another expressed dissatisfaction with care, but the grievance was not thoroughly investigated. These deficiencies highlight issues in the facility's grievance handling process.
A resident with muscle weakness and other health issues experienced a decline in ADL abilities, but the facility failed to complete a Significant Change in Status Assessment (SCSA) as required. Despite staff observations of the resident's weakening condition, there was no update to the treatment plan, and the necessary assessment was not conducted.
A LTC facility failed to accurately assess three residents, leading to deficiencies in care planning. One resident with a colostomy was incorrectly documented as continent of bowels, another with pressure ulcers was inaccurately staged without examination, and a third requiring enteral feeding was misreported as having no swallowing disorder. These errors were acknowledged by facility staff.
The facility failed to complete a Level II PASRR for a resident with SMI, ID, or related condition when the scheduled discharge did not occur, and did not ensure an accurate Level I PASRR for another resident taking Seroquel. The deficiencies involved a resident with depression, anxiety, and delirium, and another with dementia and a hip prosthesis dislocation.
The facility failed to update care plans for three residents, leading to risks of suboptimal care. One resident's care plan did not reflect their bedridden status and severe pressure ulcers. Another resident's care plan was outdated regarding their wheelchair needs, causing discomfort and safety issues. A third resident's discharge planning was incomplete, with no specific goals or interventions. These deficiencies highlight a lack of communication and care plan management.
The facility failed to follow physician orders for three residents, including not addressing a recommendation for palliative care and not checking blood pressure before administering medications. Staff interviews revealed a lack of documentation and policy on medication parameters, and the issue was not addressed in the facility's QAPI program.
A facility failed to conduct regular care conferences for a resident with dementia and a hip prosthesis dislocation, as required by their policy. The last documented conference was in January, despite the resident's spouse indicating no meetings had occurred since then. The Social Services Director could not provide documentation for any subsequent conferences, placing the resident at risk for unmet care needs.
The facility failed to ensure two residents were free from unnecessary psychotropic medications, placing them at risk for adverse events. One resident was given Seroquel without a valid diagnosis or attempts at gradual dose reduction, while another received Olanzapine without documented psychiatric disorders or behavior monitoring. Staff interviews revealed uncertainty and lack of documentation, contributing to the administration of unnecessary medications.
The facility failed to provide dental services for two residents, leading to a deficiency. One resident had dental care needs due to paralysis and dental caries but had not seen a dentist since admission. Staff were unaware of the resident's dental issues, and there was no routine dental process in place. Another resident's representative requested a dental appointment, but no follow-up occurred, and this was a repeat deficiency.
The facility failed to conduct thorough investigations for incidents involving three residents, leading to deficiencies in identifying root causes and implementing effective care plans. A resident with cognitive impairment experienced multiple falls without proper documentation or monitoring plans. Another resident received incorrect tube feeding rates, and a third resident was given blood pressure medications against parameters. Staff interviews revealed a lack of clarity and documentation in addressing these issues.
The facility failed to maintain accurate clinical records for three residents, leading to potential risks for unmet needs and diminished quality of life. A resident with Alzheimer's had falls that were not timely documented, and their food preferences were not recorded. Another resident with a stroke had discrepancies in tube-feeding and hydration documentation. A third resident had inconsistencies in medication administration records, potentially leading to medication errors.
A resident with severe cognitive impairment due to Alzheimer's disease did not receive adequate oral care as per their care plan, which required assistance twice daily. Documentation showed lapses in care, with oral hygiene not provided on one day and only once daily on nine other days. A collateral contact had to intervene to provide oral care. The facility's Administrator and DON were unable to explain the lack of care, citing missing documentation.
A resident with severe cognitive impairment and multiple medical conditions experienced five falls shortly after admission due to inadequate supervision and lack of effective fall prevention measures. Despite being identified as a high fall risk, the facility failed to consistently implement or document necessary interventions, such as one-to-one monitoring. Staff education on monitoring was informal and undocumented, and the care plan did not reflect necessary interventions to address the resident's impulsivity and fall risk.
Facility staff failed to follow infection control practices during care for two residents, leading to potential cross-contamination. A CNA used contaminated gloves to touch a privacy curtain and place a clean brief on a resident without changing gloves or performing hand hygiene. Another CNA also failed to change gloves or perform hand hygiene before placing a clean brief on a resident, resulting in contamination.
A resident with cognitive impairment and chronic health issues was not adequately monitored for a suspected UTI, leading to a lack of timely medical intervention. Despite symptoms such as fever and increased incontinence, staff failed to report changes in the resident's condition, resulting in unmet needs and the resident's passing. The facility did not complete a physical therapy evaluation as ordered, and there were lapses in documentation and communication among staff.
A resident with chronic conditions was not seen by a physician every 30 days as required, due to the departure of the overseeing physician and delayed reassignment. The resident's representative raised concerns about neglect, leading to a physician visit only shortly before the resident's passing.
A resident with chronic respiratory failure, COPD, and schizophrenia reported being punched in the eye by a staff member. The allegation was not documented or reported immediately, as required by facility policy. Staff interviews revealed that the report was not taken seriously due to the resident's schizophrenia, leading to a delay in reporting the incident to the state agency.
The facility failed to protect residents during an abuse investigation when a NAC continued to work after an allegation of abuse. The staff did not immediately suspend the alleged perpetrator, and the incident was not reported to the state hotline within the required timeframe, placing residents at risk for continued potential abuse.
Failure to Honor Resident Bathing Preferences and Maintain Consistent Shower Schedules
Penalty
Summary
The deficiency involves the facility’s failure to honor and support resident choice and preferences regarding bathing schedules for two residents. One resident with dementia and severe cognitive impairment had a care plan noting frequent shower refusals and a need for maximal assistance, but the plan did not direct staff on what to do when showers were refused. Documentation showed this resident went extended periods between showers, including 36 days and then 19 days, with multiple refusals recorded and some days marked as not applicable. Progress notes contained only one detailed entry of a refusal, where the resident stated she bathed herself at the sink each morning and did not want a shower with someone else present, and there was no documentation in the electronic medical record of the resident’s bathing preferences or how she wished to be bathed. A second resident, cognitively intact with left-sided hemiplegia after a stroke, had a care plan indicating a preference for two showers per week per the facility schedule and a need for maximal assistance. However, documentation showed this resident was showered infrequently, with gaps of over two weeks between showers, multiple refusals, and several entries marked as not applicable or not available. Nursing progress notes for this resident contained no documentation of shower refusals. Multiple NACs reported that residents were scheduled for two showers weekly, that they attempted re-approaches and notified nurses of refusals, and that refusals were documented in the electronic record. An RN/Regional Director of Clinical Operations confirmed via email that the facility did not have a resident shower policy. These findings show that resident bathing choices and preferences were not consistently honored or clearly documented for the two residents.
