Regency Wenatchee Rehabiliation & Nursing Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Wenatchee, Washington.
- Location
- 1326 Red Apple Rd, Wenatchee, Washington 98801
- CMS Provider Number
- 505382
- Inspections on file
- 30
- Latest survey
- May 6, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Regency Wenatchee Rehabiliation & Nursing Center during CMS and state inspections, most recent first.
The facility failed to identify and address accident hazards for two residents, resulting in one resident sustaining a third-degree burn from hot soup and another experiencing multiple falls without thorough investigation or consistent intervention. Staff did not assess the ability to handle hot liquids or adequately investigate the causes of repeated falls, leading to increased risk of injury and compromised resident safety.
The facility did not provide required bed hold notifications to residents or their representatives during hospital transfers and failed to notify the LTC Ombudsman of resident discharges. Staff interviews revealed that residents and their representatives were not informed about bed hold options, and the medical records staff was unaware of the obligation to notify the Ombudsman, resulting in lapses in communication and documentation for several residents.
The facility did not complete or properly document baseline care plans within 48 hours of admission for several residents with complex medical needs, resulting in missing or incomplete information such as care goals, physician and dietary orders, and treatment plans. Staff interviews indicated that recent staffing changes and lapses in following procedures led to these deficiencies.
The facility did not designate a specific IDT member to coordinate hospice care or maintain required documentation, including hospice election forms and physician certifications, for two residents receiving hospice services. Both residents' records lacked evidence of a responsible staff member and necessary hospice care plans, and staff interviews confirmed a lack of awareness and adherence to required processes for hospice coordination.
A resident with multiple mental health diagnoses, including dementia, delirium, hallucinations, anxiety, and depressive disorder, was admitted without an accurate PASARR Level I screening. The form failed to identify serious mental illness indicators and did not trigger a required Level II evaluation, despite the resident's documented conditions. Both the Social Services Director and Administrator acknowledged the oversight in the review process.
The facility did not follow CDC and internal policy for monitoring the temperature of a refrigerator storing influenza and pneumococcal vaccines, recording temperatures only once daily instead of the required twice daily. The issue was attributed to the use of an incorrect temperature log, as confirmed by the Regional Clinical Director.
A resident who was cognitively intact and required an additional pneumococcal vaccine dose was not offered the vaccine, nor was there documentation of consent, refusal, or education on risks and benefits. Staff interviews confirmed that the required process for offering and documenting the pneumococcal vaccine, including education, was not followed.
A resident with impaired cognition and recent admission reported missing cash, of which only a portion was recovered by staff. The facility did not document the grievance, failed to investigate the full amount reported missing, and did not provide the resident with updates or a written resolution, contrary to facility policy.
A nursing assistant witnessed a registered nurse verbally and physically abuse a resident with moderate cognitive impairment and other medical conditions, but did not report the incident to the State Agency within the required two-hour timeframe. The delay in reporting was confirmed by the DON, resulting in non-compliance with mandated abuse reporting policies.
Two residents were not adequately protected or thoroughly investigated following allegations of abuse and multiple falls. In one case, a resident with cognitive impairment and a recent amputation experienced alleged physical and verbal abuse by an RN, but the incident was not promptly reported or fully investigated, and the resident was not immediately protected. In another case, a resident with dementia and joint disease had multiple unobserved falls, but the facility did not complete thorough investigations or consistently update care interventions. Leadership acknowledged these deficiencies in both protection and investigative processes.
Nursing staff failed to follow professional standards for central line management by not documenting required measurements, moving a PICC line during a dressing change, and continuing IV infusions after line migration without provider notification. Additionally, staff did not process or implement physician orders for wound care for a resident with a necrotic toe, resulting in missed dressing changes and lack of prescribed interventions.
A facility failed to maintain a safe environment by placing a 1500-watt oil-filled space heater in a resident's room after the thermostat malfunctioned. The heater was hot to the touch, posing a risk of injury. The Maintenance Director placed the heater without notifying the Administrator, who stated that the correct procedure was to relocate the resident until the issue was fixed.
The facility failed to document and incorporate Advanced Directives (ADs) into the care plans for three residents, placing them at risk of not having their end-of-life care preferences followed. Interviews revealed that the Social Services Director did not have a process for follow-up if an AD was refused, and the facility administrator expected ADs to be addressed on admission and during quarterly care conferences, which was not consistently done.
The facility failed to conduct proper IDT care conferences for two residents, with one not having a care conference for over a year and another not since 2022. Additionally, required IDT members were not present at care conferences for two other residents. Staff interviews revealed inconsistencies in the understanding and execution of IDT care conferences.
The facility failed to ensure restorative therapy services, including the consistent use of braces and splints, were implemented for four residents. One resident with Parkinson's disease and contractures did not receive consistent exercises or adjustments to their new wheelchair, leading to immobility. Another resident with a stroke and hand contracture did not have a documented restorative program or wearing schedule for their hand brace. A third resident with dementia had not been assessed for therapy or placed on a restorative program since admission. Lastly, a resident requiring an ankle-foot brace did not have it consistently applied as per physician's orders.
The facility failed to ensure proper administration and documentation of enteral feedings and fluid intake via g-tube for a resident with difficulty swallowing and malnutrition. Staff did not check residuals or ask about symptoms, and documentation showed discrepancies in the amount of formula and free water administered, putting the resident at risk for dehydration and fluid imbalance.
The facility failed to maintain a medication error rate of less than five percent, resulting in an error rate of 28.57%. Errors included not priming insulin pens before administration for two residents with diabetes and administering medications three hours late for another resident. Staff admitted to not following proper procedures, and the Regional Director of Nursing Services acknowledged the need for correct insulin administration and adherence to medication schedules.
The facility failed to verify licensure for a NAR who worked with an expired license and did not provide documented annual abuse and neglect training for five staff members. This lack of oversight and training placed residents at risk for unrecognized abuse and unmet care needs.
The facility failed to complete a self-administration of medications assessment for a resident with Alzheimer's and dementia, leading to medications being left unattended in the resident's room. Staff admitted to leaving medications, which the resident sometimes destroyed, resulting in potential missed doses. An assessment was only completed after surveyor intervention, deeming the resident unsafe for self-administration.
The facility failed to provide a comfortable and appropriate length bed for a resident with lower spine degeneration and left foot drop. Despite multiple observations of the resident's feet pressing against the footboard and causing skin issues, no immediate solution was provided, as the only available bed extender was in use by another resident.
The facility failed to provide a Skilled Nursing Facility (SNF) Advance Beneficiary Notice (ABN) to a resident when their Medicare Part A skilled nursing and rehabilitation services ended. The resident, who required limited assistance for activities of daily living and had intact cognition, remained in the facility beyond the last covered day without receiving the required ABN, preventing them from making informed financial and care decisions.
The facility failed to maintain a homelike environment, with multiple rooms showing significant physical damage and improper storage of nutritional supplies. Additionally, two residents reported excessively noisy beds that disturbed their sleep, an issue acknowledged by staff but without a current plan for resolution.
A resident with dementia had a missing hearing aid, and the facility failed to follow its grievance procedure to resolve the issue. The resident's representative reported the missing item, but the Activities Director and Administrator did not document or track the grievance, leading to no resolution.
The facility failed to provide a written bed hold notice to a resident at the time of transfer to the hospital, as required by their policy. The resident, who had chronic kidney disease and required extensive assistance, was transferred without receiving the necessary documentation. Interviews confirmed that the facility's process was not being followed correctly.
The facility failed to ensure the PASARR was accurately completed for a resident admitted with depression and insomnia, placing the resident at risk of inappropriate placement and unmet care needs. Staff interviews indicated that the Social Services Director was responsible for reviewing PASARRs, but this was not done correctly.
A resident with contractures and Parkinson's disease struggled to eat independently due to the facility's policy requiring meal assistance only in the dining room. Despite the resident's preference to eat in their room, staff did not provide the necessary help, leading to frustration and difficulty during meals.
The facility failed to follow physician orders for bowel and pain management for a resident with constipation and fractures. The resident experienced multiple shifts without a bowel movement, and pain medication was inconsistently administered, leading to unmet care needs and potential negative health outcomes.
The facility failed to ensure pre/post dialysis communication forms and vital signs were completed for a resident requiring dialysis. The medical record showed inconsistent documentation, and staff interviews confirmed that vital signs were not consistently monitored after dialysis, and communication forms were often not completed or returned.
The facility failed to provide trauma-informed care for a resident with a history of trauma and loss. Despite the resident's disclosure of past trauma and the need for a care plan, no interventions were implemented. Staff changes and training issues contributed to this oversight, putting the resident at risk for re-traumatization and a decline in psychosocial well-being.
The facility failed to serve bedtime snacks to three residents, including those with diabetes, leading to inconsistent snack offerings and potential nutritional risks. Staff interviews and records revealed that snacks were available but not routinely offered, and meal service times created a long gap between dinner and breakfast.
