Royal Park Health And Rehabilitation
Inspection history, citations, penalties and survey trends for this long-term care facility in Spokane, Washington.
- Location
- 7411 North Nevada, Spokane, Washington 99208
- CMS Provider Number
- 505379
- Inspections on file
- 40
- Latest survey
- September 9, 2025
- Citations (last 12 mo.)
- 2
Citation history
Health deficiencies cited at Royal Park Health And Rehabilitation during CMS and state inspections, most recent first.
A resident with chronic pain and a history of shoulder fracture missed multiple doses of prescribed Morphine ER due to delays in obtaining a new prescription and confusion between medication formulations. Nursing staff documented the medication was on order and not available, and the resident experienced unmanaged pain and withdrawal symptoms until the medication arrived. Staff interviews revealed inconsistent application of medication reordering policies and lack of timely communication regarding the missed doses.
A resident requiring colostomy, urostomy, or ileostomy care did not receive appropriate care or services as needed.
Two dependent residents did not receive the required number of weekly baths as outlined in their care plans, with documented gaps of up to 10 days between bathing. Staff interviews revealed inconsistent procedures for making up missed showers when the designated shower aide was unavailable, resulting in lapses in personal hygiene care.
A resident with impaired mobility and multiple health conditions was injured after falling from bed during a linen change when only one nursing assistant was present. The resident, who previously used the wall for support, was in a new room where the bed was not against the wall, and was unable to stay awake during care. Staff did not consistently use two-person assistance as indicated in the care plan, resulting in the resident rolling off the bed and sustaining a subdural hematoma.
A resident with severe pain and a history of sciatica and neurological disorder was ordered 100 mg Tramadol at bedtime but received only 50 mg from an LPN. Despite the resident's request for the full dose, the nurse refused, leading to uncontrolled pain and a hospital transfer. The error was discovered during a review of ER transfers, and the DON confirmed the medication was not administered as ordered.
The facility failed to maintain adequate staffing levels, resulting in delayed responses to call lights and unmet care needs for several residents. Cognitively intact residents reported long wait times and observed staff ignoring call lights. Staff interviews revealed inconsistencies in staffing adjustments based on resident acuity, contributing to the deficiency.
The facility failed to store and handle food according to professional standards, with expired and undated items found in storage areas. Cold food items were served above recommended temperatures, and the kitchen environment was unsanitary, with unclean ovens and food warmers. Staff acknowledged the importance of proper food handling to prevent food-borne illnesses.
The facility failed to offer COVID-19 vaccines and provide education to staff, as well as maintain documentation of vaccination status. Staff G, H, and I were not recently offered vaccines, and Staff J confirmed the facility did not provide them, instead advising staff to seek external vaccination. This lack of process placed residents and staff at risk, as evidenced by a resident testing positive for COVID-19.
The facility failed to ensure residents could file grievances without fear of reprisal and did not resolve grievances promptly. Residents reported issues such as staff ignoring call lights, inappropriate staff behavior, and poor food quality. Despite the facility's grievance policy, residents felt their grievances were not addressed timely, and some experienced retaliation from staff. Interviews with staff revealed a lack of understanding of grievance resolution timeframes and inappropriate behavior that could be perceived as retaliation.
The facility failed to adhere to care plans and provider orders for several residents, leading to deficiencies in care. A resident with diabetes had their blood sugar monitored incorrectly due to a broken CGM, another resident at risk of constipation did not receive necessary bowel medications, and a resident with heart failure received excess fluids despite a restriction. Staff were unaware of these issues, leading to potential health risks.
Two residents experienced significant weight loss due to the facility's failure to implement timely nutritional interventions. One resident, who was cognitively intact, lost weight despite consuming meals, and interventions were delayed until months later. Another resident with dysphagia and cognitive impairments was not supervised during meals and used inappropriate drinking cups, leading to further weight loss. Staff interviews revealed a lack of timely response to these issues.
The facility failed to complete annual staff performance reviews as required, specifically for a Nursing Assistant who had received warnings for not completing training and for a verbal altercation. Interviews with staff confirmed that evaluations were supposed to be conducted yearly, but the facility was behind on this requirement, placing residents at risk of receiving care from inadequately trained staff.