Incomplete and Delayed Clinical Documentation by NAC Staff and Social Services
Penalty
Summary
The deficiency involves the facility’s failure to maintain complete, accurate, and accessible clinical records in accordance with professional standards for multiple residents. For one resident, review of December, January, and February documentation reports showed numerous missing Nursing Assistant Certified (NAC) entries in the electronic medical record (Point Click Care) for tasks such as “all care provided,” skin observations, behavioral symptoms, bowel monitoring, ADLs (including dressing, transfers, hygiene, toileting, bathing, bed mobility, continence, walking, and eating), and food and fluid intake across multiple dates and shifts. This resident’s fall risk assessment, dated in February, was also not locked/completed until several days after the assessment date. Another resident’s December and January documentation reports showed multiple days and shifts with no intervention/task documentation by NAC staff. Additional record review showed that three other residents had incomplete or delayed documentation of interdisciplinary care conferences in their electronic medical records. For one resident, the care conference held in February had not been completed by the Social Services Director as of the survey date. For two other residents, care conference documentation was not completed until several days after the conferences occurred. In interviews, NAC staff stated that all NAC documentation was entered into Point Click Care, and leadership staff stated that the expectation was for NAC documentation to be completed by the end of each shift and for care plan conference assessments to be completed/locked within a day of the conference. The surveyors concluded that clinical records were not maintained in accordance with accepted professional standards, placing residents at risk for unmet care needs and diminished quality of life.
Failure to Involve Resident and Representative in Ongoing Care Plan Conferences
Penalty
Summary
The facility failed to ensure that a resident and the resident’s representative were offered the opportunity to participate in person-centered care conferences as required by facility policy and WAC 388-97-0200(3). The facility’s “Interdisciplinary Care Conference” policy, dated 3/2024 and revised on 12/16, stated that an interdisciplinary care conference is to be completed upon admission, quarterly, and following a change in condition, and that the resident and/or resident representative will be invited. The resident in question was admitted with a diagnosis including dementia with anxiety. Review of the electronic medical record showed only one documented care plan conference held on 07/14/2025, with no additional conferences recorded despite the length of stay and policy requirements. During a telephone interview, the resident’s collateral contact reported having attended only one care plan conference since admission and stated that a more recent conference had been scheduled but could not be attended due to a last-minute issue, after which the collateral contact requested that the meeting be rescheduled. The collateral contact also stated a desire to be involved in the resident’s care. In a subsequent interview, the social services staff member responsible for care plan conferences confirmed that conferences are supposed to occur within the first week of admission and then quarterly in alignment with the MDS schedule. When asked specifically about this resident, the staff member could locate only the single documented conference in the EMR and acknowledged that the facility was working on scheduling another conference with the resident and the collateral contact.
Failure to Notify Responsible Party of Resident’s Medication Changes
Penalty
Summary
The facility failed to notify a resident’s responsible party of new and changed medication orders, as required, for one of three sampled residents reviewed for notification of changes. The resident had dementia with anxiety and was documented on an MDS assessment dated 12/30/2025 as having severe cognitive impairment. A physician order dated 01/21/2026 directed an increase in the resident’s acetaminophen to two tablets every 12 hours and initiation of a daily lidocaine patch to the lower back for back pain, to be removed per schedule. Review of the electronic medical record showed no documentation that the responsible party (Collateral Contact 1) had been notified of the resident’s back pain or these medication changes. During a telephone interview, the responsible party reported they were not kept informed when the resident had changes in medications, and during staff interviews, leadership staff stated that responsible parties are to be notified of medication changes, despite the lack of notification in this case. This failure prevented the person responsible for making healthcare decisions from being part of the care planning process and from being knowledgeable about the medications the resident was taking, in violation of WAC 388-97-0320(1)(c).
Failure to Complete Required PASRR Level 2 Referral Before Admission
Penalty
Summary
Surveyors found that the facility failed to follow required Pre-admission Screening and Resident Review (PASRR) procedures for one resident with intellectual disabilities. The Level 1 PASRR form for this resident, dated 02/09/2026, documented that the resident had an intellectual disability and that the form was required to be forwarded to the Regional Developmental Disabilities Administration (DDA) Intellectual Disability/Related Condition (ID/RC) PASRR team for follow-up before admission to a nursing facility. Despite this requirement, review of the resident’s electronic medical record showed no documentation that the Regional DDA ID/RC PASRR team had been contacted prior to the resident’s admission, and the resident was admitted with diagnoses including intellectual disabilities and disorders of psychological development. Interviews with facility staff confirmed a lack of awareness and implementation of the PASRR requirements. The Social Services Director stated they were unaware that the Level 1 PASRR needed to be forwarded to the Regional DDA ID/RC PASRR team before admission and reported that Admissions staff were responsible for reviewing PASRR information prior to admission. The Social Services Director also indicated they did not see a resident’s PASRR until after admission, once it was scanned into the electronic medical record. The Admissions staff member interviewed acknowledged responsibility for reviewing Level 1 PASRR forms before admission but stated they were unaware that this resident’s PASRR was required to be forwarded to the Regional DDA ID/RC PASRR team for review and determination related to the resident’s intellectual disability diagnosis.
Failure to Provide Required Bed Hold and Transfer/Discharge Notices During Hospital Transfers
Penalty
Summary
The facility failed to provide required documentation and notification regarding bed hold and transfer/discharge rights to three residents who were transferred to the hospital. For one resident with metabolic encephalopathy, Parkinson’s disease, and clostridium difficile, there was no documentation in the progress notes that a bed hold or notice of transfer/discharge was provided when the resident was sent to the hospital. Staff interviews confirmed that the transfer packet did not include the necessary documentation and staff were unaware of any facility document related to these notices. Another resident with COPD, chronic heart failure, and a pelvis fracture was transferred to the hospital after a fall, but there was no documentation of a bed hold or transfer/discharge notice. Staff confirmed the absence of these documents. A third resident with a history of falls and a fracture was also transferred to the hospital, and although a checkbox indicated that bed hold/transfer notices were sent, there were no copies or follow-up documentation to confirm that the resident or their representative was informed. Staff interviews revealed that while the form is supposed to be sent with the resident, no copies are kept, and there was no documentation in the medical record to verify that the required notifications were provided.
