Rockwood South Hill
Inspection history, citations, penalties and survey trends for this long-term care facility in Spokane, Washington.
- Location
- East 2903 25th Avenue, Spokane, Washington 99223
- CMS Provider Number
- 505033
- Inspections on file
- 22
- Latest survey
- March 23, 2026
- Citations (last 12 mo.)
- 1
Citation history
Health deficiencies cited at Rockwood South Hill during CMS and state inspections, most recent first.
A resident with a mental health disorder was admitted on a provider’s order for Seroquel 25 mg to be given once daily in the evening, but the order was incorrectly transcribed into the MAR as 25 mg once a day, give 0.5 mg in the evening. Based on this erroneous entry, the pharmacy dispensed 12.5 mg tablets (½ of a 25 mg tablet), and nursing staff administered 12.5 mg nightly over an extended period instead of the prescribed 25 mg dose. Interviews with the RCM and DON confirmed that the original order was for 25 mg every evening and that the resident received the wrong dose due to the transcription error.
The facility failed to ensure proper hand hygiene and use of hair coverings during meal service, did not monitor food temperatures for all items, and had issues with food storage and labeling. Staff were observed not changing gloves between tasks, serving food without hairnets, and not checking temperatures for mechanical soft and pureed foods. Additionally, food items were found uncovered, unlabeled, and expired, and staff lacked competency in preparing thickened liquids.
The facility failed to maintain complete and accurate medical records for three residents regarding informed consents for psychotropic medications. The consents lacked drug class categories and symptoms for medications like Nuplazid, Trazodone, citalopram, buspirone, quetiapine, sertraline, and Valium. Staff acknowledged these omissions during interviews.
The facility failed to follow its Antibiotic Stewardship Program, as it did not document or evaluate antibiotic use according to the McGeer Criteria for several residents. This included residents prescribed antibiotics for pneumonia, UTIs, and thrush without proper symptom assessment, increasing the risk of unnecessary antibiotic use.
A facility failed to notify a physician and a resident's POA of a change in condition for a resident with severe cognitive impairment and high blood pressure. Despite administering Hydralazine for elevated BP, the resident's condition remained concerning, with no documentation of notification to the physician or POA. The oversight was acknowledged by staff, highlighting a risk for delayed treatment decisions.
The facility failed to provide the required SNF Advanced Beneficiary Notice (ABN) to two residents, which is necessary for informing Medicare beneficiaries about their financial responsibilities when skilled services might not be covered by Medicare. One resident's Medicare Part A services ended, and they were discharged without receiving the SNF ABN, while another resident continued to reside in the facility without receiving the notice. The facility justified the lack of provision by stating that both residents used ten free contract days.
A facility failed to implement its policies on abuse and neglect prevention by not reporting or investigating multiple elopement incidents and a skin injury for a resident with severe cognitive impairment. Despite the resident's conditions, they managed to elope several times, and a skin tear was observed but not reported or investigated. The Director of Nursing acknowledged these failures.
The facility failed to document and communicate the transfer of two residents to the hospital, lacking physician orders and proper notification to the receiving hospital. This involved a resident with high blood pressure and heart failure, and another with sepsis and dementia, both experiencing acute symptoms requiring hospitalization.
The facility failed to notify the State LTC Ombudsman of hospital transfers for two residents. One resident, cognitively intact, was transferred due to symptoms like pain and low blood pressure, while another, with dementia, was transferred due to vomiting and low oxygen levels. Staff interviews confirmed the lack of notification documentation.
The facility failed to provide bed-hold notices to two residents during hospital transfers, as required. One resident, with high blood pressure and heart failure, was hospitalized twice without receiving a notice. Another resident, with sepsis and dementia, was also transferred without a notice. The DON confirmed that notices were only given upon admission, not during each hospital transfer.
The facility failed to create comprehensive care plans for four residents, neglecting to address specific medical needs such as high blood pressure, sleep disturbances, fragile skin, and hearing loss. This oversight led to inadequate management of conditions like hypertension, Alzheimer's, thrombocytopenia, and hearing impairment, as staff did not implement necessary interventions or document care strategies.