The facility failed to ensure proper disposal of trash, as observed over several days with the dumpster lids left open and unsecured trash bags, including a mattress. Interviews revealed that staff were unaware of the requirement to keep the dumpster lids closed, leading to unsanitary conditions.
Failure to Prevent Accidents and Investigate Falls
Penalty
Summary
The facility failed to identify and mitigate accident risks for two residents, resulting in harm and increased risk of injury. One resident, who was cognitively intact but required moderate to maximum assistance for activities of daily living following a recent pelvic fracture, suffered a third-degree burn to the left thigh when hot soup was served on an overbed table. The resident attempted to pull the tray closer, causing the soup to spill onto their lap. The soup had been held at a temperature of 187 degrees Fahrenheit in the kitchen, and there was no process in place to ensure the temperature was safe for direct consumption or handling by residents. The facility did not assess the resident's ability to safely handle hot liquids after the incident, nor did they have protocols to check the temperature of microwaved food before serving. Additionally, the facility failed to provide consistent supervision and thorough investigation following multiple falls experienced by another resident with dementia, degenerative joint disease, and moderately impaired cognition. This resident had nine falls over five months, with only two of the incidents resulting in updated interventions to reduce fall risk. For the seven unobserved falls, there were no witness statements or thorough investigations to determine the cause or to rule out abuse or neglect. The care plan for this resident identified multiple risk factors for falls, but interventions were not consistently updated after each incident. Interviews with facility staff, including the Administrator, Director of Nursing, and Regional Clinical Director, confirmed that no follow-up assessments or comprehensive investigations were conducted after the incidents. The lack of individualized assessment for handling hot liquids and insufficient investigation and intervention following repeated falls contributed to ongoing risks for the residents involved.
Failure to Provide Bed Hold Notices and Notify LTC Ombudsman During Transfers and Discharges
Penalty
Summary
The facility failed to provide required written notices of bed hold policies to residents or their representatives at the time of hospital transfers, and did not send notifications of transfers or discharges to the Office of the State LTC Ombudsman for four residents reviewed for the discharge process. Specifically, for two residents who were transferred to the hospital, there was no documentation that either the residents or their representatives received information about the bed hold policy, nor were they contacted during the hospital stay to discuss the option of holding the resident's bed. Interviews confirmed that neither the residents nor their representatives recalled receiving such notifications or being informed about the possibility of bed holds. Additionally, for two other residents who were discharged, there was no documentation that the LTC Ombudsman was notified of their discharge, as required. Staff interviews revealed that the facility's process for notifying the Ombudsman had lapsed, with the current medical records staff unaware of the requirement to send such notifications since taking their position. The administrator acknowledged that the facility had not been sending out these notifications as required. Facility staff also indicated a misunderstanding of the requirements, believing that providing a bed hold policy in the transfer packet or automatically holding beds for Medicaid residents was sufficient to meet regulatory obligations. However, there was no evidence of individualized follow-up or confirmation that residents or their representatives were informed of their rights or the specifics of the bed hold policy at the time of transfer or discharge.
Failure to Complete Baseline Care Plans Within 48 Hours of Admission
Penalty
Summary
The facility failed to develop baseline care plans (BCPs) within 48 hours of admission for six out of ten residents reviewed for new admissions. The BCPs were either incomplete or missing, lacking essential elements such as resident-specific goals, physician orders, dietary orders, treatment plans, and social service needs. This was contrary to the facility's own policy, which required a BCP to be developed within 48 hours of admission to include the minimum healthcare information necessary for resident care. For several residents, the BCPs that were completed did not include required information. For example, one resident admitted with palliative care needs, Alzheimer's disease, severe malnutrition, and hospice services had a BCP that omitted resident-specific goals and interventions for dietary, social services, and hospice care. Another resident with sepsis and a PICC line for antibiotic therapy had a BCP that lacked goals and interventions for dietary orders, physician orders, social services, and PICC line care. Additional residents with complex medical needs, such as stroke, surgical aftercare, and amputation, either had incomplete BCPs or no BCP documentation at all. Interviews with facility staff revealed that recent staffing changes contributed to gaps in the completion of BCPs. Staff acknowledged that the process for developing BCPs was not being followed as required, and some BCPs were simply missed. The facility's process was described as including a review of the BCP within 24 hours of admission, but this was not consistently implemented for the residents reviewed.
Failure to Designate Hospice Care Coordinator and Maintain Required Documentation
Penalty
Summary
The facility failed to designate a specific member of the interdisciplinary team (IDT) to coordinate care and communication with hospice providers for two residents receiving hospice services. Facility policy and a written agreement required the identification of a responsible party for this coordination, as well as the implementation of a collaborative care plan between the facility and hospice. However, record reviews for both residents revealed no documentation of a designated staff member responsible for coordinating hospice care, nor evidence of required hospice documentation such as the hospice election form, physician certification of terminal illness, or the most recent hospice care plan. For one resident with Alzheimer's disease, severe malnutrition, and significant cognitive impairment, the medical record lacked documentation of a designated coordinator, hospice election form, physician certification, and a current hospice care plan. The resident's care plan referenced hospice services but did not specify what those services were or include the hospice care plan. For the second resident, who had cancer, severe malnutrition, and was cognitively intact, similar documentation gaps were found, including the absence of a designated coordinator, hospice election form, and physician certification. Interviews with facility staff and hospice personnel confirmed that the process for coordinating hospice care was not followed. Staff were unaware of the required documentation and the need for a designated coordinator, and communication between the facility and hospice was inconsistent. The administrator acknowledged that there was no appointed staff member for hospice coordination and was not aware of the regulatory requirement to designate one in writing.
Failure to Ensure Accurate PASARR Screening for Resident with Mental Health Diagnoses
Penalty
Summary
The facility failed to ensure the accuracy of the Preadmission Screening and Resident Review (PASARR) process for a resident with multiple mental health diagnoses. According to facility policy, the admission coordinator or designee is required to request and review a PASARR Level I screening prior to admission, with Social Services responsible for verifying its accuracy. For one resident, the PASARR Level I form indicated no serious mental illness indicators and did not trigger a Level II evaluation, despite the resident having documented diagnoses of dementia, delirium, hallucinations, anxiety, and depressive disorder. The comprehensive assessment also showed the resident had severely impaired cognition, required substantial assistance with activities of daily living, and was receiving hospice services. During interviews, the Social Services Director acknowledged responsibility for reviewing the PASARR form and admitted the form was filled out incorrectly, stating it should have been referred for a Level II evaluation prior to admission. The Administrator confirmed that both the admissions coordinator and Social Services Director were responsible for reviewing the PASARR forms and was unsure how the error was missed. The deficiency was identified through observation, interview, and record review, and was cited under WAC 388-97-1915(1)(2)(a-c).
Failure to Monitor Vaccine Refrigerator Temperatures per CDC Guidelines
Penalty
Summary
The facility failed to adhere to CDC guidance and its own policy regarding the monitoring of vaccine storage temperatures. Specifically, the refrigerator used to store influenza and pneumococcal vaccines was only monitored for temperature once daily, as evidenced by the temperature log posted on the refrigerator for the months of March, April, and May. According to CDC guidance and the facility's policy, temperature monitoring should occur at least twice daily when a digital data logger is not used. During an observation, it was noted that the incorrect temperature log was posted for staff to complete, resulting in the failure to meet the required monitoring frequency. This deficiency was confirmed during an interview with the Regional Clinical Director, who acknowledged that the vaccines required twice daily monitoring and that the wrong log had been used.
Failure to Offer and Document Pneumococcal Vaccine and Education
Penalty
Summary
The facility failed to ensure that a resident was offered the pneumococcal vaccine, nor was there documentation of the resident's refusal or acceptance of the vaccine, or education on the risks and benefits. The facility's policy required that residents be offered the pneumococcal vaccine, with consent obtained and education provided, unless medically contraindicated. However, review of the resident's medical record showed that although the resident was assessed as cognitively intact and able to make their needs known, there was no evidence that the vaccine was offered or that education was provided. The resident had a history of receiving one pneumococcal vaccine, but according to the PneumoRecs VaxAdvisor tool, an additional dose was required to be up-to-date, and this was not addressed by the facility. Interviews with the resident, the DON, and the Regional Clinical Director confirmed that the correct process was not followed. The resident stated they had not been offered or educated about the pneumococcal vaccine and was unaware of the risks and benefits. Both the DON and the Regional Clinical Director acknowledged that the resident needed another dose and that the required process for offering and documenting the pneumococcal vaccine, including education, was not followed.