Delayed Review and Implementation of Pharmacist Medication Regimen Recommendations
Penalty
Summary
The facility failed to ensure that a licensed pharmacist's monthly Medication Regimen Reviews (MRRs) were reviewed and acted upon in a timely manner for five out of six months reviewed. According to facility policy, MRR reports should be received within three days of the pharmacist's review and the provider should review and respond within fourteen days. However, the policy did not specify the timeframe for the facility to note and implement the provider's recommendations. Review of records showed significant delays between the pharmacist's review, the provider's review, and the facility's implementation of recommendations for multiple months. For example, MRRs completed in January were not reviewed by the provider until February, and recommendations were not implemented until April. Similar delays occurred in subsequent months, with some recommendations not implemented until several weeks after provider review. During an interview, the Director of Nursing Services acknowledged the delays and attributed them to a recent change in pharmacy providers, which altered the timing and process for receiving MRR reports. The reports are now sent by email, printed upon arrival, and given to the provider, but the facility has not yet adjusted to the new process. The Director confirmed that not all reviews are being addressed in a timely manner, as required by policy and regulatory standards.
Failure to Adhere to Medication Administration Parameters and Documentation
Penalty
Summary
The facility failed to ensure that residents were free from significant medication errors, as evidenced by multiple instances where medications were administered outside of physician-ordered parameters or without proper documentation. For several residents with diagnoses such as hypertension, heart failure, and autonomic nervous system disorders, medications including Metoprolol, Digoxin, Lisinopril, Amlodipine, Losartan Potassium, and Propranolol were either given when vital signs were below the required thresholds or held without appropriate documentation of the reason. In some cases, vital signs were not taken as required before or after medication administration, and there was a lack of documentation in the medical records or progress notes to justify these actions. For example, one resident received Metoprolol despite a systolic blood pressure (SBP) below the ordered parameter, while another received Lisinopril and Metoprolol when their SBP was below the physician's specified threshold. In another case, a resident was given Amlodipine and Losartan Potassium outside the ordered SBP parameters. Additionally, there were instances where PRN Propranolol was administered without clear documentation of whether vital signs were taken before and after administration, as required by the provider's order. Interviews with nursing staff and the Director of Nursing Services confirmed that the expectation was for nurses to follow medication parameters and document vital signs accordingly. However, the facility's state reporting log did not reflect that these medication errors had been identified, and staff acknowledged that audits of medications with parameters were not routinely conducted. The lack of adherence to physician orders and incomplete documentation contributed to the identified deficiencies.
Expired Medications and Supplies Not Removed from Storage and Carts
Penalty
Summary
Surveyors observed that the facility failed to ensure drugs and biologicals were properly labeled and discarded when expired, as required by facility policy and professional standards. During observations of two medication carts and the medication storage room, expired medical supplies and medications were found, including medical supplies with expiration dates of 12/31/2024 and 04/13/2025, bottles of cholecalciferol (Vitamin D) and folic acid with expiration dates of 06/2025, and a box of Nicorette gum with an expiration date of 01/2025. Staff present during these observations confirmed that the items were expired and acknowledged they should have been removed. Interviews with staff revealed uncertainty regarding the facility's policy and procedures for checking and removing expired medications. One staff member indicated that pharmacy staff are responsible for reviewing medication carts but was unsure how often this occurred. Another staff member stated that charge nurses are supposed to audit medication carts to ensure expired medications are removed, and that both nurses and pharmacy staff should be involved in this process. The facility's policy requires expired medications and biologicals to be stored separately until destroyed or returned to the pharmacy, but this was not followed as evidenced by the expired items remaining on the carts and in the storage room.
Failure to Complete and Document Ordered Laboratory Tests
Penalty
Summary
The facility failed to ensure that laboratory tests were completed as ordered and that timely laboratory results were provided for six of eight residents reviewed. For one resident admitted with sepsis, multiple labs were ordered twice weekly to monitor their condition, but there were blank entries in the Medication Administration Record (MAR) for several ordered dates, and only one lab was repeated despite a critical magnesium level. Documentation showed the lab did not notify the facility of continued critical results, and the resident was later returned to the hospital due to ongoing abnormal labs and fragile status. Another resident with urinary incontinence had a physician order for a urinalysis (UA) and culture, but the MAR showed no documentation of collection attempts over several days. Progress notes indicated repeated unsuccessful attempts to obtain the sample, and the resident expressed frustration over the delay, stating the test was ordered due to increased hallucinations. For a long-term care resident recently treated for a urinary tract infection, laboratory testing was ordered, but while the record showed the labs were drawn, there were no results or further information documented. Additional residents had laboratory orders that were not completed or documented, including one who was discharged without the required labs being drawn and another with no indication that ordered labs were obtained or processed. Staff interviews revealed confusion and gaps in the lab ordering, collection, and result reporting processes, including issues with documentation, communication with the lab, and lack of a formal lab policy. The Director of Nursing confirmed the absence of a lab policy and acknowledged the need for documentation and follow-up when abnormal labs are received.
Incomplete and Inaccurate Medical Record Documentation
Penalty
Summary
The facility failed to maintain complete, accurate, and accessible medical records for multiple residents, as required by accepted professional standards and state law. Documentation for several residents included inconsistencies such as care plans and assessments with future-dated entries, late documentation of interdisciplinary care conferences, and missing signatures. Staff interviews revealed that some documentation was completed on paper and later transcribed into the electronic record due to technical issues, resulting in delayed and potentially unreliable entries. There was also an absence of an auditing process to ensure the accuracy and completeness of medical records, as acknowledged by the Administrator and Director of Nursing Services. Medication Administration Records (MARs) for one resident showed missing documentation of required weekly weights on several dates. Additionally, the immunization records for several residents lacked documentation of the lot number and expiration date for tuberculosis (TB) testing solutions, which staff confirmed should have been recorded in the clinical record. The Director of Nursing Services stated that if this information was not documented under the immunization tab, it would not be found elsewhere in the record. The facility also permitted the use of a stamped signature by an LPN/RCM to indicate that pharmacy recommendations and physician orders had been noted and implemented. The Administrator stated that stamped signatures were not allowed and were not legal in the state, and was unaware that this practice was occurring. These documentation failures were observed across one of two resident units and affected at least six residents, placing them at risk for records that did not accurately reflect their care.
Failure to Incorporate PASRR Recommendations into Care Plan
Penalty
Summary
The facility failed to incorporate the recommendations from a Level II Preadmission Screening and Resident Review (PASRR) into the assessment and care planning for a resident with a history of depression and moderate dementia with anxiety. The PASRR, completed for the resident, included specific recommendations regarding environment, staff approach and training, behavioral support, and activity engagement, such as encouraging daily activities for structure and mental stimulation, and consulting the resident's family about preferred activities. The PASRR also detailed the need for a consistent routine, consistent staff, gentle communication, and monitoring if a roommate was unavoidable due to the resident's mental health history and behavioral triggers. Despite these recommendations, review of the resident's care plan showed that none of the PASRR recommendations were included. Multiple observations over several days revealed the resident was often in their room without activity items, and staff interviews confirmed that PASRR recommendations were not being added to care plans. The Social Services Director stated they were unaware that PASRR recommendations needed to be incorporated into the care plan, and the process had only involved scanning the PASRR evaluation into the medical record.