A facility failed to administer Hydralazine as needed for a resident with high blood pressure, despite multiple readings showing systolic BP above 160. The MAR indicated an as-needed order for the medication, but there was no documentation of its administration. The Resident Care Manager confirmed the oversight and acknowledged the need for order clarification.
A resident who was cognitively impaired and required assistance with ADLs was not consistently groomed, as evidenced by observations of facial hair over several days. Despite documentation of facial hair removal on certain dates, the resident was repeatedly seen with facial hair. Staff interviews indicated that shaving was done as needed, and the DON recognized the dignity issue of not removing facial hair during bathing.
A facility failed to update a resident's code status from CPR/Full treatment to Do Not Resuscitate/Selective Treatment as requested by the resident's POA. Despite a care conference and documentation of the change, the POLST form and electronic medical record still indicated full CPR, leading to potential risk of unwanted intervention.
The facility failed to implement the bowel protocol for three residents, leading to unmet needs and potential complications. A resident with neurogenic bladder and dementia did not receive prescribed laxatives, and another with a urinary tract infection and dementia experienced similar neglect. Additionally, a resident's bowel protocol was neglected, and the facility failed to monitor them after a fall and skin tear, with no documentation of the incidents or subsequent monitoring.
A facility failed to assess and implement restorative services for a resident with impaired range of motion in their lower extremities. Despite receiving physical therapy and having a history of neuromuscular impairments, the resident was not referred for restorative services to prevent further decline. Observations showed ongoing limitations, and staff interviews confirmed the resident was not on a restorative program, despite previous participation before hospitalization.
A resident with severe cognitive impairments and swallowing difficulties was not adequately supervised during meals, leading to multiple coughing episodes. Staff failed to document these incidents and did not promptly notify therapy and providers for a swallow evaluation, leaving the resident at risk for choking.
A facility failed to ensure timely coordination of controlled substances for a resident at the end of life due to a lack of effective after-hours physician availability. The resident, who required a change from morphine to Dilaudid, experienced delays as the primary physician was unreachable, and the covering NP could not manage controlled substance orders. The DON was unaware of the issue, and no process was in place to ensure prompt physician response.
A facility failed to monitor the effectiveness of sleep medication for a resident with dementia and weakness, who was prescribed Melatonin nightly. Despite receiving the medication, no sleep monitor was in place to assess its effectiveness, as confirmed by an LPN and the DON. This oversight posed a risk of adverse side effects.
The facility failed to consistently monitor refrigerator temperatures in the medication room, risking the efficacy of stored medications like Tubersol and RSV vaccines. Temperature logs were incomplete, and the room lacked a thermometer. The DON acknowledged the oversight and reported notifying maintenance about the issue.
The facility failed to ensure nursing staff had current Washington State Food Worker Cards, with three staff members either having expired cards or no information available. A Nursing Assistant was observed serving meals without a hair covering, and it was noted that nursing assistants served food when dietary staff were unavailable. This posed a potential risk for unsafe food handling practices.
A facility failed to ensure a resident received information and was offered the recommended pneumonia vaccinations. The facility's policy required pneumococcal vaccines to be offered upon admission, with documentation of consent or refusal in the EMR. However, the resident's records showed no documentation of vaccine assessment or offer, and the admission assessment questions about vaccination status were unanswered. This was confirmed by the Infection Preventionist.
Incorrect Transcription and Dosing of Psychotropic Medication
Penalty
Summary
The deficiency involves the facility’s failure to correctly transcribe and administer a prescribed psychotropic medication for a resident admitted with a mental health disorder. On admission, the provider ordered Seroquel 25 mg to be given once daily in the evening. However, when the order was entered into the Medication Administration Record (MAR), it was incorrectly transcribed as Seroquel 25 mg once a day, give 0.5 mg in the evening. As a result of this incorrect transcription, the MAR reflected administration of only 12.5 mg (½ tablet of a 25 mg tablet) instead of the prescribed 25 mg dose. The MAR for January and February showed that the resident consistently received 12.5 mg of Seroquel every evening from early January through early February, rather than the intended 25 mg dose. A facility investigation documented that the pharmacy dispensed 12.5 mg (½ of a 25 mg tablet) based on the incorrect order, and this dose was administered throughout the period. Interviews with the Resident Care Manager and the DNS confirmed that the original provider order was for Seroquel 25 mg every evening and that the order had been transcribed incorrectly into the MAR, resulting in the resident receiving the wrong dose.
