Renton Health & Rehabilitation
Inspection history, citations, penalties and survey trends for this long-term care facility in Renton, Washington.
- Location
- 80 Southwest Second Street, Renton, Washington 98057
- CMS Provider Number
- 505280
- Inspections on file
- 34
- Latest survey
- January 13, 2026
- Citations (last 12 mo.)
- 28
Citation history
Health deficiencies cited at Renton Health & Rehabilitation during CMS and state inspections, most recent first.
The facility failed to notify Medicaid recipient residents when their personal fund balances approached the $2,000 limit, risking their Medicaid coverage. Additionally, a resident's funds were not transferred to the state Office of Financial Recovery within 30 days of discharge, as required. The Business Office Manager acknowledged the broken system and lack of timely fund management.
The facility failed to maintain a homelike environment in several resident rooms, with issues such as gouged walls, unmounted TVs, dirty fans, and unsanitary bathrooms. Observations included exposed drywall, dusty fans, and bathrooms with rust and stains. The Maintenance Supervisor and RN Manager acknowledged the need for repairs and cleaning.
The facility failed to maintain a safe environment, with an unlocked laundry room door allowing access to chemicals and an open exterior door posing elopement risks. Additionally, a resident with a history of falls had a cluttered room and inappropriate footwear, contrary to the facility's fall prevention policy. Staff interviews confirmed awareness of these issues, but care plans lacked specific interventions to mitigate risks.
The facility failed to properly store, label, and dispose of medications, resulting in several deficiencies. Narcotics were found in an unlocked refrigerator, expired medications were not removed, and a resident had medication at their bedside without proper assessment. Additionally, medication carts were left unlocked and unsupervised, posing safety risks.
The facility failed to maintain sanitary conditions in its kitchen and unit refrigerator, posing risks for foodborne illness. Observations revealed mold-like debris on the ice machine, dirty wall fans, and inadequate hand hygiene practices among dietary staff. Uncovered food was transported in hallways, and the unit refrigerator was unclean, contrary to the facility's food safety policies.
The facility failed to obtain informed consent for psychotropic medications for two residents and for bed rails for another resident. One resident received medications for anxiety and depression without prior consent, while another had a verbal consent noted but not finalized until months later. Additionally, a resident with paralysis had bed rails installed without consent. Staff acknowledged the oversight, which placed residents at risk for unwanted treatment.
The facility failed to provide the required Skilled Nursing Facility Notice of Medicare Non-coverage (SNF-NOMNC) to two residents whose skilled services coverage was ending. This notice is crucial for informing residents about the end of their Medicare A benefits and their right to an expedited appeals process. The Social Services Director confirmed that the notices were not provided, which is a violation of the facility's policy.
The facility failed to ensure accurate MDS assessments for three residents, leading to potential risks for unmet care needs. One resident's dental status was incorrectly documented, another's mobility device was inaccurately recorded, and a third resident's communication abilities were misrepresented, affecting the accuracy of their preference assessment.
A facility failed to ensure an accurate PASRR assessment for a resident with dementia, anxiety, and schizophrenia, leading to an incomplete identification of mental health needs. The resident's PASRR inaccurately listed anxiety as the only serious mental illness and failed to update the assessment to include psychosis and schizophrenia diagnoses. Additionally, the resident's primary language was incorrectly recorded, contrary to staff's identification during admission.
The facility failed to develop and implement comprehensive care plans for four residents, leading to unmet care needs. A resident with paralysis had undocumented bed rails, another with a urinary catheter lacked care plan documentation, a third resident's care plan was outdated after transitioning from tube feeding, and a fourth resident's care plan did not address care refusals. Staff acknowledged these oversights.
The facility failed to adhere to physician's orders for pain medication administration for two residents, administering opioids for pain levels below prescribed thresholds. Additionally, two other residents had issues with pain patch orders not being clarified or documented correctly, leading to improper application and removal. The DON confirmed the need for order clarification.
Several residents in the facility did not receive necessary assistance with ADLs, leading to deficiencies in care. A resident with partial paralysis was not assisted to get out of bed as required, while another resident with intact cognitive abilities had unmet personal hygiene needs, including untrimmed nails and facial hair. A third resident reported not receiving nail care since admission, and a fourth resident was observed with greasy hair and long nails despite scheduled baths. Staff interviews revealed inconsistencies in following care plans and documenting refusals.
The facility failed to provide adequate end-of-life care for two residents receiving hospice services. One resident experienced poor personal hygiene due to a lack of coordination between facility and hospice staff, while another resident's records lacked documentation of hospice services and physician orders. Additionally, there was a discrepancy in medication management for one resident, highlighting a failure in communication between the facility and hospice.
A facility failed to implement a restorative nursing program (RNP) for a resident with mobility limitations following discharge from physical therapy. Despite recommendations for ROM exercises and positioning, the RNP was not established, as confirmed by staff interviews and record reviews. Observations showed the resident was not wearing a knee brace and was not on a restorative program.
A facility failed to monitor a resident's weight adequately during their transition from tube feeding to oral intake. Despite a physician's order for monthly weight checks, the resident was not weighed for over a month before and two weeks after the transition. The dietician confirmed the importance of weight monitoring during this period, but the resident's weight was not measured since mid-August, partly due to a refusal to be weighed and documentation issues.
The facility failed to provide timely dental services for two residents, resulting in oral discomfort and diminished quality of life. One resident needed new dentures but did not receive follow-up care, while another had loose-fitting dentures with no scheduled adjustments. Staff acknowledged the oversight in scheduling necessary appointments, contrary to facility policy.
The facility failed to maintain proper infection control practices, including inadequate use of Enhanced Barrier Precautions, poor hand hygiene, and improper catheter care. Staff did not follow precautionary measures, such as wearing gowns and gloves, and neglected hand hygiene protocols during resident care. Additionally, catheter drainage bags were improperly placed on the floor, and uncleanable surfaces were present, increasing the risk of infection.
The facility failed to implement an effective Antibiotic Stewardship Program, leading to inappropriate antibiotic use for three residents. A resident received antibiotics for a UTI without proper confirmation, another had delayed treatment for pneumonia due to lack of communication, and a third was treated for pneumonia despite negative X-ray results. These actions risked adverse outcomes for the residents.
A facility failed to provide adequate supervision to prevent altercations between two residents. One resident, with a history of hip fracture and anxiety, reported incidents involving another resident with dementia, who entered their room, consumed their snacks, and left feces on their bed. Despite being informed, staff did not document or respond to these incidents until the residents were separated. The facility did not assess the second resident's wandering risk or implement a care plan, leading to safety concerns.
The facility failed to promptly initiate CPR for two residents who were designated as Full Code, leading to delays in emergency response. In both cases, staff hesitated to start CPR due to uncertainty about code status and logistical challenges, such as moving residents to the floor. The lack of proper documentation and adherence to emergency protocols further exacerbated the situation, placing additional residents at risk.
The facility failed to ensure nursing assistants received the required 12 hours of annual in-service training, including dementia management and emergency response training. Documentation was lacking, and interviews revealed that the training calendar was not followed, and no system was in place to ensure compliance.
The facility failed to ensure the availability and completeness of POLST forms for two residents. One resident's POLST form was missing from medical records, while another's was incomplete, lacking a physician's signature. This deficiency was identified after one resident was found unresponsive and CPR was performed.