Failure to Timely Update PASRR Assessments After Significant Change in Condition
Penalty
Summary
The facility failed to ensure timely completion and notification of Preadmission Screening and Resident Review (PASRR) assessments following significant changes in condition for two residents with mental health diagnoses. For one resident with PTSD, the clinical record showed a new onset of hallucinations and delusions documented in multiple Minimum Data Set (MDS) assessments and care area assessments. However, the PASRR documentation did not reflect these new symptoms, and the Level II PASRR referral was made only for a new anti-depressant order, without addressing the delusions or hallucinations. For another resident with depression and dementia, the clinical record and care plan documented the onset of vivid hallucinations and delusions, but there was no evidence of a significant change PASRR referral when these symptoms began. Interviews with facility staff revealed a lack of awareness regarding the requirement to notify the PASRR evaluator about significant changes involving delusions or hallucinations. The Director of Nursing Services stated that PASRR information should be updated and communicated to the care plan, while the Social Services Director was unaware that symptoms beyond depression or anxiety required PASRR notification. The facility's policy required PASRR reviews and updates with significant changes in residents' physical or mental condition, but this was not followed for the two residents in question.
Failure to Ensure Physician Order and Monitoring for Resident-Owned Medical Device
Penalty
Summary
The facility failed to ensure professional standards of practice were implemented for medication management for one resident. The resident, who was cognitively intact and admitted with lower extremity cellulitis and polyneuropathy, brought a Therma Zone pain management device into the facility and used it independently for joint pain. Observations confirmed the device was present and in use in the resident's room. However, there was no physician order for the device, no documentation or monitoring of its use in the Treatment Administration Record, and it was not included in the resident's care plan. Interviews with staff revealed that neither nursing assistants, LPNs, occupational therapy, nor the Resident Care Manager were aware of the device's presence or use. The Director of Nursing Services stated that facility policy requires a physician order, resident assessment, and maintenance inspection for any medical device brought in by a resident, but these steps were not followed. The deficiency was cited under WAC 388-97-1620(2)(b)(ii) for failure to obtain a doctor's order and monitor the use of resident-owned medical equipment.
Failure to Provide Timely Pharmaceutical Services for Newly Admitted Residents
Penalty
Summary
The facility failed to ensure that pharmaceutical services were provided to meet the needs of two residents upon admission, resulting in missed medication doses as ordered by their physicians. For one resident with hypomagnesemia, physician orders for magnesium supplements were not fulfilled for several consecutive days, as documented in the electronic medication administration record (EMAR) and progress notes. Staff repeatedly noted that the medication was on order or unavailable, and there was no documentation that the resident was notified of the missed doses or assessed for symptoms related to low magnesium levels, despite a critical lab result indicating hypomagnesemia. Another resident admitted with COPD and depression did not receive prescribed medications for depression and respiratory management on two occasions, as the medications were not available in the facility or from the pharmacy. Progress notes indicated the medications were on order and not yet delivered, with no documentation of resident notification or assessment for adverse outcomes. Interviews with staff confirmed that medications were not administered as ordered and that appropriate follow-up actions, such as timely notification of providers or use of emergency supplies, were not consistently documented or performed.
Failure to Initiate CPR for Full Code Resident
Penalty
Summary
Facility staff failed to perform Cardio-Pulmonary Resuscitation (CPR) on a resident who was found unresponsive, despite the resident having a physician order and a signed POLST form indicating full code status and a desire for life-sustaining treatment. The resident was admitted with diagnoses including a left femur fracture, malnutrition, and dysphagia, and was documented as cognitively intact. When the resident was discovered unresponsive, staff did not check the POLST form or initiate CPR, even though the facility's policy required immediate basic life support for residents with full code status unless there were clear signs of irreversible death. Multiple staff members, including LPNs and a nurse manager, were involved in the response. The first nurse to assess the resident did not find a pulse or signs of breathing and assumed the resident was on hospice, failing to verify the code status. The assigned nurse, who was on break at the time, also did not check the POLST form or initiate CPR upon returning to the room. Instead, staff contacted the nurse manager and were instructed to call the family, 911, and the coroner, but there was a significant delay before emergency services were contacted. No staff member performed CPR prior to the arrival of EMS. EMS arrived to find the resident warm to the touch, without rigor mortis or dependent lividity, and initiated CPR upon arrival. Documentation and interviews confirmed that no facility staff had performed CPR, and the resident's code status was only clarified when EMS inquired. The facility's failure to ensure staff were trained to respond appropriately to a resident requiring CPR, to locate and reference POLST/advance directives, and to accurately assess for signs of irreversible death led to the deficiency.
Failure to Initiate CPR and Timely EMS Response for Full Code Resident
Penalty
Summary
Facility staff failed to protect a resident's right to be free from neglect by not initiating Cardiopulmonary Resuscitation (CPR) or calling Emergency Medical Services (EMS) in a timely manner during a medical emergency. The resident, who had a history of left femur fracture, malnutrition, and dysphagia, was found unresponsive, pulseless, and not breathing. Despite the resident's documented wishes and physician orders for full code status and CPR, staff did not check the resident's POLST form or initiate CPR as required by facility policy. Multiple staff members, including two LPNs, assessed the unresponsive resident but did not begin CPR or immediately contact EMS. One LPN incorrectly assumed the resident was on hospice and did not verify code status, while another admitted to being in shock and did not use a stethoscope to confirm the absence of vital signs. Both staff members acknowledged they should have checked the POLST form and initiated CPR but failed to do so. The delay in action resulted in a 45-minute gap before EMS was called and CPR was started by EMS personnel upon arrival. Interviews with facility leadership and staff confirmed that the expectation was to check the POLST form and initiate CPR immediately for residents with full code status. Documentation and staff statements revealed that no facility staff performed CPR prior to EMS arrival, and the resident was still warm to the touch without signs of irreversible death when EMS began resuscitation efforts. The failure to follow established protocols and physician orders led to unmet care needs and was identified as neglect.
Failure to Timely Recognize and Report Allegations of Abuse, Neglect, and Unexpected Death
Penalty
Summary
The facility failed to ensure timely recognition and reporting of allegations of abuse, neglect, or unexpected death for two residents. For one resident, who was admitted with a left femur fracture, malnutrition, and dysphagia, staff found the individual unresponsive and not breathing, with no prior hospice or end-of-life care in place. Despite this being considered an unexpected death by staff, the incident was not coded or reported as such in the facility's state reporting log, nor was it investigated or reported to the appropriate authorities as required by state guidelines. Interviews revealed that key staff, including the ADNS and Administrator, were unaware of the requirement to log and report unexpected deaths for residents not on hospice or end-of-life care. For another resident with sarcopenia, chronic pain syndrome, dementia, and legal blindness, staff reported that the resident's call light was found out of reach on multiple occasions during night shifts. Although a nursing assistant reported the issue to supervisory staff, there was uncertainty about whether the potential intentional nature of the act was communicated. Supervisory staff and the Administrator were unaware that the incident could have constituted intentional neglect and did not report it as such. The facility's failure to recognize and report these incidents in accordance with abuse and neglect reporting policies resulted in a deficiency.