Deficiencies in Hand Hygiene, Food Safety, and Storage Practices
Penalty
Summary
The facility failed to ensure proper hand hygiene and the use of hair coverings during food preparation and meal service in both the North and South Dining Rooms. Observations revealed that staff members, including Nursing Assistants and Dietary Aides, did not change gloves or perform hand hygiene between tasks, such as serving food, touching residents, and handling utensils. Additionally, staff members were observed serving food without wearing hairnets, which is a requirement to prevent cross-contamination. The facility also failed to monitor and record the temperatures of all food items being served, particularly mechanical soft and pureed foods. Staff members were observed checking temperatures for regular textured food items but not for mechanical soft and pureed items, which is against the facility's policy. This oversight was acknowledged by the Food Services Director, who stated that all food items should have been checked to prevent illness. Furthermore, the facility did not adhere to proper food storage practices. Observations in the kitchen and nourishment areas revealed uncovered and unlabeled food items, as well as expired products. Staff members acknowledged these issues, noting the importance of labeling and covering food to prevent contamination and ensure food quality. Additionally, there was a lack of competency among staff in preparing thickened liquids, with staff unable to accurately determine the consistency required for residents' diets.
Incomplete Informed Consents for Psychotropic Medications
Penalty
Summary
The facility failed to maintain complete and accurate medical records for three residents, specifically regarding informed consents for psychotropic medications. For Resident 15, the November 2024 Medication Administration Record (MAR) indicated the administration of Nuplazid, Trazodone, and citalopram. However, the consents dated 05/02/2023 for Trazodone and Nuplazid did not specify the drug class categories, and the consent for Nuplazid lacked the symptoms it was prescribed for, only mentioning 'psychosis.' Similarly, Resident 17's November 2024 MAR showed the administration of citalopram, Nuplazid, buspirone, and quetiapine, but the consents for citalopram and buspirone from 01/23/2024 did not identify the drug class categories. For Resident 19, the November 2024 MAR documented the administration of quetiapine, sertraline, Trazodone, and Valium, with consents from 11/22/2023 missing the drug class categories and symptoms for sertraline and quetiapine. Staff C and Staff D, Resident Care Managers, acknowledged the omissions in the consents during interviews, noting that the necessary information should have been included.
Failure to Follow Antibiotic Stewardship Program
Penalty
Summary
The facility failed to adhere to its established Antibiotic Stewardship Program (ASP) over a two-month period, as evidenced by a lack of documentation and evaluation of antibiotic use according to the McGeer Criteria. The policy required the facility to assess residents for infections using recognized standards and to reassess the appropriateness of empirically prescribed antibiotics. However, the facility did not document whether residents' signs and symptoms met the surveillance definitions for infections, nor did they evaluate the necessity of antibiotics prescribed upon admission or transfer. Several residents were affected by this deficiency. Resident 12 was prescribed Augmentin for pneumonia without documentation of whether the symptoms met the McGeer Criteria. Resident 28 was admitted with a prescription for Bactrim for cystitis, but there was no documentation of symptom evaluation. Similarly, Resident 17 was prescribed nitrofurantoin for a UTI based on symptoms that did not meet the McGeer Criteria. Resident 2 was given azithromycin and Levaquin for pneumonia without adequate evaluation of symptoms. Resident 29, Resident 7, and Resident 21 also received antibiotics without documented evaluation against the McGeer Criteria. The facility's failure to document and evaluate antibiotic use extended to Resident 24, who was treated for thrush and later a UTI without proper symptom assessment. The Infection Preventionist acknowledged the lack of documentation and evaluation for each resident's clinical signs and laboratory reports to determine if they met the McGeer Criteria for infection. This oversight increased the risk of unnecessary antibiotic use and potential adverse outcomes for residents.