Failure to Notify Residents of Fund Balances and Timely Disbursement
Penalty
Summary
The facility failed to notify five Medicaid recipient residents when their personal fund account balances reached $1,800, which is within $200 of the $2,000 resource limit that could impact their Medicaid coverage. This oversight placed the residents at risk for personal financial liability for their care. The facility's revised Resident Personal Funds policy requires notification when a resident's account approaches the Supplemental Security Income (SSI) resource limit, but this was not adhered to. The Business Office Manager (BOM) acknowledged the issue, citing a lack of a BOM for several months and confirming that the system was broken, leading to residents exceeding the $2,000 limit. Additionally, the facility did not ensure that funds were reimbursed to the state Office of Financial Recovery (OFR) within 30 days of a resident's discharge or death. Specifically, Resident 219, who was discharged on May 30, 2024, had a balance of $3,286.02 that was not transferred to the resident or OFR until September 13, 2024, over three months later. The BOM confirmed that Resident 219's account was not closed in a timely manner and that the personal fund was not sent with the resident upon transfer to another facility.
Facility Fails to Maintain Homelike Environment
Penalty
Summary
The facility failed to maintain a homelike environment in several resident rooms, as observed during a survey. In nine out of eighteen sampled rooms, issues such as gouged walls, unmounted televisions, dirty fans, and unsanitary bathroom conditions were noted. Specific observations included gouges in the walls exposing drywall, televisions not mounted on walls, and fans covered in dust debris. Bathrooms in several rooms had rust, dirt, and brown stains on tiles and fixtures, with some toilets having dried smears and missing toilet paper holders. These conditions were confirmed by the Maintenance Supervisor, who acknowledged the need for repairs and cleaning. The report highlights that the facility's inaction in maintaining clean and sanitary conditions in resident rooms compromised the residents' right to a safe and comfortable environment. The Maintenance Supervisor and a Registered Nurse Manager acknowledged the deficiencies, noting that the walls needed repair, bathrooms required daily cleaning, and missing fixtures needed replacement. The presence of jagged foam on a sink and the poor condition of window blinds further contributed to the substandard living conditions observed in the facility.
Facility Fails to Prevent Accident Hazards and Falls
Penalty
Summary
The facility failed to ensure the environment was free of accident hazards, specifically in the laundry room and in the resident rooms. Observations on two consecutive days revealed that the laundry room door was unlocked due to a malfunctioning key code, allowing unrestricted access. Inside the laundry room, there were chemicals and an open exterior door leading outside, posing risks of elopement and chemical ingestion. Staff interviews confirmed that the lock had been broken for two weeks and that the issue had been reported to the Head of Maintenance, but no repairs had been made. Additionally, the facility did not adequately address fall hazards in the room of a resident with a history of falls and multiple medical conditions, including arthritis and altered mental status. The resident required maximal assistance for transfers and dressing, yet the care plan inaccurately stated they only needed supervision for dressing. Observations showed the resident's room was cluttered, with items scattered on the floor and furniture, creating a fall risk. The resident was also observed with inappropriate footwear, which was inconsistent with the facility's fall prevention policy. Interviews with staff revealed that the resident's room clutter was a known issue, and while some items were stored by the facility, the care plan lacked specific instructions on managing clutter and assisting with transfers. The resident's cognitive issues and failure to use the call light for assistance were also noted, contributing to the risk of falls. Despite these known risks, the facility's interventions were insufficient to prevent the resident from experiencing falls.
Medication Storage and Security Deficiencies
Penalty
Summary
The facility failed to ensure proper storage, labeling, and disposal of medications, leading to several deficiencies. Observations revealed that a narcotic medication was stored in an unlocked refrigerator within the West Hall Medication Room, contrary to the facility's policy requiring double locks for narcotics. Additionally, the Garden Wing Cart contained expired medications and eye drops without open dates, which were not removed or destroyed as required. Furthermore, a tube of medicated cream was found on Resident 60's bedside table without a self-medication assessment or physician order, violating the facility's policy on medication storage in resident rooms. The report also highlighted issues with unsecured medication carts. On the Catsablanca unit, a medication cart was left unlocked and unsupervised for 23 minutes, posing a safety risk. Similarly, on the Wild West unit, a medication cart was found unlocked with no staff present, allowing access to medications. Interviews with staff confirmed that these practices were against the facility's expectations and policies, which require medication carts to be locked when not in use to prevent unauthorized access.
Sanitation and Food Safety Deficiencies in Facility Kitchen
Penalty
Summary
The facility failed to maintain sanitary conditions in its kitchen and unit refrigerator, which posed a risk for foodborne illness and cross-contamination. Observations revealed that the ice machine in the kitchen had brownish-black and pink mold-like debris on its surfaces, indicating inadequate cleaning. Staff Z, the Dietary Supervisor, acknowledged that the kitchen staff performed daily wipes, while maintenance was responsible for deep cleaning, which was not documented since October 2023. Additionally, wall fans in the kitchen were observed to be dirty, with debris hanging from the grills, and were running during food preparation, further compromising sanitation. Hand hygiene practices were also found to be lacking among dietary staff. Staff DD was observed handling both dirty and clean dishes without changing gloves or performing hand hygiene. Similarly, Staff EE used a thermometer probe without sanitizing it between uses and handled food with soiled gloves. Staff FF was seen touching various surfaces and then handling food without changing gloves. These actions were contrary to the facility's expectations for hand hygiene and sanitation, as confirmed by Staff Z. Furthermore, food transport and storage practices were inadequate. Uncovered cookies were observed on lunch trays being distributed by nurse's aides, exposing them to the hallway environment. The unit refrigerator was found to be unclean, with dried fluid on the shelves and crisper. Staff Z confirmed the refrigerator's condition and the expectation that food should be covered during transport. These deficiencies highlight a failure to adhere to the facility's food safety policies, as outlined in their revised policies from 2024.
Failure to Obtain Informed Consent for Medications and Bed Rails
Penalty
Summary
The facility failed to obtain informed consent prior to administering psychotropic medications to two residents and before the use of bed rails for another resident. Resident 34, diagnosed with anxiety and depression, was administered two antidepressants and an antianxiety medication starting in May 2024, but the informed consent forms were only signed in September 2024. Staff P, an RN Manager, acknowledged that informed consent should have been obtained before administering these medications. Similarly, Resident 20, who was prescribed an antidepressant in May 2024, had a verbal consent noted but the form was not signed until September 2024, with Staff C finalizing the electronic record much later. Staff C could not demonstrate that consent was obtained prior to the electronic signature date. For Resident 60, who was admitted with paralysis on one side of the body, bed rails were ordered and installed without obtaining informed consent. The resident confirmed that staff did not discuss the risks and benefits of the bed rails with them. Staff C admitted that they had not obtained consent for the bed rails, although it was required by the facility's policy. This oversight in obtaining informed consent for both psychotropic medications and bed rails placed residents at risk for unwanted treatment.
Failure to Provide Medicare Non-coverage Notices
Penalty
Summary
The facility failed to provide the required Skilled Nursing Facility Notice of Medicare Non-coverage (SNF-NOMNC) to two residents, Resident 219 and Resident 119, whose skilled services coverage was ending. This notice is essential as it informs residents that their Medicare A benefits are ending and provides information about their right to an expedited appeals process. According to the facility's policy, the NOMNC should be given at least two days before the end of the Medicare-covered Part A stay. However, the records for both residents did not show that the NOMNC was provided, which was confirmed by the Social Services Director during an interview. Resident 219 was admitted to the facility and discharged to the community on May 15, 2024, with a physician's order for discharge dated May 14, 2024. Similarly, Resident 119 was admitted and discharged to the community on May 22, 2024, as noted in the nursing progress note. Despite these discharges, neither resident received the NOMNC, which is a violation of the facility's policy and regulatory requirements. This oversight placed the residents at risk of not being fully informed about their coverage and losing their right to appeal the decision.