Failure to Conduct Thorough Investigations of Abuse and Neglect Allegations
Penalty
Summary
The facility failed to conduct thorough investigations into allegations of abuse and neglect for three residents. For one resident with chronic heart failure, malnutrition, depression, anxiety, and muscle weakness, an allegation of neglect was reported by a family member. The facility's investigation relied solely on medical record review and did not include statements from staff, other residents, or potential witnesses, making it unclear how abuse or neglect was ruled out. Another resident with end stage renal disease, muscle weakness, recurrent C. difficile, a sacral pressure ulcer, and anxiety disorder had two separate allegations of staff-to-resident abuse. The investigations into these incidents were incomplete, lacking documentation of staff and witness statements, and did not include monitoring for psychosocial harm or updates to the resident's care plan. The resident reported that no interventions were implemented to prevent recurrence, and staff confirmed that required documentation and care plan updates were not completed. A third resident with cerebral palsy, expressive language disorder, and cognitive communication deficit was involved in an abuse allegation reported by a roommate. The investigation did not include statements from the reporting resident, staff, or witnesses, and there was no documentation of how abuse or neglect was ruled out. Additionally, the care plan was not updated following the allegation, and staff confirmed that alert documentation and care plan interventions should have been completed but were not.
Failure to Conduct Thorough Investigations for Allegations of Abuse/Neglect
Penalty
Summary
The facility failed to conduct thorough investigations for allegations of abuse/neglect involving two residents. For Resident 1, who was admitted with diagnoses including sepsis, acute cystitis, myasthenia gravis, and mild cognitive impairment, there was no documentation of the alleged abuse/neglect reported by the resident's family in the progress notes. The investigation completed by the Administrator and the RN Director of Nursing Services lacked statements from the resident, their family member, or the nursing staff involved. Additionally, the Social Services Director did not document the allegation or communication with the family member, and no statements were obtained as part of the investigation. For Resident 2, who was admitted with conditions such as osteoporosis, Parkinson's disease, dementia, anxiety, and major depressive disorder, the investigation into an unwitnessed fall did not include any resident or staff statements. The RN Director of Nursing Services acknowledged that statements from residents and staff should have been obtained and included in the investigation. There was also no documentation related to the allegations in Resident 1's medical record or alert charting documentation to monitor for psychosocial or latent injury. The Administrator confirmed the lack of documentation and agreed that statements should have been obtained during the investigation process.
Facility Administration Fails to Maintain Compliance and Oversight
Penalty
Summary
The facility administration failed to maintain compliance with federal and state regulatory requirements, resulting in several deficiencies that placed residents at risk for unmet care needs and diminished quality of life. The administration did not provide adequate oversight and monitoring of facility personnel, systems, policies, and practices. Specific areas of deficiency included care plan timing and revision, professional standards of care, ensuring nursing staff competency, completion of required nursing assistant performance reviews, psychotropic medication management, infection control, and coordination of dental services. The facility's last annual certification Statement of Deficiencies highlighted repeat issues in these areas, indicating a lack of improvement or corrective action. The administrator acknowledged in an interview that no quality assurance or performance improvement projects had been undertaken to address these deficiencies. This lack of action and oversight contributed to the ongoing non-compliance and risk to resident care and safety.
Failure to Assess Nursing Assistant Competencies
Penalty
Summary
The facility failed to ensure that nursing assistant competencies were assessed and completed yearly for five staff members, identified as L, N, O, P, and Q. This deficiency was identified through interviews and record reviews, which revealed that none of these staff members had documentation of a yearly skills checklist being performed. Staff L, who was hired over a year ago, confirmed in an interview that they had not undergone any competency or skill checks, except for a hand hygiene observation a few months prior. Similarly, the employee files for Staff N, O, P, and Q, all hired within the past year, showed no evidence of completed yearly skills checklists. The facility's assessment indicated that staff competencies were required for various activities of daily living, including daily care, bed mobility, transfers, and more. However, an email from the Administrator confirmed the absence of competencies for the mentioned staff members. In a joint interview, the Administrator and the Director of Clinical Services admitted that there was no performance improvement plan in place for assessing competencies. This issue was noted as a repeat deficiency from the previous year, indicating a persistent problem in maintaining staff competency assessments.
Failure to Conduct Annual NAC Performance Reviews
Penalty
Summary
The facility failed to conduct annual performance reviews for five Nurse Aide Certified (NAC) employees who had been employed for over a year. This deficiency was identified through interviews and record reviews, which revealed that the employee files for Staff L, N, O, P, and Q lacked current evaluations. The facility's handbook, dated May 2023, outlines a performance management system intended to provide feedback and set objectives for employees, but this process was not followed for the mentioned staff members. Interviews with Staff L and the facility's administration confirmed the absence of performance evaluations. Staff L, who had been employed for over a year, stated they had not received an evaluation. The facility's administrator and the Director of Clinical Services acknowledged the lack of a performance improvement plan for conducting evaluations. This issue was noted as a repeat deficiency from a previous survey conducted in November 2023.
Unsanitary Conditions in Nourishment Rooms and Kitchen
Penalty
Summary
The facility failed to maintain sanitary conditions in two nourishment rooms and the facility kitchen, placing residents at risk for foodborne illnesses. Observations revealed that the refrigerator/freezer units in the East and [NAME] unit nourishment rooms were soiled with food matter and spillage, and the microwave ovens were very soiled with food splattering and debris. Additionally, the toasters in these nourishment rooms were observed to be quite soiled. Staff K, the Dietary Manager, indicated that kitchen staff were responsible for cleaning the refrigerator/freezer units, while housekeeping was responsible for cleaning the toasters and microwave ovens. Further observations in the facility kitchen revealed that the overhead light fixtures in the food preparation and dishwashing areas were soiled with extensive splattering, debris, and dead insects. Staff K was unaware of any cleaning schedule for the overhead light fixtures. Despite the initial observation, a follow-up observation confirmed that the overhead light fixtures remained very soiled, indicating a lack of corrective action or cleaning schedule in place to address the unsanitary conditions.