Failure to Promptly Resolve and Document Resident Grievance Regarding Missing Money
Penalty
Summary
The facility failed to ensure that grievances voiced by a resident were promptly resolved and that the resident was appropriately updated on the progress and conclusion of the grievance. Specifically, a resident who was admitted with multiple medical conditions, including pneumonia, insomnia, sepsis with septic shock, and delirium, reported that $193 in cash went missing shortly after admission. Although $93 was found by staff in the laundry and turned over to the Administrator, the resident stated that an additional $100 was still missing. The resident reported discussing the missing money with the Administrator, who indicated that an investigation would be conducted, but the resident did not receive any further updates or the missing funds. Interviews with staff revealed that the process for handling found money involved filling out a grievance form and submitting the money to the Administrator. However, there was no documentation in the facility's grievance log regarding the missing money, and the Administrator acknowledged that a grievance form was not completed and that there was no documentation of investigative steps or resolution. The facility's policy required prompt efforts to resolve grievances, keep residents informed, and provide written decisions, but these procedures were not followed in this case.
Failure to Timely Report Witnessed Abuse Incident
Penalty
Summary
Nursing staff failed to immediately report a witnessed incident of verbal and physical abuse involving a resident with moderate cognitive impairment, right below the knee amputation, anxiety, long-term pain, and peripheral vascular disease. The incident occurred when a registered nurse, while providing care, grabbed the resident's arm, shoved them, and used profane language after the resident did not turn quickly enough during incontinent care. The abuse was witnessed by a nursing assistant, who did not report the incident to other staff or the State Agency until several hours later, outside the required two-hour reporting window outlined in facility policy. The Director of Nursing Services confirmed that the report to the State Agency was not made until after they were informed of the incident, which was not in accordance with the facility's policy requiring immediate reporting of abuse allegations. The failure to promptly report the witnessed abuse resulted in non-compliance with mandated reporting requirements and placed the resident at risk for unidentified and potentially ongoing abuse.
Failure to Protect Residents and Conduct Thorough Abuse/Neglect Investigations
Penalty
Summary
The facility failed to immediately implement effective protective measures and conduct thorough investigations in response to allegations of abuse and neglect for two residents. In the case of one resident with a right below-knee amputation, moderate cognitive impairment, and chronic pain, a nursing assistant reported witnessing a registered nurse physically and verbally abuse the resident during medication administration. The nursing assistant delayed reporting the incident due to fear of the nurse, and did not take steps to protect the resident from further harm. The alleged perpetrator was not immediately removed from access to the resident, and the resident’s representative was not promptly or thoroughly interviewed as part of the investigation. The investigation was incomplete, with staff interviews failing to corroborate the initial allegation, and the process for resident protection and data collection was not fully followed according to facility policy. For another resident with dementia and degenerative joint disease, the facility failed to thoroughly investigate a series of nine falls, seven of which were unobserved, over a five-month period. The incident reports for these falls lacked witness statements and did not document that abuse or neglect had been thoroughly ruled out as potential causes. The resident’s care plan, which identified a high risk for falls due to multiple medical and cognitive factors, was only updated with additional interventions after two of the nine falls, indicating a lack of comprehensive follow-up and prevention efforts after each incident. Interviews with facility leadership confirmed that investigations into the causes of the falls were not thorough and that limited interventions were implemented to prevent future incidents. The facility’s actions did not align with its own policy, which requires immediate protection of residents and comprehensive investigation of all alleged abuse, neglect, or unexplained injuries. These failures resulted in residents being at risk for unidentified abuse, unmet care needs, and potential continued exposure to abuse or neglect.
Failure to Follow Professional Standards for Central Line and Wound Care Management
Penalty
Summary
The facility failed to ensure that services provided met professional standards of practice in two key areas: management of a central vascular access device (CVAD) for one resident and processing and following physician orders for wound care for another resident. For the resident with a peripherally inserted central catheter (PICC) line, the facility's own guidance required documentation of external catheter length and upper arm circumference upon admission and during dressing changes, as well as the use of a securement device to prevent migration. However, the admission assessment did not include these measurements, and during a dressing change, the nurse moved and rotated the PICC line multiple times without a securement device in place. The external catheter length was found to have increased from six to nine centimeters, indicating migration, but IV medication continued to be infused through the line despite this finding and without provider notification, contrary to facility policy and professional standards. For the second resident, who was readmitted with a right below-the-knee amputation and a necrotic fourth toe on the left foot, the hospital transfer orders specified a dressing change every other day with betadine application and placement of gauze between the affected toes. Upon review, these orders were not processed or initiated by nursing staff, and the resident did not have a dressing or gauze in place for the necrotic toe. Nursing staff were only monitoring the toe daily and had not reviewed or implemented the wound care orders from the hospital. The omission was confirmed by both the nurse responsible for the admission assessment and the regional clinical director, who acknowledged that the transfer orders were missed and not followed. These failures resulted in residents not receiving care in accordance with professional standards and physician orders. The lack of proper documentation, assessment, and adherence to protocols for central line management and wound care placed residents at risk for improper medication delivery and delays in treatment, as evidenced by the continued use of a migrated PICC line and the absence of prescribed wound care interventions.
Improper Use of Space Heater in Resident Room
Penalty
Summary
The facility failed to ensure a resident environment free from accident hazards due to the placement of a 1500-watt oil-filled indoor electric space heater in a resident's room. During an observation, the space heater was found on the right side of the sink, turned on medium heat, and was hot to the touch, posing a risk of avoidable accidents or injury. Staff B, the Maintenance Director, admitted to placing the heater in the room after the thermostat stopped working and was unaware of any policy regarding space heaters. Staff B did not inform the Administrator about the heater placement. The Administrator stated that the correct procedure was to move the resident to another room until the heating issue was resolved, which Staff B failed to follow.
Failure to Address and Document Advanced Directives
Penalty
Summary
The facility failed to address required documentation for Advanced Directives (ADs) and incorporate them into the care planning process for three residents. Resident 6 had a Durable Power of Attorney for Healthcare (DPOA) but no preferences for end-of-life care documented in their care plan. Resident 15, who had severe cognitive impairment and required significant assistance with activities of daily living, did not have an AD in place, and their representative stated that the facility had not discussed formulating an AD or end-of-life preferences. Resident 16, who had moderate cognitive impairment and physical deficits due to a stroke, also did not have an AD, and there was no documentation showing that the facility offered assistance in formulating one or included their end-of-life care wishes in the care plan. Interviews with staff revealed that the Social Services Director (SSD) was responsible for addressing ADs upon admission but did not have a process for following up if an AD was refused. The SSD also stated they were not aware of the specifics regarding the ADs for Residents 6, 15, and 16 because they were not employed at the time those ADs were completed. The facility administrator expected ADs to be addressed on admission and followed up during quarterly care conferences, but this was not consistently done. These failures placed the residents at risk of not having their end-of-life care preferences and decisions followed.
Failure to Conduct Proper IDT Care Conferences
Penalty
Summary
The facility failed to ensure interdisciplinary team (IDT) care conferences were completed for two residents reviewed for comprehensive care planning. Resident 18, who was admitted with diagnoses including Parkinson's disease, kidney disease, and depression, had not had a care conference since 03/29/2022, despite the representative's statement that they had not been invited to a formal meeting for at least the last year. Similarly, Resident 6, admitted with diagnoses including Parkinson's disease, heart failure, and contractures, had not had a care conference since 04/14/2022, with the representative expressing a desire for more frequent meetings to discuss issues. The facility also failed to ensure that IDT care conference meetings included the required team members for two other residents. Resident 14, admitted with Alzheimer's disease and dementia, had a quarterly IDT care conference on 03/15/2024 attended only by the resident and the Social Services Director (SSD), with no other IDT members present. Resident 25, admitted with a right hip fracture, right clavicle fracture, and atrial fibrillation, had an IDT care conference on 03/15/2024 attended only by the resident, their representative, and the SSD, again with no other required IDT members present. Interviews with staff revealed inconsistencies in the understanding and execution of IDT care conferences. Staff E, the SSD, believed it was sufficient to gather information from various departments and document it without their attendance at the meetings. Staff A, the Administrator, and Staff B, the Regional Director of Nursing Services, acknowledged that all required IDT members should attend the care conferences, but this was not being consistently practiced. This lack of proper IDT involvement and failure to hold regular care conferences placed residents at risk for unmet care needs.
Failure to Implement Restorative Therapy Services
Penalty
Summary
The facility failed to ensure restorative therapy services, including the consistent use of braces and splints, were implemented for four residents. Resident 6, diagnosed with Parkinson's disease and contractures, did not consistently receive exercises for their upper and lower extremities. Despite being assessed and ordered a new wheelchair, the resident did not receive the necessary adjustments, leaving them immobile and dependent on staff assistance. The resident's restorative program was not adequately documented or modified to reflect their current status, leading to a decline in their functional abilities and quality of life. Resident 16, who had a stroke resulting in right-side weakness and a hand contracture, did not have a restorative program or a documented wearing schedule for their hand brace/splint. Observations showed the brace/splint was not consistently used, and staff were unaware of the proper schedule for its application. The resident's care plan did not address the decline in their functional abilities, and there was no documentation of a restorative program being implemented. Resident 23, admitted with dementia and muscle weakness, had not been assessed by therapy or placed on a restorative program since their admission. Despite requests from the resident's representative for therapy services, no action was taken. Similarly, Resident 17, who required an ankle-foot brace, did not consistently have the brace applied as per physician's orders. Staff were unaware of the correct process, and the brace was often found on the floor. The facility's failure to implement and monitor restorative programs and the use of braces/splints placed these residents at risk for further decline in their functional abilities and quality of life.