Inaccurate MDS Assessments for Three Residents
Penalty
Summary
The facility failed to ensure the Minimum Data Set (MDS) assessments accurately reflected the status of three residents, leading to potential risks for unmet care needs and diminished quality of life. For Resident 37, the MDS inaccurately indicated the resident had no natural teeth, despite observations showing multiple lower teeth and the resident awaiting denture repair. Staff acknowledged the error upon review. Resident 51's MDS inaccurately documented the use of a walker as the normal mobility device, while observations showed the resident in a wheelchair. This discrepancy was also confirmed as an error by the staff. For Resident 61, the MDS contained conflicting information regarding the resident's ability to be understood. Although the resident was assessed to have clear speech and intact memory, the MDS incorrectly marked the resident as rarely or never understood, leading to a staff assessment of preferences instead of a resident interview. This resulted in less specific information about the resident's preferences. Staff acknowledged the need for a resident interview, potentially using translation services, to accurately capture the resident's preferences.
Inaccurate PASRR Assessment for Resident with Mental Health Needs
Penalty
Summary
The facility failed to ensure the accuracy of a Pre-Admission Screening and Resident Review (PASRR) assessment for a resident, which is crucial for identifying mental health needs and determining appropriate nursing home placement. The resident in question, who had complex medical diagnoses including dementia, anxiety, and schizophrenia, was receiving antipsychotic medication for acute psychosis. However, the Level 1 PASRR assessment inaccurately identified the resident's serious mental illness indicator as only anxiety and failed to update the assessment to reflect the resident's psychosis and schizophrenia diagnoses. Additionally, the PASRR assessment inaccurately recorded the resident's primary language as English, despite staff identifying it as Vietnamese during the admission assessment. The Social Service Director acknowledged the importance of accurate PASRR assessments for determining the need for Level 2 evaluations and ensuring residents' success in the facility. The director also confirmed that the Level 1 PASRR should have been updated to include the correct diagnoses and primary language, highlighting a lapse in the facility's adherence to its policy and regulatory requirements.
Failure to Implement Comprehensive Care Plans
Penalty
Summary
The facility failed to develop and implement comprehensive care plans for four residents, leading to unmet care needs and a decreased quality of life. Resident 60, who was admitted with paralysis on the left side of their body, had a physician order for bilateral bed rails, but this was not documented in their care plan. The resident was not informed about the risks and benefits of the bed rails, nor was their consent obtained. Staff C, a Registered Nurse Manager, acknowledged the oversight in care planning for the bed rails. Resident 39, who had multiple diagnoses including brain damage and pressure ulcers, had an indwelling urinary catheter that was not documented in their care plan. The resident's representative expressed a desire to have the catheter removed, but was informed by staff that it was necessary until the resident's wounds healed. Staff C admitted that the catheter should have been included in the care plan to ensure proper care. Resident 58, with a history of stroke and difficulty swallowing, was receiving nutrition via a feeding tube, but the care plan was not updated after the resident transitioned to oral intake. Staff AA, a dietician, confirmed that the care plan was outdated. Resident 1, who had conditions including stroke and aphasia, had a care plan that did not address their refusal of care. Observations noted poor hygiene and refusal of care, and staff interviews revealed a lack of documentation and communication regarding refusals, which was acknowledged by the Director of Nursing.
Failure to Follow Physician's Orders and Document Care
Penalty
Summary
The facility failed to provide nursing care within professional standards by not adhering to physician's orders for pain medication administration for two residents. Resident 34, who experienced occasional pain affecting sleep and daily activities, was given opioid pain medication for pain levels below the prescribed threshold on multiple occasions. Similarly, Resident 20, diagnosed with chronic pain, received incorrect dosages of opioid pain medication for pain levels that did not meet the physician's specified parameters. These actions were confirmed by the Registered Nurse Manager, who acknowledged the importance of following physician-provided parameters for as-needed pain medications. Additionally, the facility did not clarify physician orders or accurately document the completion of tasks for two other residents. Resident 25 had a topical pain patch applied without proper documentation of its removal, and staff incorrectly signed the MAR indicating the patch was applied when it was not. Resident 52's orders for a pain patch were not followed as the MAR did not direct staff to remove the patch after the prescribed 12 hours. The Director of Nursing confirmed the need for clarification of pain patch orders for these residents.
Deficiencies in ADL Assistance for Residents
Penalty
Summary
The facility failed to provide necessary assistance with Activities of Daily Living (ADLs) for several residents, leading to deficiencies in care. Resident 58, who required substantial assistance due to a history of stroke and partial paralysis, was observed multiple times in bed despite orders to be up in a wheelchair daily. Staff interviews revealed that aides were expected to follow care plans, but Resident 58 remained in bed, expressing a preference to get up. Resident 52, who was dependent on staff for personal hygiene, was observed with long fingernails and facial hair, despite orders for regular nail care and shaving. The resident reported that staff did not offer to cut their fingernails as ordered and placed their electric razor out of reach, preventing self-care. Staff interviews confirmed that nail care should be offered as ordered, and refusals should be documented, but this was not consistently done. Resident 60, admitted with paralysis and no memory impairment, also experienced neglect in personal hygiene care. The resident reported not receiving nail care since admission, and staff interviews indicated a lack of documentation for refusals of nail care. Additionally, Resident 1, who required maximum assistance for various ADLs, was observed with greasy hair and long fingernails, despite scheduled bed baths. Staff interviews highlighted a failure to provide care even when residents refused, and a lack of documentation for care provided.
Deficiencies in Hospice Care Coordination and Documentation
Penalty
Summary
The facility failed to provide necessary end-of-life care and services for two residents receiving hospice care, compromising their quality of life. Resident 1, who had multiple medical conditions including stroke and paralysis, was observed with greasy hair and body odor over several days, indicating a lack of personal hygiene care. Despite the care plan specifying cooperation with hospice services to meet the resident's needs, staff interviews revealed that Resident 1 frequently refused bathing, and there was a lack of communication and coordination between the facility and hospice to address these refusals. Additionally, there was a discrepancy in medication management for Resident 1. The facility's records showed that a high blood pressure medication was discontinued in June, but hospice orders in September still included the medication. This inconsistency highlighted a failure in coordinating medication orders between the facility and hospice services, as confirmed by the Director of Nursing. For Resident 7, who had complex medical diagnoses including cancer, there was a lack of documentation and physician orders for hospice services in the resident's records. Despite being admitted to hospice services in early July, there were no hospice notes or logged visits in the resident's records from late July to early September. Staff interviews confirmed the absence of hospice documentation, indicating a failure in maintaining accurate and complete records of hospice care provided to the resident.
Failure to Implement Restorative Program for Resident with Mobility Limitations
Penalty
Summary
The facility failed to provide a restorative program for a resident with mobility limitations, as identified by staff and reviewed for Range of Motion (ROM). The resident, who had a history of stroke with muscle weakness and functional limitations in ROM, was discharged from physical therapy with recommendations for a restorative nursing program (RNP) to maintain ROM and positioning. However, the facility did not implement the recommended RNP after the discharge from therapy, as confirmed by staff interviews and record reviews. Observations revealed that the resident was not wearing a knee brace and was not on a restorative program, despite the physical therapy discharge summary and referral form recommending specific interventions. Interviews with facility staff, including the Registered Nurse Manager and the Director of Rehabilitation, confirmed that the RNP was not established within the expected timeframe after the referral. The Director of Nursing also acknowledged that the RNP should have been implemented promptly to prevent a decline in the resident's function.