Failure to Maintain Clean and Sanitary Privacy Curtains
Penalty
Summary
The facility failed to maintain a clean and sanitary environment for its residents, specifically in relation to the laundering or replacement of privacy curtains in resident rooms. Observations and interviews revealed that the privacy curtains in the rooms of two residents were heavily soiled with brown and black stains. These curtains remained unchanged over several days, indicating a lack of regular housekeeping services to address the issue. Both residents reported being unaware of when their curtains were last laundered or replaced, highlighting a gap in the facility's housekeeping practices. Interviews with staff members, including the Housekeeping Supervisor and the Administrator, revealed that there was no established schedule or policy for replacing or laundering privacy curtains. The Housekeeping Supervisor mentioned that curtains were only changed when a new resident moved into a room, if time permitted. The Administrator acknowledged the issue and stated that more privacy curtains had been ordered, but confirmed the absence of a formal policy regarding curtain maintenance. This lack of protocol contributed to the unsanitary conditions observed in the residents' rooms.
Failure to Resolve and Document Resident Grievances
Penalty
Summary
The facility failed to promptly resolve and document resident grievances for two residents, leading to delays in grievance resolution and potential impacts on their quality of life. Resident 67, who had no cognitive impairment, reported missing clothing items, including a nightgown, pajamas, and pants, which had been missing for nearly a month. Despite informing various staff members, including a housekeeper and a nursing assistant, the grievance was not documented or resolved in a timely manner. The facility's grievance log did not reflect any grievances for Resident 67 during the relevant period, and the resident was dissatisfied with the resolution offered, which involved providing donated clothes instead of recovering the missing items. Resident 4, who had a history of cerebrovascular accident with hemiparesis and mild cognitive impairment, expressed dissatisfaction with the care provided by a nurse's aide, stating that the aide did not provide adequate care. Although the grievance was documented, there was no evidence of a thorough investigation or monitoring of the resident's care following the complaint. The grievance was not escalated to an incident report, and there was no documentation in the clinical record or incident reporting log regarding the resident's concerns. The facility's failure to document, investigate, and resolve these grievances in a timely manner highlights deficiencies in their grievance handling process. The lack of proper documentation and follow-up for both residents' grievances suggests a systemic issue in addressing and resolving resident concerns, potentially affecting the residents' quality of life and satisfaction with their care.
Failure to Complete Significant Change Assessment for Resident
Penalty
Summary
The facility failed to complete a Significant Change in Status Assessment (SCSA) for a resident who experienced a decline in their Activities of Daily Living (ADL) abilities. Resident 12, who was admitted with diagnoses including muscle weakness, major depressive disorder, and alcoholic cirrhosis of the liver, did not have an ADL care plan with interventions or goals in place. Despite the resident's expressed concerns about losing muscle strength and feeling weaker, the facility did not complete the required SCSA within the mandated timeframe, as indicated by the review of the Quarterly MDS assessment. Interviews with staff revealed a lack of communication and coordination regarding the resident's decline. A Nursing Assistant Certified (NAC) and a Licensed Practical Nurse (LPN) both noted the resident's weakening condition, yet there was no update to the resident's treatment plan. The Director of Nursing (DON) mentioned reliance on physical therapy to determine the need for restorative services, but it was unclear if a program was in place or if the resident was following it. The Registered Nurse (RN) responsible for MDS assessments acknowledged that a significant change assessment should have been completed, but it was not done for Resident 12.
Inaccurate Resident Assessments in LTC Facility
Penalty
Summary
The facility failed to accurately assess three residents, leading to deficiencies in care planning and service provision. Resident 67, who was admitted with a colostomy, was inaccurately assessed in the Minimum Data Set (MDS) as having no ostomy and being continent of bowels, despite having a colostomy for bowel movements. This discrepancy was confirmed during an interview with the Director of Nursing, who acknowledged the MDS was incorrect. Resident 4, who had a history of cerebrovascular accident with hemiparesis and hemiplegia, was inaccurately assessed for pressure ulcers. The MDS nurse coded the resident's pressure ulcers as stage III and IV without examining the resident, relying instead on wound notes. This was inconsistent with a provider's visit note that documented stage IV ulcers. Additionally, Resident 65, who required enteral feeding due to dysphagia, was incorrectly coded in the MDS as having no swallowing disorder or feeding tube, despite receiving tube feeding. The MDS nurse admitted to coding errors and limited interviews during the admission process.
Failure to Complete and Update PASRR Screenings
Penalty
Summary
The facility failed to ensure a Level II Preadmission Screening and Resident Review (PASRR) was completed for a resident with serious mental illness (SMI), intellectual disability (ID), or a related condition when the scheduled discharge did not occur. Resident 18, who was admitted with diagnoses including depression, anxiety disorder, and a history of delirium, had a Level I PASRR form indicating an exempted hospital discharge. However, a Level II evaluation was required as the resident remained in the facility beyond 30 days. Despite notifications to the PASRR evaluator, the assessment was not completed in a timely manner, as confirmed by the Social Services Director and other staff members. Additionally, the facility did not ensure the accuracy of a Level I PASRR screening form for another resident prior to admission. Resident 38, admitted with a dislocation of a right hip prosthesis and dementia with behavioral disturbance, was taking Seroquel, an antipsychotic medication, which was not reflected in the PASRR form. The medication was started after a hospital discharge, and the Licensed Practical Nurse/Resident Care Manager confirmed the absence of an updated PASRR. The Social Services Director stated that the hospital should have provided an updated PASRR reflecting the new medication.
Care Plan Revision Deficiencies
Penalty
Summary
The facility failed to ensure that care plans were revised to reflect changes or the current status of three residents, leading to a risk of suboptimal care. Resident 4, who was admitted with a cerebrovascular accident and related conditions, had a care plan that did not reflect their current status. Despite having a history of recurring skin breakdown and current Stage IV pressure ulcers, the care plan was not updated to reflect that the resident was mostly bedridden, contrary to the care plan's indication that they preferred to remain in a wheelchair. Resident 7, diagnosed with multiple sclerosis and quadriplegia, experienced issues with their electric wheelchair, which had been non-functional for nearly ten months. The care plan, which directed staff to provide an appropriate adaptive electric wheelchair, was not updated to reflect the resident's current use of a manual wheelchair, which lacked a seatbelt and was uncomfortable. Staff were unaware of the resident's current wheelchair situation, indicating a lack of communication and care plan revision. Resident 17, with a right artificial hip and chronic conditions, had a care plan that lacked specific goals and interventions for discharge planning. Despite the resident's goal to return home by Thanksgiving, the care plan did not reflect this, and staff had not discussed discharge planning with the resident. The Social Services Director admitted to not completing the necessary care plan updates, which contributed to the deficiency. This issue was a repeat deficiency, indicating ongoing problems with care plan management.