Failure in Enteral Feeding Administration and Documentation
Penalty
Summary
The facility failed to ensure appropriate administration and documentation of enteral feedings and fluid intake via gastrostomy tube (g-tube) for Resident 16. The resident, who had difficulty swallowing, malnutrition, and was unable to speak, received more than 51% of their nutritional needs via the g-tube. Staff N, an LPN, administered fluids and medications to Resident 16 but did not check residuals before flushing the g-tube or ask the resident about symptoms. Additionally, the documentation showed discrepancies in the amount of formula and free water administered, with Resident 16 receiving greater than one and a half times the amount of formula ordered on 27 out of 31 days and 370 ml less free water than required on all 31 days reviewed. Interviews with staff revealed a lack of awareness and adherence to physician orders and proper documentation procedures. Staff N admitted to forgetting to ask the resident about symptoms and was unaware of the need to clear the pump after each shift. The Registered Dietician (RD) and the Regional Director of Nursing Services (RDNS) both indicated that they expected orders to be entered and followed accurately, but were not aware of the inaccuracies in the g-tube orders and documentation. This failure in proper administration and documentation put Resident 16 at risk for dehydration, fluid overload, and weight fluctuations.
Medication Administration Errors
Penalty
Summary
The facility failed to ensure a medication error rate of less than five percent, resulting in an error rate of 28.57%. Eight medication errors were identified for three residents during 28 medication administration opportunities. For Resident 9, the LPN did not prime the insulin pen before administering insulin, despite the resident having a diagnosis of diabetes and requiring insulin based on a sliding scale. The LPN admitted to not priming the needle on this occasion. Similarly, for Resident 5, the LPN did not prime the insulin pen before administration and was unaware of the need to do so. Resident 5 also had a diagnosis of diabetes and required insulin administration based on a sliding scale and physician orders. For Resident 13, the Resident Care Manager administered multiple medications three hours past the scheduled time, acknowledging the delay due to being busy. The observations and interviews revealed that the staff did not follow proper procedures for insulin administration and medication timing. The Regional Director of Nursing Services stated that they expected the nurses to know how to administer insulin correctly and follow the medication pass times and physician orders. The failure to prime insulin pens and administer medications on time placed the residents at risk for side effects and/or reduced or increased medication effectiveness.
Failure to Verify Licensure and Provide Abuse Training
Penalty
Summary
The facility failed to implement two components of their abuse policy, specifically in verifying licensure and providing abuse training. Staff AA, a Nursing Assistant Registered (NAR), continued to work with an expired license for several days, providing care to vulnerable adults without the facility's knowledge. The Administrator and Housekeeping Supervisor/Scheduler were unaware of the expired license, and there was no process in place to ensure licenses were up to date. This lack of oversight allowed Staff AA to work unsupervised with an expired license, which was only discovered later, leading to their removal from the schedule. Additionally, the facility did not provide documented annual abuse and neglect training for five staff members (Staff O, T, U, R, and V). The Infection Preventionist/Staff Development acknowledged that while the required training was offered, there was no process to track or ensure completion, especially for part-time staff. The Regional Director of Nursing Services was also unaware of the inefficiency in tracking the training. This failure to provide necessary training placed residents at risk for unrecognized abuse and unmet care needs.
Failure to Complete Self-Administration Assessment for Resident
Penalty
Summary
The facility failed to ensure a clinically appropriate self-administration of medications assessment was completed by the interdisciplinary team for Resident 14, who was reviewed for safe self-administration of medications. Resident 14, diagnosed with Alzheimer's disease and dementia, was observed with medications left unattended at their bedside on multiple occasions. The resident was found with broken and melted pills, indicating improper medication management. Staff interviews revealed that medications were frequently left in Resident 14's room unattended, and the resident sometimes poured water on the medications or chopped them up, leading to the destruction of the medications and potential missed doses. Staff members, including nursing assistants and nurses, admitted to leaving medications in Resident 14's room, assuming the resident would take them at their own pace. However, there was no documentation of a self-administration assessment until it was brought to the facility's attention by the surveyor. The assessment, completed after the surveyor's intervention, deemed Resident 14 unsafe to self-administer medications. The facility's Regional Director of Nursing Services confirmed that an assessment for appropriateness and safety was part of the process for self-administration of medications and acknowledged that Resident 14 should not have been left with unattended medications.
Failure to Provide Appropriate Length Bed for Resident
Penalty
Summary
The facility failed to provide a comfortable and appropriate length bed for Resident 33, who was admitted with diagnoses including degeneration of the lower spine and left foot drop. The comprehensive assessment indicated that the resident's cognition was intact, required one staff member supervision for transferring, and was independent with bed mobility. Multiple observations showed Resident 33 lying in bed with both feet pushed up against the footboard, causing redness, softness, and wrinkling on the bottom of their left foot. Despite the resident's attempts to adjust their position, they continued to slide down, resulting in their feet pressing against the footboard. During an interview, Resident 33 expressed that the bed did not fit them properly due to their height of 70 inches. The facility's administrator stated that the beds were 80 inches long and suggested that the resident could elevate the bottom of the bed to prevent their feet from touching the footboard. However, the only footboard bed extender available was being used by the resident's roommate, and no immediate solution was provided. This failure to accommodate the resident's needs placed them at risk for discomfort and skin issues.
Failure to Provide Required ABN to Resident
Penalty
Summary
The facility failed to provide a Skilled Nursing Facility (SNF) Advance Beneficiary Notice (ABN) to Resident 149 when their Medicare Part A skilled nursing and rehabilitation services ended. Resident 149, who was admitted with an infection of the left lower leg and venous insufficiency, required limited assistance for activities of daily living and had intact cognition. The resident was not discharged as planned and remained in the facility beyond the last covered day for Medicare Part A without receiving the required ABN, which would have informed them of the potential financial liability for continued services. Interviews with facility staff, including the Business Office Manager, Administrator, and Regional Director of Nursing Services, confirmed that Resident 149 should have received an ABN when their Medicare Part A benefits ended. The staff acknowledged that there were issues with the process of issuing beneficiary notices at the time, leading to the failure to provide the necessary notification to Resident 149. This oversight prevented the resident from making informed financial and care decisions regarding their continued stay in the facility.
Failure to Maintain Homelike Environment and Address Noisy Beds
Penalty
Summary
The facility failed to ensure a quiet, comfortable, and homelike environment for several resident rooms and residents. Observations revealed that multiple rooms had significant physical damage, including scraped paint and missing drywall. Specifically, Room 7 had areas greater than 24 inches by 4 inches and 36 inches by 4 inches with scraped paint and missing drywall. Room 5 had an area greater than 48 inches by 18 inches with similar damage. Room 4 had multiple areas of missing drywall, including a softball-sized hole and other areas with significant damage. Additionally, nutritional supplies were improperly stored in cardboard boxes on the floor in Room 3, posing a risk to residents' safety and cleanliness. Residents 25 and 33 reported that their beds were excessively noisy, which disturbed their sleep and that of their roommates. The noise was confirmed by the surveyor and staff, with the Maintenance Director acknowledging the issue but stating that no alternative beds were available. The Administrator also acknowledged the problem but indicated that there was no current plan for room repairs or bed replacements.
Failure to Resolve Grievance for Missing Hearing Aid
Penalty
Summary
The facility failed to ensure prompt efforts were made to resolve a grievance involving a missing hearing aid for Resident 23. The resident, who was admitted with a diagnosis of dementia and had severely impaired cognition, required extensive assistance for activities of daily living. Despite the facility's policy stating that grievances should be resolved immediately and documented, there was no record of a grievance being logged for the missing hearing aid. The resident's representative reported the missing hearing aid to the Activities Director, who did not fill out a grievance form, assuming someone else had done so. Consequently, the Administrator, who was aware of the missing hearing aid, also failed to follow the grievance procedure, resulting in no tracking or resolution of the issue. Interviews with the resident's representative and staff members revealed that the normal process for handling grievances was not followed. The Activities Director admitted to not filling out the grievance form, and the Administrator acknowledged the failure to adhere to the grievance procedure. This lack of action disallowed the resident their right to a timely grievance resolution and placed them at risk for hearing difficulties and financial concerns due to the unresolved issue of the missing hearing aid.