Failure to Monitor Resident Weight During Transition from Tube Feeding
Penalty
Summary
The facility failed to adequately monitor the weight of a resident, identified as Resident 58, who was transitioning from tube feeding to oral intake. According to the facility's policy, weights should be collected monthly or more frequently as needed. Resident 58, who had a history of stroke, partial paralysis, and swallowing difficulties, was receiving over half of their calories via a feeding tube. A physician's order from May 2024 directed that Resident 58 be weighed monthly. However, there was a significant gap in weight monitoring, with the resident not being weighed for over a month prior to the discontinuation of tube feeding and not for two weeks after the transition to oral intake. The dietician, Staff AA, confirmed the importance of monitoring weight during such transitions to ensure adequate nutritional intake. Despite the policy and the physician's order, Resident 58's weight was not measured since mid-August 2024. The September Medication Administration Record noted that the resident refused to be weighed, and there was no space to document a weight after the refusal, which may have contributed to the oversight. This failure to monitor weights as ordered placed the resident at risk for weight loss and other negative health outcomes.
Failure to Provide Prompt Dental Services
Penalty
Summary
The facility failed to provide prompt dental services for two residents, leading to oral discomfort and a diminished quality of life. Resident 52, who had intact mental processing abilities and was dependent on staff for denture care, experienced mouth and facial pain due to ill-fitting upper dentures. Despite a recommendation for new dentures from a dental consult in February 2024, no follow-up appointments were scheduled, and the resident was not seen by a dentist since that time. The resident expressed the need for bottom dentures and reported an incident where they waited for a dental appointment that was never fulfilled due to overbooking. Resident 37, who required substantial assistance for oral hygiene, had issues with loose-fitting upper dentures, causing difficulty in chewing and discomfort. Despite multiple dental visits and recommendations for denture realignment, no follow-up appointments were scheduled. The resident expressed a desire to wear their dentures if they fit properly, indicating the ongoing issue with loose dentures. Staff interviews revealed that the referral for denture adjustment was overlooked, and no pending appointments were scheduled since June 2024. The facility's policy required coordination of dental care and transportation as needed, but these actions were not executed for the residents in question. Staff members, including the Medical Records Supervisor and the Director of Nursing, acknowledged the oversight in scheduling necessary dental appointments, which was contrary to the facility's expectations and policies.
Infection Control Deficiencies in LTC Facility
Penalty
Summary
The facility failed to maintain proper infection control practices, as evidenced by several observations and interviews. Staff did not adhere to Enhanced Barrier Precautions (EBP) for residents requiring such measures. For instance, two nurse's aides were observed repositioning a resident with an infectious immune disease without wearing gowns, despite signage indicating the need for gowns and gloves. This oversight was confirmed by the Licensed Practical Nurse responsible for infection control, who acknowledged the importance of following precaution signs to minimize disease transmission. Hand hygiene practices were also inadequate. A Certified Nursing Assistant (CNA) was observed performing incontinence care for a resident without changing gloves or performing hand hygiene between tasks, leading to potential cross-contamination. Another CNA similarly failed to change gloves during incontinence care, touching clean items with soiled gloves. These actions were contrary to the facility's expectations, as stated by the infection control nurse, who emphasized the need for hand hygiene after glove removal. Additionally, the facility did not provide catheter care in accordance with professional standards. A resident with a history of urinary tract infections and a catheter was observed with their catheter drainage bag lying on the floor, which is against infection control protocols. Staff interviews confirmed that the catheter bag should not be on the floor to prevent infection. Furthermore, the facility had uncleanable surfaces, such as worn toilet seats and damaged wheelchair armrests, which could harbor bacteria and contribute to cross-contamination, as noted by the infection control nurse.
Failure in Antibiotic Stewardship Program
Penalty
Summary
The facility failed to implement an effective Antibiotic Stewardship Program, which led to inappropriate and unnecessary use of antibiotics for three residents. Resident 223 was prescribed antibiotics for a urinary tract infection (UTI) that did not meet the criteria for treatment. The facility did not follow physician orders to collect a urinalysis to confirm the UTI, and there was no documentation of a culture and sensitivity report to ensure the appropriate prescription of antibiotics. Staff interviews revealed that the necessary steps to confirm the infection and appropriate antibiotic use were not followed. Resident 224 was treated with antibiotics for pneumonia, but the facility failed to communicate the chest X-ray results to the provider in a timely manner, resulting in a delay in treatment. Similarly, Resident 38 was treated with multiple antibiotics for pneumonia, despite a chest X-ray showing no diagnosis of pneumonia. The staff did not review the antibiotic medications appropriately. These failures in communication and adherence to the facility's antibiotic stewardship policy placed residents at risk for adverse outcomes associated with inappropriate antibiotic use.
Inadequate Supervision Leads to Resident Altercations
Penalty
Summary
The facility failed to provide adequate supervision to prevent resident-to-resident altercations, specifically between two residents. Resident 1, who had a history of a right hip fracture with surgical repair, anxiety, and insomnia, reported multiple incidents involving Resident 2. These incidents included Resident 2 entering Resident 1's room, consuming their snacks, wearing their clothes, and leaving feces on their bed sheets. On one occasion, Resident 2 sat on Resident 1's leg, causing discomfort and pain, especially given Resident 1's recent hip surgery and existing knee issues. Despite Resident 1 informing the staff about these incidents, there was no documentation of staff response or intervention until Resident 2 was moved to another room. Resident 2, who had a history of dementia, psychotic disorder, and insomnia, was admitted to the facility without a proper assessment for wandering risk. The facility's policies required such assessments and care plans to address wandering behaviors, but these were not implemented for Resident 2. Staff documented Resident 2's behaviors, such as attempting to get out of bed, using fecal matter inappropriately, and wandering around the room, but there was no evidence of actions taken to manage these behaviors or ensure the safety of both residents. Interviews with staff revealed a lack of communication and documentation regarding the incidents and the necessary interventions. The Director of Nursing Services did not recall reviewing Resident 2's admission referral, and there was no care plan in place for Resident 2's wandering risk. The facility's investigation confirmed that staff were aware of the issues but did not take appropriate actions to address them, leading to a delay in moving Resident 2 to a different room and ensuring the safety and well-being of both residents.
Failure to Initiate Timely CPR for Residents
Penalty
Summary
The facility failed to ensure that basic life support, including CPR, was initiated immediately for two residents who experienced unexpected deaths. For Resident 1, the facility's staff did not promptly initiate CPR despite the resident being designated as a Full Code. The resident's family member alerted staff to the emergency, but there was a delay in initiating CPR as staff were unsure of the resident's code status and required additional personnel to move the resident to the floor. The absence of a Code Blue Emergency Recorder form further complicated the documentation of the sequence of events. In the case of Resident 2, the facility again failed to initiate CPR in a timely manner. Although the resident was found unresponsive with weak breathing and pulse, staff did not immediately begin CPR. Instead, there was a delay as staff communicated with each other and called 911. The facility's investigation revealed that the staff member who first assessed the resident did not initiate CPR due to a back injury, and CPR was only started after another staff member returned from making the emergency call. The facility's lack of a clear and immediate response to these medical emergencies placed additional residents at risk, as there were 35 other residents with current physician orders to receive CPR. The absence of proper documentation and adherence to emergency response protocols contributed to the deficiencies observed in these incidents.