Failure to Notify Physician and POA of Resident's Condition Change
Penalty
Summary
The facility failed to notify the physician and the resident's power of attorney (POA) of a change in condition for a resident with severe cognitive impairment and medically complex conditions, including high blood pressure and arrhythmia. The resident had an as-needed order for Hydralazine if their systolic blood pressure exceeded 160. On a particular day, after being showered, the resident exhibited signs of lethargy and a drooped lip, with a blood pressure reading of 194/95. Despite administering Hydralazine, the resident's blood pressure remained elevated, and there was no documentation of notification to the physician or the resident's representative about the ineffective medication or the continued high blood pressure. The staff documented the resident's condition and the administration of Hydralazine but failed to monitor the resident's status for adverse effects from the elevated blood pressure until 12 hours later. The lack of communication with the physician and the POA was acknowledged by a staff member, who stated that the nurse should have contacted the doctor and informed the POA about the interventions attempted. This oversight placed the resident at risk for delayed treatment decisions by the legal representative and the physician.
Failure to Provide Required Beneficiary Notices
Penalty
Summary
The facility failed to provide the required Skilled Nursing Facility (SNF) Advanced Beneficiary Notice (ABN) to two residents, which is necessary for informing Medicare beneficiaries about their financial responsibilities when skilled services might not be covered by Medicare. Resident 83's Medicare Part A services ended on August 22, 2024, and the resident was discharged on September 4, 2024, without receiving the SNF ABN. The facility justified the lack of provision by stating that the resident used ten free contract days before discharge. Similarly, Resident 1, whose Medicare Part A services ended on June 7, 2024, continued to reside in the facility without receiving the SNF ABN. The facility explained that Resident 1 also utilized ten free days under a contract agreement. The Director of Nursing, Staff B, confirmed that the SNF ABNs were not given due to the contract with the retirement community, which included ten free days, and asserted that the residents were aware of their costs. No additional information was provided.
Failure to Report and Investigate Elopement and Injury
Penalty
Summary
The facility failed to implement its Abuse and Neglect Prohibition Policies and Procedures, specifically in not reporting or investigating elopement episodes and a skin injury for one resident. The facility's policy required immediate investigation and reporting of any suspicion or actual abuse, neglect, or exploitation, with specific time frames for reporting to the Administrator and state agency. However, the facility did not document or report the elopement incidents or the skin injury of Resident 30, nor did it investigate the circumstances surrounding these events to determine if abuse or neglect contributed. Resident 30, who had a traumatic brain injury, restlessness, agitation, and Parkinson's disease, was assessed with severe cognitive impairment. Despite these conditions, the resident managed to elope multiple times, including reaching an independent living area and being found near a maintenance office. Additionally, a skin tear was observed on the resident's elbow, but the facility did not report or investigate this injury. The Director of Nursing acknowledged these failures when the findings were shared, but no further information was provided.
Failure to Document and Communicate Resident Transfers
Penalty
Summary
The facility failed to ensure proper documentation and communication during the transfer of two residents to the hospital, which resulted in a deficiency. Resident 24, who had diagnoses including high blood pressure, heart failure, and thrombocytopenia, was sent to the hospital on two occasions due to complaints of pain and low blood pressure. However, there was no documentation in the resident's medical record indicating that an order was obtained for the transfer or that the receiving hospital was informed of the resident's condition. Interviews with staff revealed that a transfer form should have been completed and that the hospital should have been notified, but this was not done. Similarly, Resident 22, who had diagnoses of sepsis and dementia, was sent to the hospital after experiencing vomiting and low oxygen levels. Again, there was no documentation of a physician's order for the transfer or communication with the receiving hospital. Staff interviews confirmed that a transfer form should have been sent with the resident, but there was no evidence that the hospital was informed of the resident's condition. These failures placed the residents at risk for delays in treatment and unmet care needs.
Failure to Notify Ombudsman of Resident Transfers
Penalty
Summary
The facility failed to ensure that the Office of the State Long-Term Care Ombudsman was notified in writing of hospital transfers for two residents, Resident 24 and Resident 22. Resident 24, who was cognitively intact and had diagnoses including heart failure, pneumonia, and thrombocytopenia, was transferred to the hospital on two occasions due to symptoms such as pain, lethargy, and low blood pressure. Despite these transfers, there was no documentation indicating that the Ombudsman was notified, as confirmed by interviews with staff members including the Medical Records staff, Resident Care Manager, and Director of Nursing. Similarly, Resident 22, who was not cognitively intact and had diagnoses of sepsis and dementia, was transferred to the hospital after experiencing vomiting, abdominal pain, and low oxygen levels. Again, there was no documentation of notification to the Ombudsman regarding this transfer. The lack of notification was acknowledged by staff during interviews, indicating a systemic issue in the facility's process for notifying the Ombudsman of resident transfers.