The facility failed to provide palatable meals, as residents reported food being tough, dry, flavorless, and served at inappropriate temperatures. A resident experienced significant weight loss and malnutrition, attributing it to the poor food quality. The dietary manager acknowledged complaints, citing under-seasoning and lack of menu changes as issues.
The facility failed to implement its Abuse and Neglect Policy, leading to inadequate investigations and reporting of potential abuse allegations. A resident's unanticipated death was not thoroughly investigated, and other residents reported issues with staff behavior, such as rudeness and rough handling, which were not properly addressed. The facility's actions left residents at risk for abuse and neglect.
The facility failed to implement proper infection control measures, including transmission-based precautions and hand hygiene, for a resident with shingles. Staff did not consistently wear PPE or perform hand hygiene, and shared equipment was not adequately cleaned. These deficiencies were observed during meal service and in the handling of waste in the resident's room, placing residents at risk of infection.
The facility failed to maintain dignity in urinary catheter care for two residents, leading to potential embarrassment and infection risk. One resident's catheter bag was observed uncovered and dragging on the floor, while another's was visible from the hallway. Staff confirmed the need for dignity covers and proper positioning, but these were not consistently applied.
A facility failed to implement its self-administration of medication policy for a resident with COPD, leading to unsecured medications at the bedside. The resident had medications not approved for bedside storage, including Mentholatum ointment, which posed a safety risk when used with oxygen therapy. Staff interviews revealed a lack of adherence to policy, placing residents at risk of medication errors and accidents.
The facility failed to maintain a safe and homelike environment for two residents. A resident's personal refrigerator contained expired foods without proper labeling, and temperature logs were incomplete. Another resident's room had a large hole in the drywall, identified as a potential fire hazard. Additionally, an exit door was offset and did not latch properly, posing a safety risk. Staff were aware of these issues but did not adequately address them.
A facility failed to provide a timely bed-hold notice to a resident with severe cognitive impairments who was hospitalized due to a rapid heart rate and low oxygen levels. The notice was not given within the required 24-hour period, as it was delayed by four days. The Admissions Director confirmed the usual practice of offering bed holds within 24 hours, except when transfers occurred on Fridays.
A resident with Parkinson's disease experienced a decline in their ability to perform ADLs due to inconsistent restorative care. Despite a care plan that included a restorative program, staffing shortages led to missed or reduced RNA sessions. The resident's condition worsened, requiring more assistance with mobility and personal care tasks. Staff interviews confirmed the impact of staffing issues on the resident's care.
A resident with a traumatic brain injury and muscle weakness was not provided adequate assistance during meals, leading to difficulties in eating and drinking. Despite requiring set-up assistance, the resident was observed eating with their fingers and taking long breaks between bites, with no staff present to assist. The care plan indicated varying levels of assistance, but staff failed to update it to reflect the need for stand-by assistance.
A facility failed to follow a care plan for a resident with stroke and hemiplegia, who was frequently incontinent. The care plan required the use of a bedpan for toileting, but staff did not provide it, relying instead on briefs. The resident expressed a preference for continence, and staff interviews confirmed the lack of bedpan use, contrary to the care plan.
A resident with sleep apnea was not consistently using their BIPAP machine as ordered by the physician, particularly during naps, despite the care plan's instructions. Observations showed the resident sleeping without the BIPAP, and staff interviews revealed a misunderstanding of the care requirements. The Director of Nursing confirmed the need for the BIPAP to be used whenever the resident was sleeping.
A facility failed to timely act on a pharmacist's recommendations for a resident on cholesterol medication, delaying necessary blood tests for monitoring. Despite repeated recommendations from July to October, the lipid panel was only completed in late November, 95 days after the initial order. Staff interviews revealed confusion about the medication review process, especially with outside providers.
A resident did not receive prescribed medications, Enbrel and amitriptyline, on multiple occasions due to a breakdown in the medication ordering and administration process. Staff interviews revealed issues with obtaining authorization for Enbrel and delays in receiving amitriptyline from the pharmacy. This deficiency was a repeat citation from previous surveys.