Failure to Provide Bed Hold Notice at Time of Hospital Transfer
Penalty
Summary
The facility failed to provide a written notice to the resident and/or resident's representative of the facility policy for bed hold at the time of transfer to the hospital. This deficiency was identified for one resident who was reviewed for hospitalization. The facility's policy, dated 10/2018, required that residents and/or their representatives be given a bed hold notice at the time of transfer to the hospital or social leave, along with information on the appeal process if denied readmission. However, this policy was not followed in the case of Resident 9, who was transferred to the hospital on 01/30/2024 without receiving the required bed hold notice. Resident 9, who had a diagnosis of chronic kidney disease and required extensive assistance for activities of daily living, was admitted to the facility on an unspecified date. The comprehensive assessment on 02/04/2024 showed the resident had intact cognition. Despite the facility's policy, there was no documentation indicating that a Bed Hold/Notice of Transfer/Discharge was provided to the resident at the time of transfer. Interviews with the Business Office Manager and the Administrator confirmed that the correct process was not being followed, as the bed hold notice was typically offered a day or two after the transfer, rather than at the time of transfer as required by the policy.
Failure to Accurately Complete PASARR for Resident
Penalty
Summary
The facility failed to ensure that the Pre-Admissions Screening and Resident Review (PASARR) was accurately completed upon or prior to admission for one of the six residents reviewed. Specifically, Resident 33, who was admitted with diagnoses of depression and insomnia, had a PASARR dated 02/09/2024 that did not identify these conditions. This oversight placed the resident at risk of inappropriate placement and not receiving timely and necessary services to meet their mental health and developmental disability care needs. Interviews with staff revealed that the Social Services Director (SSD) was responsible for reviewing and correcting PASARRs on admission. However, in the absence of the SSD, the nursing department was expected to take on this responsibility. Despite these protocols, the PASARR for Resident 33 was not corrected to reflect the resident's diagnoses of depression and insomnia, as evidenced by the resident's medical record and medication administration record showing treatment for these conditions.
Failure to Provide Meal Assistance in Resident's Room
Penalty
Summary
The facility failed to provide necessary assistance with meals to a resident diagnosed with contractures and Parkinson's disease, who required help due to tremors and limited use of their right hand. Despite the resident's preference to eat in their room for comfort and dignity, staff insisted that assistance was only available in the dining room. This led to the resident struggling to eat independently, often dropping food and experiencing frustration and embarrassment during meals. The resident's medical record indicated they needed one staff member's assistance for meal setup or cleanup, and their diet slip specified bite-sized pieces and finger foods. However, observations showed the resident receiving meals that were not appropriately prepared, such as large pieces of roast beef and a casserole that was difficult to cut. Staff interviews revealed a consistent policy of requiring residents to go to the dining room for assistance, citing staffing limitations as the reason for not providing one-on-one help in the resident's room. The resident's representative and the resident themselves expressed concerns about the lack of assistance and the resident's preference to eat in their room. Despite these concerns, staff maintained that assistance was only available in the dining room, leading to the resident's continued struggle with meals. The facility's administrator acknowledged the staffing challenges but did not provide a solution for residents who preferred or needed to eat in their rooms. The Regional Director of Nursing Services stated that residents should be allowed to eat in their rooms with one-on-one assistance, contradicting the facility's practice.
Failure to Follow Physician Orders for Bowel and Pain Management
Penalty
Summary
The facility failed to follow physician orders for bowel and pain management for Resident 25, who was admitted with diagnoses including constipation, a right hip fracture, and a right displaced collar bone fracture. The resident's comprehensive assessment indicated they were dependent on two staff members for bed mobility, transfers, and toileting, and were receiving opioids, which contributed to their constipation. Despite having a bowel management program in place, the facility did not consistently administer the prescribed medications or document their effectiveness. For example, the resident went multiple shifts without a bowel movement, and several steps in the bowel program were either not initiated or not documented properly, leading to ineffective management of the resident's constipation. Additionally, the facility did not adhere to physician orders for pain management. Resident 25 reported increased pain and confusion about their pain medication regimen, stating that their pain medication had been reduced without explanation. The Medication Administration Record (MAR) showed discrepancies in the administration of pain medication, with doses given that did not align with the resident's reported pain levels. Staff interviews revealed inconsistencies in following the prescribed pain management protocol, with some nurses administering medication based on the resident's request rather than the documented pain level. Interviews with staff indicated a lack of clear communication and documentation regarding the resident's bowel and pain management. Alerts in the medical record system were not consistently acted upon, and there was no facility policy for bowel protocols. The facility's failure to follow physician orders and properly document care placed Resident 25 at risk for unmet care needs and negative health outcomes.
Failure to Complete Pre/Post Dialysis Communication Forms and Vital Signs
Penalty
Summary
The facility failed to ensure that pre/post dialysis communication forms and vital signs were completed for a resident requiring dialysis services. The resident, diagnosed with end-stage renal disease, was scheduled for dialysis on Mondays, Wednesdays, and Fridays. However, the medical record showed inconsistent documentation of pre/post dialysis vital signs and a lack of dialysis communication forms for staff to review and monitor the resident's post-dialysis condition. Specifically, there were multiple missed opportunities to complete the communication forms in January, February, and March 2024. Interviews with the resident and staff revealed that vital signs were not consistently monitored after dialysis, and the communication forms were often not completed or returned. The Resident Care Manager acknowledged that vital signs were only being monitored before dialysis and that the communication forms were not being done. The Regional Director of Nursing Services admitted that the correct process was not being followed and that there was no good system in place to ensure compliance with the required procedures.
Failure to Provide Trauma-Informed Care
Penalty
Summary
The facility failed to ensure culturally competent, trauma-informed care for a resident with a history of trauma and loss. The resident, who had a history of depression and insomnia, was admitted with a comprehensive assessment indicating intact cognition and the need for assistance with mobility. Despite the resident's disclosure of past trauma related to their occupation as a firefighter and the loss of a significant other, the facility did not develop a care plan to address these issues. The resident expressed experiencing nightmares and flashbacks, and stated that talking about their trauma helps them cope, yet no care plan focus, goals, or interventions were implemented for trauma-informed care. Interviews with staff revealed that the Social Services Director (SSD) responsible for the resident's assessment had left the facility, and the new SSD had not assessed the resident for trauma. The facility's policy required screening for trauma on admission and the development of a care plan, but this was not followed. The Administrator acknowledged that the new SSD was still in training and could not explain why the former SSD did not create a care plan for the resident's trauma. This oversight put the resident at risk for re-traumatization and a decline in psychosocial well-being.
Failure to Serve Bedtime Snacks
Penalty
Summary
The facility failed to serve a nourishing snack at bedtime for three residents, placing them at risk for hunger, weight loss, and unmet nutritional needs. Resident 1, who required moderate to maximum assistance for activities of daily living (ADLs) and had moderately impaired cognition, reported that they had to ask for a snack, and it depended on which staff was working. Resident 4, who had cerebral palsy and type II diabetes mellitus, required substantial to dependent assistance for ADLs and had intact cognition, stated that they would love a snack before going to sleep but did not always receive one. Resident 17, who had type II diabetes mellitus, kidney disease, and heart disease, required maximum to dependent assistance for ADLs and had intact cognition, also reported not receiving a snack at bedtime consistently and often had to ask for one. Staff interviews revealed that snacks were available but not routinely offered to residents. The Registered Dietician stated that diabetic-friendly snacks were served in the evening, but residents had to ask for them. The Regional Director of Nursing Services was unsure if snacks were being served in the evening, and the Administrator confirmed that staff were not serving snacks at bedtime unless residents asked for them. Review of the Diabetic Administration Records for Residents 4 and 17 showed that they were offered snacks on most days but not consistently every day. The meal service times had been changed, resulting in a greater than 14-hour gap between the evening meal and breakfast, which went unnoticed by the staff.
Improper Disposal of Trash
Penalty
Summary
The facility failed to ensure the proper disposal of trash for the dumpster reviewed for outdoor refuse storage. Observations over several days showed the dumpster with both lids open and unsecured trash bags, including a mattress, which were not contained properly. Interviews with the Maintenance Director, Administrator, and Regional Director of Nursing Services revealed a lack of awareness regarding the requirement to keep the dumpster lids closed, contributing to the unsanitary conditions observed.
Latest citations in Washington
A resident with cerebral palsy and a court-appointed guardian experienced multiple episodes of nausea, vomiting, loose stools, abdominal discomfort, fatigue, and later refusal of meals and medications, leading to changes in the care plan including close monitoring, lab testing, and IV fluid administration. Despite a facility policy recognizing court-appointed guardians as resident representatives with decision-making authority, staff did not document any notification to the guardian during these changes in condition or treatment decisions. The guardian reported not being contacted when the resident stopped eating or developed stomach issues and felt the facility did not respect the guardianship, while the DON acknowledged there were multiple missed opportunities to notify the guardian of the resident’s change from baseline.