Failure to Provide Bed-Hold Notices During Hospital Transfers
Penalty
Summary
The facility failed to provide a bed-hold notice to residents or their representatives at the time of discharge or within 24 hours of transfer to the hospital, as required by regulations. This deficiency was identified for two residents who were hospitalized. Resident 24, who was cognitively intact and had diagnoses including high blood pressure and heart failure, was sent to the hospital on two occasions due to pain, lethargy, and low blood pressure. However, there was no documentation indicating that a bed-hold notice was provided to the resident during these hospitalizations. Similarly, Resident 22, who had diagnoses including sepsis and dementia, was sent to the hospital after experiencing vomiting, abdominal pain, and low oxygen levels. Again, there was no documentation of a bed-hold notice being provided. During an interview, the Director of Nursing acknowledged that bed-hold notices were only offered upon admission and not each time a resident was transferred to the hospital, which is contrary to the requirements.
Failure to Develop Comprehensive Care Plans for Residents
Penalty
Summary
The facility failed to develop comprehensive person-centered care plans for four residents, leading to deficiencies in addressing their specific medical needs. Resident 15, who was admitted with high blood pressure and arrhythmia, had multiple instances of elevated systolic blood pressure readings, yet there was no care plan developed to manage these conditions. Staff acknowledged the absence of a care plan for these active diagnoses, which should have been in place to guide the management of the resident's health issues. Resident 19, diagnosed with Alzheimer's disease and severe cognitive impairment, was receiving Melatonin as a sleep aid. However, the resident's care plan did not include any interventions or considerations for sleep disturbances, despite the ongoing administration of the medication. Staff confirmed that a care plan addressing the resident's sleep needs should have been developed to ensure appropriate care. Resident 24, with diagnoses including high blood pressure, heart failure, and thrombocytopenia, exhibited significant bruising on their arms due to low platelet count. Despite the high risk for bruising and bleeding, there were no care plan interventions in place to protect the resident's fragile skin. Staff interviews revealed that protective measures such as sleeves and gentle care should have been documented in the care plan. Additionally, Resident 8, with Alzheimer's disease and bilateral hearing loss, had no care plan addressing their hearing aids, which were essential for communication. Observations showed the resident often without their hearing aids, and staff did not assist in managing them, impacting the resident's ability to communicate effectively.
Failure to Administer As-Needed Medication for Elevated Blood Pressure
Penalty
Summary
The facility failed to implement a physician's order for the treatment of elevated blood pressures for Resident 15, who was admitted with medically complex conditions including high blood pressure and arrhythmia. The November 2024 Medication Administration Record (MAR) indicated an as-needed order for Hydralazine every six hours if the resident's systolic blood pressure exceeded 160. However, multiple readings showed the resident's systolic blood pressure was above 160 on several occasions, yet there was no documentation that the staff administered the Hydralazine as ordered. Staff C, the Resident Care Manager, confirmed the lack of documentation and acknowledged that the order required clarification, as there were no instructions to cue the staff on administering the medication when needed.
Failure to Consistently Provide Grooming for a Resident
Penalty
Summary
The facility failed to consistently provide grooming for a resident, identified as Resident 25, who was cognitively impaired and required partial to moderate assistance with activities of daily living, including personal hygiene. According to the resident's care plan, assistance with personal hygiene was necessary. However, observations from December 3 to December 6, 2024, noted that Resident 25 had facial hair approximately a centimeter long, indicating a lack of grooming. Despite documentation showing facial hair removal on specific dates in November and December, the resident was observed with facial hair on multiple occasions. Interviews with staff revealed that shaving was performed as needed, and the Director of Nursing acknowledged that not removing facial hair during bathing was a dignity issue.