The facility failed to ensure proper medication management and storage, with undated and expired medications found in medication rooms, inconsistent refrigerator temperature monitoring, and unsanitary medication carts. Additionally, medications were unsecured in a resident's room without proper orders or evaluations. Staff acknowledged these deficiencies.
The facility failed to ensure dietary staff had the required training, as four staff members lacked valid credentials. Staff P had an expired Washington State Food Workers card, while Staff M, N, and O had certificates from an unapproved program. The Dietary Manager was unaware of the credentialing requirements, posing a risk for unsafe food handling and potential foodborne illnesses among residents.
Two residents with severe cognitive impairment signed arbitration agreements without understanding them or involving their legal representatives. Staff lacked adequate training to explain the arbitration process, leading to residents signing agreements they could not comprehend.
A facility failed to safeguard resident information and maintain complete medical records for a resident with severe cognitive impairment. The resident was found unresponsive with a head injury, and a staff member used a personal phone to photograph the injury, violating HIPAA standards. The photos were sent to the medical examiner but not included in the medical record, highlighting a breach in facility policy regarding the use of personal electronic devices.
A resident with diabetes and lung disease was found unresponsive with low blood sugar. Despite facility policy, an LPN administered glucose gel orally, leading to aspiration. The resident was later diagnosed with aspiration pneumonia after EMS intervention.
A resident in a long-term care facility reported sexual abuse by a staff member, which was confirmed by a sexual assault exam showing abrasions consistent with penile penetration. The resident, who was alert and oriented, described the staff member but could not provide a name. The facility's investigation led to the suspension of three staff members matching the description. The incident highlighted the facility's failure to protect the resident from abuse, placing them at risk for further harm.
A resident with severe cognitive impairment and high fall risk fell from an elevated bed when left unattended by staff during a transfer, resulting in a head injury and subsequent death. The facility failed to follow the care plan, which required the bed to be in a low position and the resident not to be left alone during transfers.
A resident at risk for pressure ulcers due to Diabetes and paraplegia developed an unstageable pressure ulcer that was not identified by the facility. Despite a care plan that included skin inspections and repositioning, there was no documentation of the resident's skin condition from admission until hospital transfer. The deficiency was discovered when the resident was hospitalized with the ulcer.
A resident with blindness and dementia was taken to an appointment dressed inappropriately in a nightgown, without undergarments or socks, and with uncombed hair. Despite staff instructions to dress the resident appropriately, the resident returned in the same attire, highlighting a failure to promote dignity.
A resident with spinal cord dysfunction was not able to move their lower extremities but could communicate their needs. The facility failed to notify the resident's representative of a change in condition, as the representative was not informed of the resident's worsening condition until the resident was being sent to the hospital. Despite the resident experiencing nausea and lack of appetite for several days, there was no documentation of notification to the family until the day of hospital transfer. The facility lacked a specific policy for notifying changes in condition.
A resident with spinal cord dysfunction experienced nausea and reduced appetite, but the facility failed to consistently monitor and document the condition change. Despite procedures for alert charting and notifying providers and family, there was a documentation gap from when the issue was first noted until the resident was sent to the hospital due to lethargy.
Failure to Provide Timely Pain Medication Due to Pharmacy and Communication Delays
Penalty
Summary
The facility failed to ensure that pharmaceutical services were provided to meet the needs of a resident with a history of chronic pain and a shoulder fracture, who was dependent on Morphine for pain management. The resident had a care plan and physician orders for Morphine 30 mg extended release to be administered twice daily. However, a breakdown in communication and medication management led to the resident missing multiple doses of their prescribed Morphine. Documentation showed that the medication was not available due to delays in obtaining a new prescription and confusion between immediate release and extended release formulations, resulting in the pharmacy not dispensing the medication on time. Nursing staff documented that the Morphine was on order and not available, and communicated with the pharmacy and provider regarding the need for a new prescription. Despite these communications, there was a lapse of at least two doses before the medication was received. The resident reported experiencing unrelieved pain and withdrawal symptoms during this period, and staff notes confirmed the resident endorsed withdrawal after missing the doses. The facility's policy required nurses to reorder medications when a seven-day supply remained, but staff interviews revealed inconsistent understanding and application of this policy, with some staff unaware of the missed doses until after the fact. Interviews with the resident, their spouse, and various staff members indicated that the resident's complaints of pain and withdrawal were not taken seriously at the time, and there was a lack of timely communication and oversight by nursing management. The provider confirmed that the interruption in Morphine administration was not planned or recommended, and there was no documentation of provider-patient communication regarding the missed medication. The failure to provide the ordered medication as required by the care plan and physician orders resulted in the resident experiencing unmanaged pain and withdrawal symptoms.