A resident with depression, anxiety, moderate cognitive impairment, and urinary incontinence, care-planned for q2h checks and assistance with toileting, was found by a visitor to be soaking wet, unusually agitated, and reporting they had been told to wait to be changed and referred to with a derogatory remark. The visitor filed a written grievance alleging abuse/neglect related to delayed incontinence care and removal of the resident’s tablet as a consequence. Although an incident report noted that the matter was reported to the state and that the resident was not soaking wet, a CNA who actually changed the resident later reported the resident’s brief, pants, wheelchair, and socks were soaked and that the resident was acting timid and repeatedly saying they had to sit for five minutes, but this CNA was never interviewed. The DON acknowledged not investigating the resident’s behavior or interviewing this CNA, and the grievance official acknowledged the facility did not fully investigate or communicate findings and resolution to the complainant, resulting in a failure to follow the facility’s grievance policy.
A resident with dementia, respiratory failure, and heart failure developed new shortness of breath with an O2 sat of 90%, and a physician ordered transfer to the ED for tx and eval. An RN completed an SBAR, notified the MD and family, and reported to the oncoming nurse that the resident needed ED transfer and that paramedics should be contacted, then left the facility. Instead of calling 911 for this emergent respiratory distress, staff arranged non-emergent transport through a contracted ambulance service, resulting in the resident remaining at the facility for several hours without pickup until the dispatcher later instructed staff to call 911. The DON stated that 911 is expected to be used for emergent conditions and the contracted service only for non-emergent transport.
A resident with anoxic brain injury, dysarthria, and documented lack of decisional capacity alleged physical abuse and expressed fear of their identified representative, yet social services only reported the allegation to the state and did not complete an incident report, revise the care plan, or implement protective interventions. The same representative continued to be treated as the resident’s decision-maker and visited frequently, with staff noting suspicious odors of foreign substances and concerns about possible illicit substance use. Psychiatry later documented concern that the representative was providing illicit substances, and the resident was subsequently hospitalized for altered mental status and overdose, after which the representative was banned. Key staff, including the DON, unit manager, and administrator/abuse coordinator, were unaware of the initial abuse allegation, and social services did not timely explore or clarify legal decision-making authority or alternative representation for the resident.
A resident with severe cognitive impairment, osteoarthritis, and spinal spondylosis, care planned for 2-person Hoyer transfers, was being moved by two CNAs using a mechanical lift when one corner loop of the sling became disengaged, causing the resident to fall about four feet, strike the floor and the lift, and sustain head abrasion, multiple rib fractures, and lumbar vertebral fractures. Facility policy required staff to verify secure sling attachment, examine hooks, clips, fasteners, and strap stability, and ensure the sling bar was sound before lifting, but during this transfer the sling loop detached despite staff believing it was properly fastened and hearing it click into place; post-incident assessment showed the loop had come loose, the sling appeared in good condition, and a CNA later reported thinking one of the round metal disks on the lift might have been slightly loose, while maintenance logs documented no prior concerns with the lifts or slings.
The facility failed to revise and individualize care plans to reflect current needs and preferences for multiple residents, including one cognitively intact resident with hemiplegia, hemiparesis, and mononeuropathy who had bilateral shoulder surgery and could not tolerate BP measurements on the upper arms but preferred forearm readings. Despite repeatedly informing staff, this preference was not documented in the care plan or Kardex, and direct care staff and the RN/UM were unaware of it. Another cognitively intact resident with hemiplegia, contractures, and weakness reported they were supposed to get out of bed for two hours daily, but some NACs did not know this, even though the MAR/TAR contained an order to document times up and back to bed. The surveyors concluded that care plans were not accurately revised for several residents, placing them at risk for unidentified and unmet care needs and diminished quality of life.
Surveyors found that two residents with hemiplegia, hemiparesis, weakness, and contractures did not receive restorative nursing services, including ROM exercises and splint/brace or orthotic assistance, after therapy discharge. Although PT and OT discharge summaries documented established restorative ROM and transfer programs, recommended PROM to affected extremities, and recommended splint/brace use and assistance with orthotic wear, these recommendations were not entered as restorative referrals in the EHR. As a result, the residents’ care plans and records showed no restorative programs, and both residents reported that therapy and restorative exercises had stopped, while the DON, rehab director, and MDS coordinator confirmed they were unaware of and had not implemented the recommended restorative services.
A resident with cancer, cognitive impairment, and declining strength experienced multiple unwitnessed falls, most occurring while attempting to toilet or move toward the bathroom, culminating in a fractured ankle requiring ED treatment. Although assessments identified fall and incontinence risks and the facility’s policy required individualized interventions, the comprehensive care plan lacked a toileting plan and did not include several interventions that were discussed in incident investigations, such as consistent wheelchair placement and frequent rounding for bathroom assistance. Staff reported relying on verbal reminders and education to use the call light, despite acknowledging the resident’s impulsivity and failure to call for help, and the resident’s bed remained furthest from the bathroom while repeated bathroom-related falls occurred without the trend being recognized or addressed in the care plan.
A resident with a history of acute urinary retention and acute kidney injury had a Foley catheter deemed permanent by the hospital, with instructions that it not be removed in the SNF. At a later urology visit, the catheter was removed, and the resident returned with no new orders documented. Facility staff did not document bladder assessments, post-void residuals, or urine output, and CNA documentation showed the resident did not void that evening. Over the next day, the resident had vomiting, poor intake, altered level of consciousness, tachycardia, hypotension, and no documented wet briefs. A bladder scan eventually showed more than 2000–2500 mL of retained urine, and a new catheter drained a large volume. The resident and a roommate reported moaning, crying out in pain, and repeatedly alerting staff that the resident was not urinating and that the catheter was not draining, while nurses documented catheter care when no catheter was in place and later had to flush and replace the catheter due to continued complaints.
Surveyors found that nurses and nurse aides did not consistently administer medications according to professional standards and facility policy. Multiple residents reported that agency nurses were slow with medications, did not fully follow instructions, and often gave routine meds late. Observations showed an LPN administering expired Humalog/Lispro insulin well past the scheduled time, an LPN giving several scheduled meds (including Tizanidine) late and all at once, and an RN attempting to give sliding-scale insulin nearly two hours late, which a resident refused after already eating. Another resident received Methocarbamol two hours late after questioning the RN, and a resident on scheduled Tramadol had doses given without timely documentation, with a discrepancy between the narcotic count and pills remaining. These events demonstrated failures in timely administration, use of non-expired medications, and immediate, accurate MAR and narcotic documentation.
Failure to Notify Court-Appointed Guardian of Resident’s Clinical Changes
Penalty
Summary
The deficiency involves the facility’s failure to notify a resident’s court-appointed guardian of significant clinical changes and care decisions, contrary to its own policy and state requirements. The facility’s policy on Resident Representatives, revised 02/2021, states that a resident representative includes a court-appointed guardian or conservator and that the facility treats the representative’s decisions as those of the resident to the extent delegated or required by the court. Resident 1, admitted with cerebral palsy, had a Superior Court guardianship letter dated 02/07/2025 indicating a guardian of person and conservator of the estate with full authority, identifying Collateral Contact 1 (CC1) as the guardian. Despite this, multiple clinical events and changes in condition were documented without any corresponding documentation that CC1 was notified. Progress notes and provider notes show that Resident 1 experienced an episode of nausea and vomiting, frequent loose stools, abdominal discomfort, bloating, worsening fatigue, generalized weakness, and later refusal of meals and medications over at least a 24-hour period, with observations that the resident appeared frailer, more fatigued, and had no energy or interest to talk. The provider developed care plans including close monitoring for deterioration, sending stool to the lab, and later initiating IV fluids for rehydration, with a plan to call family/POA for discussion. However, there was no documentation that the guardian was notified at any of these points, including when IV fluids were started. CC1 reported that they were not contacted when the resident stopped eating or developed stomach issues, and expressed that the facility did not respect their guardianship and that involvement in care planning took too long. The DON confirmed on record review that there were many opportunities to notify the guardian when the resident’s condition changed from baseline and that there was no evidence staff did so.
Failure to Thoroughly Investigate and Resolve Resident Grievance Regarding Incontinence Care and Staff Conduct
Penalty
Summary
The deficiency involves the facility’s failure to thoroughly investigate and resolve a grievance alleging neglect and disrespect toward a resident, as required by its grievance policy. The resident had depression, anxiety, moderate cognitive impairment, occasional urinary incontinence, and required moderate assistance with toileting, with a care plan directing staff to check the resident every two hours, ask about toileting needs, and ensure they were clean and dry. A collateral contact reported arriving to visit the resident and finding them soaking wet and agitated, with behavior that was not typical for the resident. The collateral contact documented in a written grievance that the resident’s tablet was off, the resident appeared upset, and the resident reported being told they had to wait five minutes to be changed and that staff would change their “nasty *ss” in five minutes, leading the collateral contact to believe the resident had been given a consequence of no tablet and sitting in wet clothes, which they characterized as abuse/neglect and requested immediate removal of the responsible staff and a report filed. The facility documented receipt of the grievance and created an incident report indicating the matter was reported to the state agency, and that the unit manager interviewed the collateral contact and the resident, with the resident described as confused and denying being soaking wet. The incident report stated that a different nursing assistant was assigned to assist with the brief change and that the unit manager believed the resident was not soaking wet, and that the resident and collateral contact were satisfied when they left the room. However, a CNA who actually changed the resident reported that the resident’s brief was soaked through their pants onto the wheelchair and their socks were soaked, and that the resident was timid, repeatedly saying they had to sit for five minutes, and not acting like themselves; this CNA stated they were never interviewed or asked about the grievance or the resident’s condition. The DON acknowledged not interviewing this CNA or investigating the resident’s behavior and why they were upset, and the unit manager did not recall whether the collateral contact was present during follow-up and did not believe they followed up with the collateral contact regarding the grievance. The administrator, identified as the Grievance Official, stated the facility should have thoroughly investigated the grievance and discussed findings and resolution with the collateral contact, indicating the grievance process was not fully carried out in accordance with policy and WAC 388-97-0460.