Removal Plan
- Audited the records of all residents
- Audited the Physician Order for Life Sustaining Treatment (POLST) binders
- Educated staff on the facility's Medical Emergency Response Policy and Code Blue Emergency Recorder process during CPR
- Performed CPR drills
- Implemented a plan of correction to sustain ongoing compliance
Inadequate In-Service Training for Nursing Assistants
Penalty
Summary
The facility failed to develop, implement, and maintain an in-service training program that ensured nursing assistants received the required 12 hours of annual training and education. This deficiency was identified through observation, interviews, and record reviews, which revealed that three nursing assistants did not receive the necessary training. The facility's assessment indicated that in-service training should include dementia management, communication, resident rights, cultural competency, and identification of changes in resident conditions. However, the facility could not provide documentation to confirm that the required training was completed for the nursing assistants reviewed. Additionally, the facility lacked documentation of staff training on the use of an Automated External Defibrillator (AED) and the facility's Medical Emergency Response policy. Interviews with the facility's administrator and corporate consultant revealed that there was an in-service training calendar, but it was not followed by the previous staff development coordinator. The Vice President of Operations acknowledged the absence of a system to ensure the required training was provided to each nursing aide, further contributing to the deficiency.
Deficiency in POLST Form Management
Penalty
Summary
The facility failed to ensure the availability and completeness of Physician Orders for Life-Sustaining Treatment (POLST) forms for two residents, which are crucial for honoring residents' medical treatment preferences during emergencies. For Resident 3, the facility did not have a POLST form accessible in the medical records, despite an order indicating the resident was a Full Code and wanted CPR. Staff interviews confirmed the absence of the POLST form, with suggestions that it might have been sent to the hospital with the resident. For Resident 4, the POLST form was initiated and signed by the resident but was incomplete as it lacked the facility provider's signature, indicating that the information was not discussed with the resident or their representative. This deficiency was noted after Resident 4 was found unresponsive and CPR was performed. Staff confirmed the form remained unsigned by the physician until after the resident's death.
Latest citations in Washington
A resident with cerebral palsy and a court-appointed guardian experienced multiple episodes of nausea, vomiting, loose stools, abdominal discomfort, fatigue, and later refusal of meals and medications, leading to changes in the care plan including close monitoring, lab testing, and IV fluid administration. Despite a facility policy recognizing court-appointed guardians as resident representatives with decision-making authority, staff did not document any notification to the guardian during these changes in condition or treatment decisions. The guardian reported not being contacted when the resident stopped eating or developed stomach issues and felt the facility did not respect the guardianship, while the DON acknowledged there were multiple missed opportunities to notify the guardian of the resident’s change from baseline.
A resident with depression, anxiety, moderate cognitive impairment, and urinary incontinence, care-planned for q2h checks and assistance with toileting, was found by a visitor to be soaking wet, unusually agitated, and reporting they had been told to wait to be changed and referred to with a derogatory remark. The visitor filed a written grievance alleging abuse/neglect related to delayed incontinence care and removal of the resident’s tablet as a consequence. Although an incident report noted that the matter was reported to the state and that the resident was not soaking wet, a CNA who actually changed the resident later reported the resident’s brief, pants, wheelchair, and socks were soaked and that the resident was acting timid and repeatedly saying they had to sit for five minutes, but this CNA was never interviewed. The DON acknowledged not investigating the resident’s behavior or interviewing this CNA, and the grievance official acknowledged the facility did not fully investigate or communicate findings and resolution to the complainant, resulting in a failure to follow the facility’s grievance policy.
A resident with dementia, respiratory failure, and heart failure developed new shortness of breath with an O2 sat of 90%, and a physician ordered transfer to the ED for tx and eval. An RN completed an SBAR, notified the MD and family, and reported to the oncoming nurse that the resident needed ED transfer and that paramedics should be contacted, then left the facility. Instead of calling 911 for this emergent respiratory distress, staff arranged non-emergent transport through a contracted ambulance service, resulting in the resident remaining at the facility for several hours without pickup until the dispatcher later instructed staff to call 911. The DON stated that 911 is expected to be used for emergent conditions and the contracted service only for non-emergent transport.
A resident with anoxic brain injury, dysarthria, and documented lack of decisional capacity alleged physical abuse and expressed fear of their identified representative, yet social services only reported the allegation to the state and did not complete an incident report, revise the care plan, or implement protective interventions. The same representative continued to be treated as the resident’s decision-maker and visited frequently, with staff noting suspicious odors of foreign substances and concerns about possible illicit substance use. Psychiatry later documented concern that the representative was providing illicit substances, and the resident was subsequently hospitalized for altered mental status and overdose, after which the representative was banned. Key staff, including the DON, unit manager, and administrator/abuse coordinator, were unaware of the initial abuse allegation, and social services did not timely explore or clarify legal decision-making authority or alternative representation for the resident.
A resident with severe cognitive impairment, osteoarthritis, and spinal spondylosis, care planned for 2-person Hoyer transfers, was being moved by two CNAs using a mechanical lift when one corner loop of the sling became disengaged, causing the resident to fall about four feet, strike the floor and the lift, and sustain head abrasion, multiple rib fractures, and lumbar vertebral fractures. Facility policy required staff to verify secure sling attachment, examine hooks, clips, fasteners, and strap stability, and ensure the sling bar was sound before lifting, but during this transfer the sling loop detached despite staff believing it was properly fastened and hearing it click into place; post-incident assessment showed the loop had come loose, the sling appeared in good condition, and a CNA later reported thinking one of the round metal disks on the lift might have been slightly loose, while maintenance logs documented no prior concerns with the lifts or slings.
The facility failed to revise and individualize care plans to reflect current needs and preferences for multiple residents, including one cognitively intact resident with hemiplegia, hemiparesis, and mononeuropathy who had bilateral shoulder surgery and could not tolerate BP measurements on the upper arms but preferred forearm readings. Despite repeatedly informing staff, this preference was not documented in the care plan or Kardex, and direct care staff and the RN/UM were unaware of it. Another cognitively intact resident with hemiplegia, contractures, and weakness reported they were supposed to get out of bed for two hours daily, but some NACs did not know this, even though the MAR/TAR contained an order to document times up and back to bed. The surveyors concluded that care plans were not accurately revised for several residents, placing them at risk for unidentified and unmet care needs and diminished quality of life.
Surveyors found that two residents with hemiplegia, hemiparesis, weakness, and contractures did not receive restorative nursing services, including ROM exercises and splint/brace or orthotic assistance, after therapy discharge. Although PT and OT discharge summaries documented established restorative ROM and transfer programs, recommended PROM to affected extremities, and recommended splint/brace use and assistance with orthotic wear, these recommendations were not entered as restorative referrals in the EHR. As a result, the residents’ care plans and records showed no restorative programs, and both residents reported that therapy and restorative exercises had stopped, while the DON, rehab director, and MDS coordinator confirmed they were unaware of and had not implemented the recommended restorative services.
A resident with cancer, cognitive impairment, and declining strength experienced multiple unwitnessed falls, most occurring while attempting to toilet or move toward the bathroom, culminating in a fractured ankle requiring ED treatment. Although assessments identified fall and incontinence risks and the facility’s policy required individualized interventions, the comprehensive care plan lacked a toileting plan and did not include several interventions that were discussed in incident investigations, such as consistent wheelchair placement and frequent rounding for bathroom assistance. Staff reported relying on verbal reminders and education to use the call light, despite acknowledging the resident’s impulsivity and failure to call for help, and the resident’s bed remained furthest from the bathroom while repeated bathroom-related falls occurred without the trend being recognized or addressed in the care plan.