Failure to Follow Physician Orders and Medication Parameters
Penalty
Summary
The facility failed to adhere to professional standards of practice for medication administration and follow-up on physician orders for three residents. Resident 38, who was admitted with a dislocated right hip prosthesis and dementia, was sent to the emergency room for a hip dislocation. The emergency department recommended palliative or hospice care, but the facility did not document any follow-up on this recommendation. Interviews with staff revealed that there was no documentation of discussions with the resident or their spouse regarding the recommended care. For Resident 7, who was admitted with heart failure, the facility did not consistently check blood pressure before administering Lasix, as required by the physician's order. The medication was given without daily blood pressure checks, and the Medication Administration Records (MAR) lacked a section to document blood pressure readings. Similarly, Resident 17, admitted with hypertension, received Hydralazine without the necessary blood pressure checks as per the physician's order. The MAR did not include a section for documenting blood pressure every six hours, and staff interviews confirmed the absence of a policy on medication parameters. The facility's failure to follow these orders was not addressed in their Quality Assurance Performance Improvement (QAPI) program, and this issue was a repeat deficiency.
Failure to Conduct Regular Care Conferences for Resident
Penalty
Summary
The facility failed to advocate and assist a resident, identified as Resident 38, in exercising their rights within the facility, specifically by not conducting care planning meetings to ensure the resident's voice was heard regarding their care and preferences. Resident 38 was admitted with diagnoses including dislocation of a right hip prosthesis and unspecified dementia with behavioral disturbance. The facility's policy required interdisciplinary care conferences upon admission, quarterly, and following significant changes in condition, with the resident and/or their representative invited to attend. However, the last documented care conference for Resident 38 was on January 24, 2024, despite the resident's spouse, CC1, indicating that no care conferences had occurred since then. Interviews with CC1 revealed dissatisfaction with the facility's communication regarding Resident 38's care, as they had not been informed about any care conferences since January 2024. The Social Services Director, Staff G, confirmed that care conferences should occur at least quarterly and that the electronic health records system would notify them 14 days in advance of a due conference. Despite this, Staff G could not provide documentation of any care conferences for Resident 38 after January 2024 and was unsure why further conferences had not been held. This lack of care conferences placed residents at risk for unmet care needs and diminished quality of life.
Failure to Ensure Residents Are Free from Unnecessary Psychotropic Medications
Penalty
Summary
The facility failed to ensure that two residents were free from unnecessary psychotropic medications, which placed them at risk for adverse events and diminished quality of life. Resident 38 was administered Seroquel, an antipsychotic medication, for unspecified dementia with behavioral disturbance, which is not an appropriate indication for its use. The facility did not have documentation of a valid diagnosis for the use of Seroquel, nor did they attempt gradual dose reductions (GDR) or provide documentation of contraindications for GDR. Interviews with staff revealed uncertainty about the appropriateness of the diagnosis and lack of documentation regarding GDR attempts. Resident 58 was administered Olanzapine, another antipsychotic medication, despite having no documented psychiatric or mood disorders or behaviors that warranted such treatment. The facility's records lacked any behavior monitoring to justify the use of Olanzapine, and staff interviews indicated a lack of awareness of any signs or symptoms of psychosis in the resident. This deficiency was noted as a repeat issue from a previous survey. The facility's policy required that psychotropic medications be reviewed quarterly to determine the appropriateness of continued use and the need for GDR. However, the facility failed to adhere to this policy, as evidenced by the lack of recent reviews for Resident 38 and the absence of behavior monitoring for Resident 58. These oversights contributed to the administration of unnecessary psychotropic medications to the residents.
Failure to Provide Dental Services for Residents
Penalty
Summary
The facility failed to assist with access to preventative and emergency dental services for two residents, leading to a deficiency. Resident 44, who was admitted with diagnoses including heart failure, history of stroke, and difficulty swallowing, had a care plan indicating dental care needs due to paralysis and dental caries. Despite this, the resident had not seen a dentist since admission and was unaware of the option to do so. Staff interviews revealed a lack of routine dental processes, with dental services only sought if requested by a resident. The Resident Care Manager was unaware of Resident 44's dental issues, and the facility administrator was not aware of the lack of a preventative dental service process. Resident 15, a long-term care resident, also experienced a lack of follow-up on dental services. The resident's representative had requested a preventative dental appointment during a care conference, but no appointment was scheduled, and there was no order for a dental visit in the resident's clinical record. Staff interviews indicated that the Resident Care Manager was not informed of the need for a dental appointment, and this issue was a repeat deficiency from the previous year.
Deficiencies in Incident Investigations and Care Planning
Penalty
Summary
The facility failed to conduct thorough investigations for several incidents involving three residents, leading to deficiencies in identifying root causes and implementing effective care plans. Resident 1, who had severe cognitive impairment and required assistance with daily activities, experienced multiple falls. The investigations into these falls lacked witness statements, documentation of the last time the resident was checked on, and whether the care plan was followed. Staff interviews revealed a lack of clarity on monitoring plans and interventions to prevent future falls. Resident 6, who had a stroke, was involved in an incident where their tube feeding was administered at an incorrect rate. The investigation did not identify the nurses involved, lacked witness statements, and failed to document the duration of the incorrect feeding rate. Staff interviews indicated uncertainty about which nurses were responsible and a lack of documentation on the education provided to prevent recurrence. Resident 7, also a stroke patient, received blood pressure medications that should have been withheld due to low pulse parameters. The investigation showed discrepancies between the medication administration records and progress notes, with no witness statements or identification of the nurse responsible. Staff interviews highlighted a lack of documentation and clarity on the measures taken to prevent similar incidents.
Inaccurate Clinical Records and Documentation Discrepancies
Penalty
Summary
The facility failed to maintain complete and accurate clinical records for three residents, leading to potential risks for unmet needs and diminished quality of life. For Resident 1, who was admitted with Alzheimer's disease and post-surgical rehabilitation needs, there was a lack of timely documentation regarding multiple falls. An incident on 09/04/2024 was not documented until 09/06/2024, and the care plan inaccurately recorded the locations of subsequent falls. Additionally, there was no documentation of the resident's food preferences, which led to issues with obtaining fresh fruit. Resident 6, admitted with a stroke, had discrepancies in the documentation of their Jevity tube-feeding solution and free water flushes. The Medication Administration Records (MARs) showed inconsistent and conflicting entries regarding the amounts administered, with some entries missing entirely. This lack of accurate documentation could affect the resident's nutritional and hydration status. For Resident 7, also admitted with a stroke, there was a discrepancy between the MARs and progress notes regarding the administration of blood pressure medications. The progress note and incident investigation indicated that medications were given despite the resident's heart rate being below the parameter limits, while the MARs showed they were not administered. This inconsistency in documentation could lead to medication errors and adverse health outcomes.