Failure to Provide Appropriate Ostomy Care
Penalty
Summary
A resident who required colostomy, urostomy, or ileostomy care did not receive appropriate care or services as needed. The report identifies a failure to provide the necessary ostomy care for a resident with such a medical requirement. Specific details regarding the actions or omissions that led to this deficiency are not provided in the report.
Failure to Provide Required Number of Weekly Baths to Dependent Residents
Penalty
Summary
The facility failed to ensure that two dependent residents received the required number of baths per week, as specified in their care plans. One resident, who had a history of stroke with one-sided weakness and aphasia, was care planned to receive showers twice weekly but preferred bed baths. Review of bathing records showed significant gaps between bed baths, with intervals of 7 to 10 days between each, rather than the expected twice-weekly schedule. The resident confirmed a preference for bed baths and indicated they did not receive them twice a week. Another resident with dementia, who required partial to moderate assistance for personal hygiene, also did not receive showers according to the required schedule. Bathing records indicated an 8-day gap between showers. Staff interviews revealed that when the designated shower aide was absent or reassigned to other duties, there was uncertainty among staff about how to make up missed showers. The Director of Nursing acknowledged that shower aides were sometimes pulled to the floor and that floor staff were expected to assist with missed showers, but this did not consistently occur.
Inadequate Supervision During Bed Mobility Leads to Resident Fall and Injury
Penalty
Summary
A deficiency occurred when staff failed to provide adequate supervision and reassessment of a resident's ability to assist with bed mobility following a room change and changes in level of consciousness. The resident, who had diagnoses including heart failure, below-the-knee amputation, obesity, and impaired functional mobility, was dependent on staff for transfers, toileting, and bed mobility. The care plan indicated the need for extensive assistance from one to two staff for bed mobility. However, staff determined the number of assisting personnel based on their assessment of the resident's ability to help during care, which varied depending on the resident's alertness and environment. After a room change, the resident's bed was no longer against the wall, removing a support the resident previously used for stability during care. During a bed linen change, a single nursing assistant attempted to provide care while the resident was drowsy and unable to remain awake. The resident was rolled toward the edge of the bed and subsequently fell headfirst onto the floor, resulting in a subdural hematoma and hospitalization. Staff interviews revealed inconsistent practices regarding the number of staff required for bed mobility, with some relying on the resident's ability to assist and others always using two staff for safety. The incident was attributed to inadequate supervision, failure to reassess the resident's needs after environmental changes, and not ensuring sufficient staff assistance during care.
Failure to Administer Ordered Pain Medication Dose Resulting in Uncontrolled Pain and Hospital Transfer
Penalty
Summary
A resident with diagnoses including sciatica and a progressive neurological disorder was admitted to the facility and had a care plan that included pain medication therapy. The resident had physician orders for Tramadol 50 mg every six hours as needed and 100 mg scheduled at bedtime. On the evening in question, the resident received only 50 mg of Tramadol at bedtime instead of the ordered 100 mg. The resident continued to experience severe pain, rating it as a 10 out of 10, and was subsequently given Tylenol, which did not alleviate the pain. The nurse did not administer the additional 50 mg of Tramadol, stating there was no order for more, despite the resident's request and clarification that only half the ordered dose had been given. As a result of the inadequate pain management, the resident's pain remained uncontrolled, leading to a transfer to the hospital emergency room, where the resident continued to report intense pain. The facility's review of emergency room transfers revealed the medication error. The Director of Nursing confirmed that the resident had an order for 100 mg of Tramadol at bedtime but only received 50 mg, resulting in harm due to uncontrolled pain.