A resident with a history of acute urinary retention and acute kidney injury had a Foley catheter deemed permanent by the hospital, with instructions that it not be removed in the SNF. At a later urology visit, the catheter was removed, and the resident returned with no new orders documented. Facility staff did not document bladder assessments, post-void residuals, or urine output, and CNA documentation showed the resident did not void that evening. Over the next day, the resident had vomiting, poor intake, altered level of consciousness, tachycardia, hypotension, and no documented wet briefs. A bladder scan eventually showed more than 2000–2500 mL of retained urine, and a new catheter drained a large volume. The resident and a roommate reported moaning, crying out in pain, and repeatedly alerting staff that the resident was not urinating and that the catheter was not draining, while nurses documented catheter care when no catheter was in place and later had to flush and replace the catheter due to continued complaints.
Surveyors found that nurses and nurse aides did not consistently administer medications according to professional standards and facility policy. Multiple residents reported that agency nurses were slow with medications, did not fully follow instructions, and often gave routine meds late. Observations showed an LPN administering expired Humalog/Lispro insulin well past the scheduled time, an LPN giving several scheduled meds (including Tizanidine) late and all at once, and an RN attempting to give sliding-scale insulin nearly two hours late, which a resident refused after already eating. Another resident received Methocarbamol two hours late after questioning the RN, and a resident on scheduled Tramadol had doses given without timely documentation, with a discrepancy between the narcotic count and pills remaining. These events demonstrated failures in timely administration, use of non-expired medications, and immediate, accurate MAR and narcotic documentation.
Failure to Notify Court-Appointed Guardian of Resident’s Clinical Changes
Penalty
Summary
The deficiency involves the facility’s failure to notify a resident’s court-appointed guardian of significant clinical changes and care decisions, contrary to its own policy and state requirements. The facility’s policy on Resident Representatives, revised 02/2021, states that a resident representative includes a court-appointed guardian or conservator and that the facility treats the representative’s decisions as those of the resident to the extent delegated or required by the court. Resident 1, admitted with cerebral palsy, had a Superior Court guardianship letter dated 02/07/2025 indicating a guardian of person and conservator of the estate with full authority, identifying Collateral Contact 1 (CC1) as the guardian. Despite this, multiple clinical events and changes in condition were documented without any corresponding documentation that CC1 was notified. Progress notes and provider notes show that Resident 1 experienced an episode of nausea and vomiting, frequent loose stools, abdominal discomfort, bloating, worsening fatigue, generalized weakness, and later refusal of meals and medications over at least a 24-hour period, with observations that the resident appeared frailer, more fatigued, and had no energy or interest to talk. The provider developed care plans including close monitoring for deterioration, sending stool to the lab, and later initiating IV fluids for rehydration, with a plan to call family/POA for discussion. However, there was no documentation that the guardian was notified at any of these points, including when IV fluids were started. CC1 reported that they were not contacted when the resident stopped eating or developed stomach issues, and expressed that the facility did not respect their guardianship and that involvement in care planning took too long. The DON confirmed on record review that there were many opportunities to notify the guardian when the resident’s condition changed from baseline and that there was no evidence staff did so.
Failure to Thoroughly Investigate and Resolve Resident Grievance Regarding Incontinence Care and Staff Conduct
Penalty
Summary
The deficiency involves the facility’s failure to thoroughly investigate and resolve a grievance alleging neglect and disrespect toward a resident, as required by its grievance policy. The resident had depression, anxiety, moderate cognitive impairment, occasional urinary incontinence, and required moderate assistance with toileting, with a care plan directing staff to check the resident every two hours, ask about toileting needs, and ensure they were clean and dry. A collateral contact reported arriving to visit the resident and finding them soaking wet and agitated, with behavior that was not typical for the resident. The collateral contact documented in a written grievance that the resident’s tablet was off, the resident appeared upset, and the resident reported being told they had to wait five minutes to be changed and that staff would change their “nasty *ss” in five minutes, leading the collateral contact to believe the resident had been given a consequence of no tablet and sitting in wet clothes, which they characterized as abuse/neglect and requested immediate removal of the responsible staff and a report filed. The facility documented receipt of the grievance and created an incident report indicating the matter was reported to the state agency, and that the unit manager interviewed the collateral contact and the resident, with the resident described as confused and denying being soaking wet. The incident report stated that a different nursing assistant was assigned to assist with the brief change and that the unit manager believed the resident was not soaking wet, and that the resident and collateral contact were satisfied when they left the room. However, a CNA who actually changed the resident reported that the resident’s brief was soaked through their pants onto the wheelchair and their socks were soaked, and that the resident was timid, repeatedly saying they had to sit for five minutes, and not acting like themselves; this CNA stated they were never interviewed or asked about the grievance or the resident’s condition. The DON acknowledged not interviewing this CNA or investigating the resident’s behavior and why they were upset, and the unit manager did not recall whether the collateral contact was present during follow-up and did not believe they followed up with the collateral contact regarding the grievance. The administrator, identified as the Grievance Official, stated the facility should have thoroughly investigated the grievance and discussed findings and resolution with the collateral contact, indicating the grievance process was not fully carried out in accordance with policy and WAC 388-97-0460.
Failure to Obtain Timely Emergency Transport for Resident in Respiratory Distress
Penalty
Summary
The deficiency involves the facility’s failure to obtain timely emergency medical services for a resident experiencing new-onset respiratory distress. The resident had dementia, respiratory failure, and heart failure, with severe cognitive impairment and a need for substantial assistance with activities of daily living. On the day the resident was sent to the hospital, a collateral contact observed the resident having difficulty breathing, appearing unable to get enough air, and looking as if they were sleeping or unconscious, and reported this to staff with a request to contact the doctor. An SBAR Communication Form documented that the resident was experiencing shortness of breath that had not occurred before, with an oxygen saturation of 90%. The physician was notified and ordered the resident sent to the emergency department for treatment and evaluation, and the collateral contact was notified shortly thereafter. Progress notes later documented that, despite the order for emergency department transfer, the resident was still awaiting pickup by Olympic transportation several hours later, with no estimated time of arrival. At approximately 3:30 AM, the dispatcher informed the facility that they could not provide transportation and instructed that 911 be called; only then was 911 contacted and the resident transported to the hospital via ambulance for respiratory distress. The RN caring for the resident stated they completed the SBAR, notified the physician and family, and at the end of their shift reported to the oncoming nurse that the resident needed to be sent to the emergency department for respiratory distress and that paramedics should be contacted, then left assuming 911 would be called. The DON stated that staff are expected to contact 911 for emergent conditions such as shortness of breath or respiratory distress, and that Olympic Ambulance is used only for non-emergent transport.