Failure to Obtain Timely Emergency Transport for Resident in Respiratory Distress
Penalty
Summary
The deficiency involves the facility’s failure to obtain timely emergency medical services for a resident experiencing new-onset respiratory distress. The resident had dementia, respiratory failure, and heart failure, with severe cognitive impairment and a need for substantial assistance with activities of daily living. On the day the resident was sent to the hospital, a collateral contact observed the resident having difficulty breathing, appearing unable to get enough air, and looking as if they were sleeping or unconscious, and reported this to staff with a request to contact the doctor. An SBAR Communication Form documented that the resident was experiencing shortness of breath that had not occurred before, with an oxygen saturation of 90%. The physician was notified and ordered the resident sent to the emergency department for treatment and evaluation, and the collateral contact was notified shortly thereafter. Progress notes later documented that, despite the order for emergency department transfer, the resident was still awaiting pickup by Olympic transportation several hours later, with no estimated time of arrival. At approximately 3:30 AM, the dispatcher informed the facility that they could not provide transportation and instructed that 911 be called; only then was 911 contacted and the resident transported to the hospital via ambulance for respiratory distress. The RN caring for the resident stated they completed the SBAR, notified the physician and family, and at the end of their shift reported to the oncoming nurse that the resident needed to be sent to the emergency department for respiratory distress and that paramedics should be contacted, then left assuming 911 would be called. The DON stated that staff are expected to contact 911 for emergent conditions such as shortness of breath or respiratory distress, and that Olympic Ambulance is used only for non-emergent transport.
Failure to Provide Social Service Advocacy After Abuse Allegation and Questionable Representative
Penalty
Summary
The deficiency involves the facility’s failure to provide appropriate medically-related social services and advocacy for a resident following an allegation of abuse and concerns about the resident’s representative. The resident had an anoxic brain injury, dysarthria, moderate cognitive impairment, and was dependent on staff for activities of daily living. A hospital palliative care note documented that the resident lacked decisional capacity, had no DPOA, that the legal next of kin (CC4) did not want to be part of care decisions, and that care decisions were being deferred to another contact (CC5). CC5 accompanied the resident on admission, signed admission forms, and was listed as the primary contact in the medical record profile. On a date in February, during communication therapy, the resident reported that CC5 had done something to them, pounded their hands on their chest, recalled being hit in the back of the head by an unknown person, and stated they were sometimes afraid of CC5. A social services staff member reported this allegation to the state agency but did not complete a facility incident report, did not initiate care plan changes or interventions, and took no further action. CC5 continued to be treated as the resident’s representative, and progress notes documented CC5 at the bedside on multiple dates, including an entry noting the room smelled like foreign substances and that CC5 was seen waking the resident and then asking the nurse to administer pain medications. A psychiatry note later documented concern that CC5 was providing the resident with illicit substances and stated it would be prudent for the resident to identify a POA. Subsequently, the resident was found unresponsive, transported to the hospital, and later readmitted after altered mental status and overdose, with a provider note stating that CC5 posed a significant danger to the resident and was banned from visiting. After readmission, staff attempted to contact CC4 for consent to treat but initially reached someone who stated they were not CC4. The social service director acknowledged that, beyond reporting the initial allegation, no additional interventions were implemented, that CC5 continued to be used as the resident’s representative after the allegation, and that they had not explored legal authority for decision making following the abuse allegation or concerns about substances. The social service assistant reported they did not speak with the resident about the hospital stay or CC5 and did not complete an incident report or care plan changes after the allegation. The unit manager and DON were unaware of the initial abuse allegation, and the administrator, who served as abuse coordinator, also stated they were unaware of the allegation and that an investigation should have been initiated and a representative for the resident investigated at a minimum.
Injury from Mechanical Lift Sling Detachment During Transfer
Penalty
Summary
The facility failed to ensure a safe mechanical lift transfer when a resident was being moved with a Hoyer lift and sling, resulting in a fall and injury. Facility policy for using a mechanical lifting machine required staff to securely attach sling straps to the sling bar according to manufacturer’s instructions, double-check the security of the sling attachment before lifting, examine all hooks, clips, or fasteners, check strap stability, and ensure the sling bar was securely attached and sound. Despite these requirements, during a transfer for dinner, two CNAs placed the sling under the resident, attached the loops at each corner of the sling to the lift, and raised the resident off the bed into the space between the bed and wheelchair when the bottom left corner of the sling became disengaged from the lift. The resident involved had multiple diagnoses including osteoarthritis, cervical and thoracic spondylosis, and Alzheimer’s disease, with the Minimum Data Set documenting severely impaired cognitive skills for daily decision-making. The resident’s care plan required the assistance of two staff during Hoyer lift transfers. During the transfer, the resident fell approximately four feet, landing on her buttocks, bouncing, and then falling backward and striking her head on the leg of the Hoyer lift. Hospital records documented that the resident sustained an abrasion to the back of the head, fractures of the 6th, 7th, 8th, and 10th ribs, and fractures of the 1st and 2nd lumbar vertebra. Staff interviews and observations showed that staff believed the sling loops had been securely fastened and reported hearing the loops click into place before lifting. One CNA stated that they had barely lifted the resident off the bed when the bottom left loop became disconnected and the resident fell. Another CNA reported being shocked and unable to figure out what had happened. A nurse who assessed the resident and then examined the equipment after the fall noted that one of the loops of the sling had become disengaged but stated the sling appeared to be in good condition. During a later demonstration, a CNA indicated she thought one of the round metal disks on the lift might have been a little loose. Maintenance logs for Hoyer slings and lifts for the preceding months documented no concerns with the slings or lifts, and the DON acknowledged expecting a citation due to the resident’s injury from the fall.
Failure to Revise Care Plans to Reflect Resident Needs and Preferences
Penalty
Summary
The deficiency involves the facility’s failure to revise and individualize comprehensive care plans to reflect residents’ current needs and preferences, as required by its own care planning policy. For one resident with hemiplegia, hemiparesis following cerebrovascular disease, and mononeuropathy of the upper limb, the admission MDS showed intact cognition and upper extremity impairment. This resident reported having bilateral shoulder surgery and an inability to tolerate blood pressure measurements on the upper arms due to pain, and stated a preference for BP measurements on the forearms. The resident reported having informed multiple nursing staff of this preference, but staff continued to place the cuff on the upper arms. Review of the resident’s care plan and Kardex showed no interventions or instructions regarding forearm BP cuff placement. A NAC confirmed they were unaware of the preference until the resident told them directly and that this instruction was not documented in the Kardex. The RN/Unit Manager, who stated they were responsible for revising and reviewing care plans when there were changes, also confirmed they were not aware of the resident’s preference and that it should have been updated in the care plan. Another resident, readmitted with hemiplegia and hemiparesis following a nontraumatic subarachnoid hemorrhage, contracture of the left hand, and weakness, was cognitively intact and required maximum assistance for bed mobility per a quarterly MDS. This resident stated they were supposed to get out of bed for two hours every day, but some NACs were not aware of this care requirement. Review of the resident’s March 2026 MAR/TAR showed an order to document the time the resident got up and the time they returned to bed daily. The report states that, overall, the facility failed to revise care plans accurately to reflect residents’ needs for three of four residents reviewed for care plan revision, placing them at risk for unidentified and unmet care needs and a diminished quality of life.