Failure to Update Resident's Code Status
Penalty
Summary
The facility failed to follow up on a resident's request to change their code status, which is the level of intervention a resident chooses if their heart or breathing stops. This failure involved Resident 17, who was admitted with medically complex conditions and severe cognitive impairment. During a care conference, the resident's Power of Attorney (POA) requested a change in the code status from CPR/Full treatment to Do Not Resuscitate/Selective Treatment. The facility documented this change and faxed the POLST form to the provider for signature. However, the POLST form in the electronic medical record still indicated full CPR and full treatment, contrary to the POA's decision. Staff M, a Registered Nurse, was unable to confirm the correct code status for Resident 17, as the resident roster did not display code statuses, and the CPR book and electronic medical record both directed staff to initiate CPR. This discrepancy was acknowledged by Staff C, the Resident Care Manager, who confirmed that the electronic medical record and POLST did not reflect the POA's choice. This oversight placed Resident 17 at risk of receiving CPR against the legal representative's wishes.
Failure to Implement Bowel Protocol and Monitor Post-Incident
Penalty
Summary
The facility failed to implement the bowel protocol for the management of constipation for three residents, leading to unmet needs and potential complications. Resident 14, diagnosed with neurogenic bladder and dementia, did not receive the prescribed laxatives as per the bowel protocol during specific periods in November 2024, despite having no bowel movements for several days. The Resident Care Manager confirmed the protocol was not followed, which was necessary to prevent constipation and related complications. Resident 28, with diagnoses including a urinary tract infection and dementia, also did not receive the prescribed laxatives according to the bowel protocol. The resident experienced multiple periods of no bowel movements from November to December 2024, yet there was no documentation of laxative administration during these times. The Resident Care Manager acknowledged the oversight and emphasized the importance of following the protocol to avoid constipation and further medical issues. Resident 30's bowel protocol was similarly neglected, with no documentation of laxative administration despite the absence of bowel movements over several days. Additionally, the facility failed to monitor Resident 30 after a fall and a skin tear, with no documentation of the fall's occurrence, the abrasion's details, or subsequent monitoring. The Director of Nursing confirmed the lack of documentation and expected monitoring for at least 72 hours post-incident.
Failure to Assess and Implement Restorative Services for Resident
Penalty
Summary
The facility failed to assess the need for restorative services for a resident with impaired range of motion in their lower extremities. The resident, who had diagnoses including dementia and abnormalities of gait and mobility, required substantial to total assistance with activities of daily living and had received physical and occupational therapy. Despite a physical therapy evaluation identifying new or worsened neuromuscular impairments and high tone in the resident's bilateral lower extremities, there was no assessment or referral for restorative services to prevent further decline. The resident's care plan lacked interventions related to their lower extremity limitations or directions for range of motion or restorative exercises. Observations of the resident showed their legs stretched out and foot pointing upward while sitting in a wheelchair, indicating ongoing limitations. Interviews with staff revealed that the resident was not on a restorative program, despite having been on one prior to a hospitalization. Staff acknowledged the oversight, noting that the resident should have been placed back on a restorative program after therapy completion to prevent contractures and maintain their current level of functioning.
Inadequate Supervision During Resident's Coughing Episodes
Penalty
Summary
The facility failed to provide adequate supervision during a coughing episode for a resident with severe cognitive impairments and a history of dementia and stroke. The resident required total assistance with eating and was on a mechanical soft diet with nectar thick liquids due to swallowing difficulties. Despite these needs, the resident was observed coughing during meals on multiple occasions without immediate intervention or documentation of the episodes. Staff left the resident alone after a coughing episode, and there was a delay in notifying the appropriate personnel for a swallow evaluation. The resident's care plan required one-to-one feeding assistance and specific instructions for safe swallowing, which were not consistently followed. Staff failed to document the coughing episodes and did not promptly communicate the resident's condition to therapy and providers. The lack of immediate assessment and documentation of the resident's condition after the coughing episodes contributed to the deficiency, as it placed the resident at risk for choking and compromised their quality of life.