Failure to Provide Social Service Advocacy After Abuse Allegation and Questionable Representative
Penalty
Summary
The deficiency involves the facility’s failure to provide appropriate medically-related social services and advocacy for a resident following an allegation of abuse and concerns about the resident’s representative. The resident had an anoxic brain injury, dysarthria, moderate cognitive impairment, and was dependent on staff for activities of daily living. A hospital palliative care note documented that the resident lacked decisional capacity, had no DPOA, that the legal next of kin (CC4) did not want to be part of care decisions, and that care decisions were being deferred to another contact (CC5). CC5 accompanied the resident on admission, signed admission forms, and was listed as the primary contact in the medical record profile. On a date in February, during communication therapy, the resident reported that CC5 had done something to them, pounded their hands on their chest, recalled being hit in the back of the head by an unknown person, and stated they were sometimes afraid of CC5. A social services staff member reported this allegation to the state agency but did not complete a facility incident report, did not initiate care plan changes or interventions, and took no further action. CC5 continued to be treated as the resident’s representative, and progress notes documented CC5 at the bedside on multiple dates, including an entry noting the room smelled like foreign substances and that CC5 was seen waking the resident and then asking the nurse to administer pain medications. A psychiatry note later documented concern that CC5 was providing the resident with illicit substances and stated it would be prudent for the resident to identify a POA. Subsequently, the resident was found unresponsive, transported to the hospital, and later readmitted after altered mental status and overdose, with a provider note stating that CC5 posed a significant danger to the resident and was banned from visiting. After readmission, staff attempted to contact CC4 for consent to treat but initially reached someone who stated they were not CC4. The social service director acknowledged that, beyond reporting the initial allegation, no additional interventions were implemented, that CC5 continued to be used as the resident’s representative after the allegation, and that they had not explored legal authority for decision making following the abuse allegation or concerns about substances. The social service assistant reported they did not speak with the resident about the hospital stay or CC5 and did not complete an incident report or care plan changes after the allegation. The unit manager and DON were unaware of the initial abuse allegation, and the administrator, who served as abuse coordinator, also stated they were unaware of the allegation and that an investigation should have been initiated and a representative for the resident investigated at a minimum.
Injury from Mechanical Lift Sling Detachment During Transfer
Penalty
Summary
The facility failed to ensure a safe mechanical lift transfer when a resident was being moved with a Hoyer lift and sling, resulting in a fall and injury. Facility policy for using a mechanical lifting machine required staff to securely attach sling straps to the sling bar according to manufacturer’s instructions, double-check the security of the sling attachment before lifting, examine all hooks, clips, or fasteners, check strap stability, and ensure the sling bar was securely attached and sound. Despite these requirements, during a transfer for dinner, two CNAs placed the sling under the resident, attached the loops at each corner of the sling to the lift, and raised the resident off the bed into the space between the bed and wheelchair when the bottom left corner of the sling became disengaged from the lift. The resident involved had multiple diagnoses including osteoarthritis, cervical and thoracic spondylosis, and Alzheimer’s disease, with the Minimum Data Set documenting severely impaired cognitive skills for daily decision-making. The resident’s care plan required the assistance of two staff during Hoyer lift transfers. During the transfer, the resident fell approximately four feet, landing on her buttocks, bouncing, and then falling backward and striking her head on the leg of the Hoyer lift. Hospital records documented that the resident sustained an abrasion to the back of the head, fractures of the 6th, 7th, 8th, and 10th ribs, and fractures of the 1st and 2nd lumbar vertebra. Staff interviews and observations showed that staff believed the sling loops had been securely fastened and reported hearing the loops click into place before lifting. One CNA stated that they had barely lifted the resident off the bed when the bottom left loop became disconnected and the resident fell. Another CNA reported being shocked and unable to figure out what had happened. A nurse who assessed the resident and then examined the equipment after the fall noted that one of the loops of the sling had become disengaged but stated the sling appeared to be in good condition. During a later demonstration, a CNA indicated she thought one of the round metal disks on the lift might have been a little loose. Maintenance logs for Hoyer slings and lifts for the preceding months documented no concerns with the slings or lifts, and the DON acknowledged expecting a citation due to the resident’s injury from the fall.
Failure to Revise Care Plans to Reflect Resident Needs and Preferences
Penalty
Summary
The deficiency involves the facility’s failure to revise and individualize comprehensive care plans to reflect residents’ current needs and preferences, as required by its own care planning policy. For one resident with hemiplegia, hemiparesis following cerebrovascular disease, and mononeuropathy of the upper limb, the admission MDS showed intact cognition and upper extremity impairment. This resident reported having bilateral shoulder surgery and an inability to tolerate blood pressure measurements on the upper arms due to pain, and stated a preference for BP measurements on the forearms. The resident reported having informed multiple nursing staff of this preference, but staff continued to place the cuff on the upper arms. Review of the resident’s care plan and Kardex showed no interventions or instructions regarding forearm BP cuff placement. A NAC confirmed they were unaware of the preference until the resident told them directly and that this instruction was not documented in the Kardex. The RN/Unit Manager, who stated they were responsible for revising and reviewing care plans when there were changes, also confirmed they were not aware of the resident’s preference and that it should have been updated in the care plan. Another resident, readmitted with hemiplegia and hemiparesis following a nontraumatic subarachnoid hemorrhage, contracture of the left hand, and weakness, was cognitively intact and required maximum assistance for bed mobility per a quarterly MDS. This resident stated they were supposed to get out of bed for two hours every day, but some NACs were not aware of this care requirement. Review of the resident’s March 2026 MAR/TAR showed an order to document the time the resident got up and the time they returned to bed daily. The report states that, overall, the facility failed to revise care plans accurately to reflect residents’ needs for three of four residents reviewed for care plan revision, placing them at risk for unidentified and unmet care needs and a diminished quality of life.
Failure to Implement Restorative Nursing and Splint/Brace Programs After Therapy Discharge
Penalty
Summary
The deficiency involves the facility’s failure to provide restorative nursing services, including range of motion (ROM) exercises and splint/brace assistance, to maintain or prevent decline in mobility and contractures for two residents with significant motor impairments. The facility’s undated Restorative Nursing Services policy stated that residents would receive restorative care as needed to achieve and maintain optimal functioning and that residents may initiate a restorative program upon discharge from rehabilitative care. Despite this, surveyors found that residents with documented hemiplegia, hemiparesis, weakness, and contractures were not placed on restorative programs and had no restorative interventions documented in their electronic health records (EHRs). Resident 1 was admitted with hemiplegia and hemiparesis following cerebrovascular disease, a left lower leg fracture, and weakness, and the admission MDS showed intact cognition, moderate assistance needs for bed mobility and transfers, and one-sided upper and lower extremity impairment. During observation, the resident was seen lying in bed with a bent inward left forearm and hand and reported no longer receiving therapy or nursing-assisted exercises. The care plan initiated in January showed no restorative services, and the care plan history and EHR contained no restorative nursing interventions. However, the PT discharge summary from February documented that restorative ROM and transfer programs had been established and trained, including PROM to the left upper and lower extremities and stand-by assist with transfers, and the OT discharge summary recommended a splint/brace to prevent contracture. The OT stated that the splint/brace was not tried due to lack of time before insurance was discontinued, and both the Director of Rehab and the MDS coordinator confirmed there was no restorative referral in the EHR and they were unaware of the recommendations. Resident 2 was readmitted with hemiplegia and hemiparesis following a nontraumatic subarachnoid hemorrhage, a left-hand contracture, and weakness, and the quarterly MDS showed intact cognition, maximum assistance needs for bed mobility, total assistance for transfers, bilateral upper and lower extremity impairment, and no therapy or restorative programs. The resident reported that therapy had been discontinued months earlier and that no restorative staff were assisting with exercises. The care plan and EHR showed no restorative services. OT evaluation documented left upper extremity ROM impairment, a left-hand contracture, and prior use of a left orthotic to manage flexion tone, and the OT discharge summary recommended restorative care and assistance with donning/doffing the orthotic. The PT discharge summary recommended restorative programs if Medicaid Part B services did not continue. The Director of Rehab confirmed therapy was discontinued and that restorative nursing programs were recommended, but both the Director of Rehab and the MDS coordinator stated there were no restorative referrals in the EHR after readmission, and the MDS coordinator confirmed the resident had no restorative programs since readmission.