Failure to Implement Restorative Nursing and Splint/Brace Programs After Therapy Discharge
Penalty
Summary
The deficiency involves the facility’s failure to provide restorative nursing services, including range of motion (ROM) exercises and splint/brace assistance, to maintain or prevent decline in mobility and contractures for two residents with significant motor impairments. The facility’s undated Restorative Nursing Services policy stated that residents would receive restorative care as needed to achieve and maintain optimal functioning and that residents may initiate a restorative program upon discharge from rehabilitative care. Despite this, surveyors found that residents with documented hemiplegia, hemiparesis, weakness, and contractures were not placed on restorative programs and had no restorative interventions documented in their electronic health records (EHRs). Resident 1 was admitted with hemiplegia and hemiparesis following cerebrovascular disease, a left lower leg fracture, and weakness, and the admission MDS showed intact cognition, moderate assistance needs for bed mobility and transfers, and one-sided upper and lower extremity impairment. During observation, the resident was seen lying in bed with a bent inward left forearm and hand and reported no longer receiving therapy or nursing-assisted exercises. The care plan initiated in January showed no restorative services, and the care plan history and EHR contained no restorative nursing interventions. However, the PT discharge summary from February documented that restorative ROM and transfer programs had been established and trained, including PROM to the left upper and lower extremities and stand-by assist with transfers, and the OT discharge summary recommended a splint/brace to prevent contracture. The OT stated that the splint/brace was not tried due to lack of time before insurance was discontinued, and both the Director of Rehab and the MDS coordinator confirmed there was no restorative referral in the EHR and they were unaware of the recommendations. Resident 2 was readmitted with hemiplegia and hemiparesis following a nontraumatic subarachnoid hemorrhage, a left-hand contracture, and weakness, and the quarterly MDS showed intact cognition, maximum assistance needs for bed mobility, total assistance for transfers, bilateral upper and lower extremity impairment, and no therapy or restorative programs. The resident reported that therapy had been discontinued months earlier and that no restorative staff were assisting with exercises. The care plan and EHR showed no restorative services. OT evaluation documented left upper extremity ROM impairment, a left-hand contracture, and prior use of a left orthotic to manage flexion tone, and the OT discharge summary recommended restorative care and assistance with donning/doffing the orthotic. The PT discharge summary recommended restorative programs if Medicaid Part B services did not continue. The Director of Rehab confirmed therapy was discontinued and that restorative nursing programs were recommended, but both the Director of Rehab and the MDS coordinator stated there were no restorative referrals in the EHR after readmission, and the MDS coordinator confirmed the resident had no restorative programs since readmission.
Failure to Implement Effective Fall and Toileting Interventions for High-Risk Resident
Penalty
Summary
The deficiency involves the facility’s failure to provide adequate supervision, identify fall trends, and implement progressive, resident-centered interventions for a resident with multiple falls and declining strength. The facility’s own Falls and Fall Risk Management policy required staff to identify interventions related to residents’ specific risks and causes to prevent falls and minimize complications. The resident’s Care Area Assessment identified cancer-related risks for pain, falls, and ADL decline, and stated that falls and urinary incontinence would be addressed in the care plan with an objective of improvement and risk minimization. However, the comprehensive care plan did not include a urinary or ADL care plan and contained no toileting plan, despite the resident’s identified risks and prior fall history. Over a series of falls, the resident repeatedly fell while attempting to toilet or move toward the bathroom, yet the facility did not recognize or address this pattern in its investigations or care planning. The resident had multiple unwitnessed falls: next to the bed while getting up to use the restroom, in the bathroom while standing to use the toilet, and near or in the bathroom on several occasions. Incident investigations and post-fall assessments documented environmental factors such as clutter, items on the floor, water on the floor, and issues with footwear, as well as the resident’s increasing weakness, impulsivity, poor safety awareness, and poor insight into limitations. Interventions documented in investigations and risk reviews included encouraging use of the front-wheeled walker, keeping the wheelchair and walker accessible, ensuring proper footwear and non-skid socks, and providing resident education on safe transfers, ambulation, and assistive device use. However, several of these planned interventions, including placement of the wheelchair and frequent rounding/toileting assistance, were not added to or reflected in the care plan as stated. Staff interviews further showed that the resident frequently fell while trying to go to the bathroom and that staff relied on verbal education and reminders to use the call light, even though the resident often did not use it. Staff acknowledged the resident’s impulsivity and tendency to get up independently despite instructions, and one staff member stated that nursing assistants were verbally instructed to offer bathroom assistance, but this intervention was not documented in the care plan. The resident’s bed remained the one furthest from the bathroom throughout the stay, and none of the facility’s investigations identified the trend of bathroom-related falls or addressed toileting options in the care plan. Ultimately, the resident sustained a left ankle fracture after another bathroom-related fall, requiring transfer to the emergency department for evaluation and treatment, and later records documented additional fractures and a decline in condition. The surveyors concluded that the facility’s failures placed residents at risk of repeated falls and injuries.
Failure to Monitor Urinary Retention After Foley Removal Leading to Prolonged Pain
Penalty
Summary
The deficiency involves the facility’s failure to adequately assess and monitor a resident for complications associated with an indwelling urinary catheter and urinary retention, particularly after catheter removal. The resident had a history of acute kidney injury due to urinary retention, which improved after Foley catheter placement in the hospital. Hospital discharge documentation indicated the catheter was placed for acute urinary retention, was deemed permanent, and included instructions that, given the resident’s significant retention and acute renal failure, staff at the skilled nursing facility should not attempt Foley removal. The facility’s catheter care plan directed staff to empty the catheter as needed and record output in milliliters, but review of the last 30 days of documentation showed continence was not rated due to the indwelling catheter and there was no documented urinary output in milliliters on the treatment administration records. The resident had a scheduled urology appointment at which the urinary catheter was discontinued. Upon return from this appointment, nursing documentation initially indicated no new orders, and an alert note later stated the catheter was discontinued and staff were monitoring for retention or pain. However, there was no documented bladder assessment or urinary output following catheter removal. Nursing assistant documentation showed that the resident did not void on the evening shift that same day. Despite the catheter having been removed, the treatment administration record showed staff continued to document provision of catheter care on subsequent shifts when no catheter was in place. Over the next day, the resident experienced vomiting, decreased oral intake, and an altered level of consciousness, with vital signs showing tachycardia and low blood pressure, and staff documented decreased urine output. A bladder scan performed later revealed more than 2000–2500 milliliters of urine in the bladder, and an indwelling catheter was reinserted, initially draining a large volume of urine. The provider note indicated the resident had not eaten since the prior night, was unable to hold down fluids, and staff were unsure whether the resident had urinated in incontinence briefs, with no wet briefs reported since the resident’s return from the hospital after catheter removal. The provider expressed concern that the documented early-morning wet brief might not be accurate given the large bladder volume on scan and stated this should require further investigation. Subsequent notes described the resident moaning and complaining of pain, with limited urine output in the catheter bag and staff flushing and then replacing the catheter due to continued complaints. Interviews with the resident, the roommate, and staff indicated the resident was crying out and moaning in pain, the roommate repeatedly alerted staff that the resident was not urinating and that the catheter was not draining, and staff had to seek assistance to replace the catheter. Facility leadership and clinical staff later acknowledged that typical practice after catheter removal would include contacting the provider, placing the resident on alert, performing post-void residuals with bladder scans, and documenting monitoring, which was not done in this case.
Medication Administration Delays, Documentation Errors, and Use of Expired Insulin
Penalty
Summary
The deficiency involves the facility’s failure to ensure sufficient nursing staff with appropriate competencies and skill sets to administer medications according to professional standards of practice, facility policy, and prescriber orders. The facility’s medication administration policy required medications to be given as prescribed, in accordance with manufacturers’ specifications and good nursing principles, with no expired medications used, and doses administered within 60 minutes of the scheduled time and documented immediately after administration. Multiple residents reported that agency nurses often gave medications late, did not read full instructions, or were slow in bringing medications, and that routinely scheduled medications were not consistently provided without residents having to ask. Surveyors observed several specific medication administration failures. For a resident with diabetes, an LPN drew up and administered Humalog/Lispro insulin from a multi-dose vial that had been opened and dated “02/16” with no year, making it expired per policy, and administered the dose nearly 1 hour and 45 minutes after it was due. Another resident with care plan instructions to receive medications as ordered had multiple scheduled medications (Gabapentin, Oxybutynin, Baclofen, and Tizanidine) that were ordered at specific times throughout the day; the LPN was observed administering all four together and acknowledged that at least one (Tizanidine) was late, while the resident reported that receiving them together at that time was typical and not at their request. For another diabetic resident, an RN checked blood sugar and prepared sliding scale Humalog/Lispro insulin almost two hours after the scheduled time; the resident refused the insulin, stating they had already finished lunch. Additional deficiencies were identified with other residents’ pain and scheduled medications. One resident with a pain care plan and an order for Methocarbamol four times daily at set times approached the cart requesting Methocarbamol and Tylenol; the RN initially stated the Methocarbamol had already been given, but then administered it two hours after it was due when the resident pointed out the scheduled timing. For another resident with a risk for pain care plan and Tramadol ordered three times daily at specific times, an LPN retrieved a PRN pain medication while the electronic record showed no 8:00 AM medications documented; the LPN stated they had given them but had not yet documented. Later, an RN prepared the 2:00 PM Tramadol dose, and review of the narcotic count showed a discrepancy between the number of pills documented and the number remaining in the card. The RN stated they had given the 8:00 AM Tramadol but had not signed it out, then signed out both the 8:00 AM and 2:00 PM doses at that time. Residents interviewed consistently reported that medications were sometimes or frequently late, that agency nurses did not always follow instructions, and that they often had to request medications that were routinely scheduled.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release May 27, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