Delayed Physician Response for End-of-Life Medication
Penalty
Summary
The facility failed to ensure the timely coordination of controlled substances for a resident at the end of life, due to a lack of an effective system for physician availability after hours. Resident 31, who was readmitted to the facility for comfort care following a rapid health decline, was described as alert but confused and incoherent. The resident was administered morphine to manage symptoms of anxiety and agitation, but the medication was not effective, and a change to Dilaudid was needed. However, the facility's staff encountered delays in obtaining the necessary physician orders for the medication change. Staff F, a registered nurse, attempted to contact the resident's primary physician, Staff I, who was also the facility's Medical Director, but was unable to reach them promptly. Despite leaving messages with the physician's answering service, the nurse was informed that a nurse practitioner was covering for the physician, who could not manage orders for controlled substances. This led to further delays, as Staff I was not able to call in the order to the pharmacy immediately. The Director of Nursing, Staff B, was unaware of the issue and stated that no process was in place to ensure prompt physician response, highlighting a gap in the facility's emergency procedures for medication management at the end of life.
Failure to Monitor Sleep Medication Effectiveness
Penalty
Summary
The facility failed to ensure that sleep medications were consistently monitored for a resident, identified as Resident 183, who was reviewed for unnecessary medications. Resident 183 had diagnoses including dementia and weakness and was prescribed Melatonin for sleep, to be administered every night at bedtime. The medication administration records for November and December 2024 confirmed that the resident received Melatonin nightly. However, interviews with Staff K, an LPN, and Staff B, the Director of Nursing, revealed that a sleep monitor should have been in place to assess the effectiveness of the Melatonin, which was not done. This oversight placed the resident at risk for potential adverse side effects and medical conditions.
Improper Medication Storage Due to Inconsistent Temperature Monitoring
Penalty
Summary
The facility failed to maintain proper storage conditions for medications, as observed during a survey. On December 6, 2024, a Registered Nurse and surveyors found that the refrigerator in the medication room contained a vial of Tubersol and respiratory syncytial virus vaccines. However, the temperature logs for the refrigerator were inconsistently monitored, with only 14 days recorded in September, 16 days in October, and 16 days in November 2024. Additionally, the medication room lacked a thermometer to monitor the storage temperature of medications. During an interview, the Director of Nursing acknowledged that the refrigerator's temperature should have been monitored to ensure medication efficacy and mentioned that maintenance had been notified about the need for a temperature gauge in the medication room. This deficiency placed residents at risk of receiving compromised or ineffective medications.
Deficiency in Food Worker Card Compliance
Penalty
Summary
The facility failed to ensure that nursing staff had the required qualifications, specifically current Washington State Food Worker Cards, for three nursing staff members. This deficiency was identified through observation, interview, and record review. During an observation, a Nursing Assistant, Staff G, was seen serving meals from the steam table without wearing a hair covering. In an interview, a Cook, Staff Z, stated that nursing assistants served food from the steam table when dietary staff were unavailable. Upon request, the facility was unable to provide current Food Worker Cards for the dietary and nursing staff. A review of the dietary cards revealed that Staff N and Staff BB had expired cards, and there was no information available for Staff CC. This lack of proper qualifications posed a potential risk for unsafe food handling practices, which could lead to foodborne illness among residents.
Failure to Offer Pneumonia Vaccination to Resident
Penalty
Summary
The facility failed to ensure that a resident, identified as Resident 183, received information on and was offered the recommended pneumonia vaccinations as per the Centers for Disease Control and Prevention guidelines. The facility's policy, dated 10/19/2022, required that pneumococcal vaccines be offered to all residents upon admission unless medically contraindicated. The policy also mandated that staff assess residents for vaccine eligibility upon admission and annually, counsel them on the benefits and adverse effects, and document consent or refusal in the electronic medical record (EMR). However, upon review of Resident 183's records, there was no documentation indicating that the resident was assessed for vaccine eligibility or offered the pneumonia vaccine. The comprehensive admission assessment for Resident 183, dated 11/26/2024, included questions about the resident's pneumococcal vaccination status, but these were left unanswered. Additionally, the Immunizations section of the EMR and the Miscellaneous section for uploaded files showed no evidence that the staff assessed the resident's eligibility or offered the vaccine. This oversight was confirmed during an interview with the Infection Preventionist, Staff E, on 12/09/2024, who was unable to provide further information.
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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