Failure to Implement Effective Fall and Toileting Interventions for High-Risk Resident
Penalty
Summary
The deficiency involves the facility’s failure to provide adequate supervision, identify fall trends, and implement progressive, resident-centered interventions for a resident with multiple falls and declining strength. The facility’s own Falls and Fall Risk Management policy required staff to identify interventions related to residents’ specific risks and causes to prevent falls and minimize complications. The resident’s Care Area Assessment identified cancer-related risks for pain, falls, and ADL decline, and stated that falls and urinary incontinence would be addressed in the care plan with an objective of improvement and risk minimization. However, the comprehensive care plan did not include a urinary or ADL care plan and contained no toileting plan, despite the resident’s identified risks and prior fall history. Over a series of falls, the resident repeatedly fell while attempting to toilet or move toward the bathroom, yet the facility did not recognize or address this pattern in its investigations or care planning. The resident had multiple unwitnessed falls: next to the bed while getting up to use the restroom, in the bathroom while standing to use the toilet, and near or in the bathroom on several occasions. Incident investigations and post-fall assessments documented environmental factors such as clutter, items on the floor, water on the floor, and issues with footwear, as well as the resident’s increasing weakness, impulsivity, poor safety awareness, and poor insight into limitations. Interventions documented in investigations and risk reviews included encouraging use of the front-wheeled walker, keeping the wheelchair and walker accessible, ensuring proper footwear and non-skid socks, and providing resident education on safe transfers, ambulation, and assistive device use. However, several of these planned interventions, including placement of the wheelchair and frequent rounding/toileting assistance, were not added to or reflected in the care plan as stated. Staff interviews further showed that the resident frequently fell while trying to go to the bathroom and that staff relied on verbal education and reminders to use the call light, even though the resident often did not use it. Staff acknowledged the resident’s impulsivity and tendency to get up independently despite instructions, and one staff member stated that nursing assistants were verbally instructed to offer bathroom assistance, but this intervention was not documented in the care plan. The resident’s bed remained the one furthest from the bathroom throughout the stay, and none of the facility’s investigations identified the trend of bathroom-related falls or addressed toileting options in the care plan. Ultimately, the resident sustained a left ankle fracture after another bathroom-related fall, requiring transfer to the emergency department for evaluation and treatment, and later records documented additional fractures and a decline in condition. The surveyors concluded that the facility’s failures placed residents at risk of repeated falls and injuries.
Failure to Monitor Urinary Retention After Foley Removal Leading to Prolonged Pain
Penalty
Summary
The deficiency involves the facility’s failure to adequately assess and monitor a resident for complications associated with an indwelling urinary catheter and urinary retention, particularly after catheter removal. The resident had a history of acute kidney injury due to urinary retention, which improved after Foley catheter placement in the hospital. Hospital discharge documentation indicated the catheter was placed for acute urinary retention, was deemed permanent, and included instructions that, given the resident’s significant retention and acute renal failure, staff at the skilled nursing facility should not attempt Foley removal. The facility’s catheter care plan directed staff to empty the catheter as needed and record output in milliliters, but review of the last 30 days of documentation showed continence was not rated due to the indwelling catheter and there was no documented urinary output in milliliters on the treatment administration records. The resident had a scheduled urology appointment at which the urinary catheter was discontinued. Upon return from this appointment, nursing documentation initially indicated no new orders, and an alert note later stated the catheter was discontinued and staff were monitoring for retention or pain. However, there was no documented bladder assessment or urinary output following catheter removal. Nursing assistant documentation showed that the resident did not void on the evening shift that same day. Despite the catheter having been removed, the treatment administration record showed staff continued to document provision of catheter care on subsequent shifts when no catheter was in place. Over the next day, the resident experienced vomiting, decreased oral intake, and an altered level of consciousness, with vital signs showing tachycardia and low blood pressure, and staff documented decreased urine output. A bladder scan performed later revealed more than 2000–2500 milliliters of urine in the bladder, and an indwelling catheter was reinserted, initially draining a large volume of urine. The provider note indicated the resident had not eaten since the prior night, was unable to hold down fluids, and staff were unsure whether the resident had urinated in incontinence briefs, with no wet briefs reported since the resident’s return from the hospital after catheter removal. The provider expressed concern that the documented early-morning wet brief might not be accurate given the large bladder volume on scan and stated this should require further investigation. Subsequent notes described the resident moaning and complaining of pain, with limited urine output in the catheter bag and staff flushing and then replacing the catheter due to continued complaints. Interviews with the resident, the roommate, and staff indicated the resident was crying out and moaning in pain, the roommate repeatedly alerted staff that the resident was not urinating and that the catheter was not draining, and staff had to seek assistance to replace the catheter. Facility leadership and clinical staff later acknowledged that typical practice after catheter removal would include contacting the provider, placing the resident on alert, performing post-void residuals with bladder scans, and documenting monitoring, which was not done in this case.
Medication Administration Delays, Documentation Errors, and Use of Expired Insulin
Penalty
Summary
The deficiency involves the facility’s failure to ensure sufficient nursing staff with appropriate competencies and skill sets to administer medications according to professional standards of practice, facility policy, and prescriber orders. The facility’s medication administration policy required medications to be given as prescribed, in accordance with manufacturers’ specifications and good nursing principles, with no expired medications used, and doses administered within 60 minutes of the scheduled time and documented immediately after administration. Multiple residents reported that agency nurses often gave medications late, did not read full instructions, or were slow in bringing medications, and that routinely scheduled medications were not consistently provided without residents having to ask. Surveyors observed several specific medication administration failures. For a resident with diabetes, an LPN drew up and administered Humalog/Lispro insulin from a multi-dose vial that had been opened and dated “02/16” with no year, making it expired per policy, and administered the dose nearly 1 hour and 45 minutes after it was due. Another resident with care plan instructions to receive medications as ordered had multiple scheduled medications (Gabapentin, Oxybutynin, Baclofen, and Tizanidine) that were ordered at specific times throughout the day; the LPN was observed administering all four together and acknowledged that at least one (Tizanidine) was late, while the resident reported that receiving them together at that time was typical and not at their request. For another diabetic resident, an RN checked blood sugar and prepared sliding scale Humalog/Lispro insulin almost two hours after the scheduled time; the resident refused the insulin, stating they had already finished lunch. Additional deficiencies were identified with other residents’ pain and scheduled medications. One resident with a pain care plan and an order for Methocarbamol four times daily at set times approached the cart requesting Methocarbamol and Tylenol; the RN initially stated the Methocarbamol had already been given, but then administered it two hours after it was due when the resident pointed out the scheduled timing. For another resident with a risk for pain care plan and Tramadol ordered three times daily at specific times, an LPN retrieved a PRN pain medication while the electronic record showed no 8:00 AM medications documented; the LPN stated they had given them but had not yet documented. Later, an RN prepared the 2:00 PM Tramadol dose, and review of the narcotic count showed a discrepancy between the number of pills documented and the number remaining in the card. The RN stated they had given the 8:00 AM Tramadol but had not signed it out, then signed out both the 8:00 AM and 2:00 PM doses at that time. Residents interviewed consistently reported that medications were sometimes or frequently late, that agency nurses did not always follow instructions, and that they often had to request medications that were routinely scheduled.
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