Failure to Provide Adequate Oral Care for Resident
Penalty
Summary
The facility failed to provide necessary assistance with activities of daily living (ADLs), specifically oral care, for a resident with severe cognitive impairment due to Alzheimer's disease. The resident was admitted with a care plan indicating the need for oral care twice daily with supervision or touching assistance. However, documentation revealed that the resident did not receive oral care on one day and only received it once daily on nine other days within the review period. A collateral contact reported that staff were not brushing the resident's teeth, necessitating their intervention. During an interview, the facility's Administrator and Director of Nursing could not provide information regarding the lack of oral care, acknowledging the absence of documentation as evidence of the deficiency.
Inadequate Supervision and Fall Prevention for High-Risk Resident
Penalty
Summary
The facility failed to provide adequate supervision and implement appropriate interventions to prevent accidents and falls for a resident with severe cognitive impairment and multiple medical conditions, including Alzheimer's disease and atrial fibrillation. The resident experienced five falls within the first eight days of admission, indicating a lack of effective fall prevention measures. Despite being identified as a high fall risk, the facility did not consistently implement or document necessary interventions, such as one-to-one monitoring or frequent checks. The report highlights several incidents where the resident was found on the floor, often unwitnessed, and attempts to transfer or ambulate without assistance were identified as root causes. The facility's response to these incidents was inadequate, as there was no documented plan for increased supervision or consistent implementation of interventions like one-to-one monitoring. Staff education on monitoring the resident was informal and undocumented, and the care plan did not reflect necessary interventions to address the resident's impulsivity and fall risk. Interviews with facility staff revealed a lack of documentation and planning to prevent future falls. The facility did not have a documented plan for increased supervision, and there was no evidence of staff education or consistent monitoring. The resident's care plan was not updated to include necessary interventions, and the facility's failure to provide adequate supervision placed the resident at risk for further falls and injuries.
Infection Control Breach During Resident Care
Penalty
Summary
Facility staff failed to adhere to appropriate infection control practices during the care of two residents, leading to potential cross-contamination. Resident 2, who was cognitively intact and incontinent of urine and bowels, was observed receiving peri care from Staff C, a CNA. During the process, Staff C used contaminated gloves to touch the privacy curtain and then placed a clean brief on the resident without changing gloves, thereby contaminating the clean brief. Furthermore, after removing the contaminated gloves, Staff C did not perform hand hygiene before adjusting the resident's gown and blanket, leading to further contamination. Similarly, Resident 3 was observed receiving peri care from Staff D, a CNA, who failed to doff gloves or perform hand hygiene before placing a clean brief on the resident, resulting in contamination. Staff C, who assisted in the care, also used contaminated gloves to secure the resident's clean brief. These actions were in violation of infection control standards, as outlined in WAC 388-97-1320 (1)(a)(c), and placed residents at risk of living in a contaminated environment.
Failure to Monitor and Address Resident's UTI Symptoms
Penalty
Summary
The facility failed to provide resident-focused care by not consistently monitoring, assessing, and evaluating the condition of a resident suspected of having a urinary tract infection (UTI). The resident, who had a history of low back pain, chronic pain, cardiomyopathy, and spondylosis, was admitted with moderately impaired cognition and dementia. Despite these conditions, the facility did not adequately monitor the resident's health status, leading to a lack of timely intervention for a suspected UTI. The resident experienced unwitnessed falls and was referred for a physical therapy evaluation, which was not completed. Progress notes indicated that the resident was on alert monitoring for pain management, but there were lapses in documentation and communication regarding changes in the resident's condition. The resident exhibited symptoms such as fever, elevated heart rate, increased respirations, and gastrointestinal issues, which were not promptly addressed, and the physician was not notified until the day of the resident's passing. Interviews with staff revealed that there were missed opportunities to report changes in the resident's condition, such as increased incontinence and changes in behavior. The facility's infection preventionist expected staff to report any changes in urination patterns or cognitive function, but this did not occur. The Director of Nursing Services acknowledged the need for staff to report changes in residents' conditions, but the lack of communication and follow-through contributed to the resident's unmet needs and eventual passing.
Failure to Ensure Timely Physician Visits
Penalty
Summary
The facility failed to ensure timely physician visits for a resident, as required by regulations. The resident, who was admitted with conditions including low back pain, chronic pain, cardiomyopathy, and spondylosis, was not seen by a physician every 30 days for the first 90 days after admission. The electronic health record indicated that the resident was seen by a physician on four occasions but missed visits in two consecutive months. This lapse in care was attributed to the departure of the physician overseeing the resident's care, and the subsequent delay in assigning a new physician. Interviews with facility staff and the resident's representative revealed that the resident's care was neglected due to the physician's departure. The resident's representative expressed concerns about neglect, which prompted a physician visit. The medical director confirmed that the physician left their practice, and they had to fill in as needed, but did not see the resident until the day before the resident expired. The administrator acknowledged the requirement for residents to be seen by a physician within three days of admission but did not provide further information.
Failure to Report Allegation of Abuse Promptly
Penalty
Summary
The facility failed to ensure that an allegation of abuse was reported immediately, as required by their policy. Resident 1, who has diagnoses including chronic respiratory failure, chronic obstructive pulmonary disease, and schizophrenia, reported to multiple staff members that they had been punched in the eye by a staff member. Despite this, there was no documentation of the allegation in the resident's progress notes on the day of the incident. The allegation was eventually reported to the state over 12 hours after it was initially made, which is a violation of the facility's policy that mandates immediate reporting within 2 hours. Staff interviews revealed that the initial report of abuse was not taken seriously due to the resident's diagnosis of schizophrenia. Staff C, who was informed of the allegation by both the resident and the accused staff member, did not report the incident to the state agency as required. The Director of Nursing Services confirmed that the expectation was for an immediate response, including mandated reporting and ensuring the safety of the resident. The failure to report the allegation promptly placed Resident 1 and other residents at risk for potential continued abuse and unrecognized abuse.
Failure to Protect Residents During Abuse Investigation
Penalty
Summary
The facility failed to ensure residents were protected during the investigation phase of an alleged abuse incident involving a Nursing Assistant Certified (NAC). After Resident 1 reported being slapped by Staff E, the facility did not immediately suspend Staff E as required by their policy. Instead, Staff E continued to provide care to Resident 1 and other residents for the remainder of their shift. This failure to act promptly placed all residents at risk for continued potential abuse and decreased their quality of life. Additionally, the allegation was not reported to the state hotline within the required 2-hour timeframe, and there was no documentation of the incident in Resident 1's progress notes on the day of the allegation. Interviews with various staff members revealed that Staff C, who was initially informed of the allegation, did not believe the resident's claim and failed to take appropriate action, including removing Staff E from duty and reporting the incident. The Director of Nursing Services confirmed that no safety precautions or protections were put in place for Resident 1 or other residents on the morning of the incident. The facility's policy clearly stated that the alleged perpetrator should be immediately suspended to protect residents from further harm, but this protocol was not followed, leading to a significant deficiency in resident safety and care.
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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