Inadequate Staffing Leads to Delayed Resident Care
Penalty
Summary
The facility failed to ensure adequate staffing levels to meet the needs of its residents, as evidenced by multiple grievances and incidents reported by residents and staff. Resident 40, who was cognitively intact, reported that staff ignored call lights and used the Oak activity room as a break room, leading to delays in receiving medications and assistance. Resident 31, also cognitively intact, experienced long wait times for assistance with personal hygiene and oxygen needs, resulting in self-transfer attempts due to staff not responding to call lights in a timely manner. Resident 27, with moderate cognitive impairment and a history of falls, required substantial assistance for transfers and toileting. Despite this, the resident experienced multiple falls after being left unattended, and their friend reported excessively long call light wait times. Resident 24, who required substantial assistance for activities of daily living, also reported long wait times for staff assistance. Resident 28 observed staff sitting around while call lights were going off, further indicating insufficient staffing levels. Interviews with staff revealed confusion and inconsistency in how staffing levels were determined and adjusted based on resident acuity. Staff reported that when call-ins occurred, they were often required to pull staff from other units or programs, such as restorative nursing, which were not adequately replaced. The Director of Nursing and other staff acknowledged that residents in certain areas, particularly the back of Oak hall, required more assistance due to higher care needs, but section assignments were not consistently adjusted to reflect this. The lack of a tracking log for staffing adjustments and the failure to honor management's changes to assignments contributed to the ongoing issue of insufficient staffing and long call light wait times.
Food Safety and Sanitation Deficiencies
Penalty
Summary
The facility failed to adhere to professional standards for food service safety, as evidenced by the improper storage and handling of food items. During an inspection, it was observed that expired food items were not discarded in one of the two refrigerators and the dry storage area. Additionally, food items in the refrigerator and freezer were not dated when opened, which is crucial for maintaining food safety. Specific items found included expired salad dressings, thickened cranberry cocktail, coconut, and nutritional drinks in the dry storage area. The refrigerator contained wilted and undated salad greens, while the freezer housed expired and undated items such as ham, tortillas, zucchini, pecan pies, meatballs, egg rolls, chicken breasts, beef fritters, and freezer-burned wheat rolls. Staff S, a Registered Dietician, acknowledged the importance of dating food items to prevent food-borne illnesses. The facility also failed to maintain appropriate food temperatures and a clean cooking environment. During a lunch tray line observation, cold food items such as salad, cottage cheese, and Jello were found to be above the recommended temperature of 41 degrees Fahrenheit. Staff Q, the Dietary Manager, placed these items in an ice bath but did not recheck their temperatures before serving. Additionally, Staff Q served chicken breasts and sandwiches without checking their temperatures. The kitchen environment was also found to be unsanitary, with food debris on the outside and inside of the oven and food warmer. Despite initial cleaning claims, a follow-up observation revealed that the thick layer of burned food debris remained, and the equipment was still unclean.
Failure to Offer and Document COVID-19 Vaccination for Staff
Penalty
Summary
The facility failed to ensure that staff were offered the COVID-19 vaccine, provided with education regarding the risks and benefits of the vaccine, and maintained proper documentation of vaccine education, declination, or administration. This deficiency was identified for three sampled staff members, Staff G, H, and I. Staff G and H reported not receiving recent education or offers for the COVID-19 vaccine, and Staff J, the temporary acting Infection Prevention Nurse, confirmed that the facility did not offer COVID-19 vaccines to staff. Instead, staff were encouraged to seek vaccination from external providers and bring proof to the facility, but there was no system in place to track this information. The report highlights that the facility's lack of a structured process for offering and documenting COVID-19 vaccinations and education placed both residents and staff at risk of illness or exposure to the virus. Observations included a resident in the Evergreen Unit testing positive for COVID-19, which necessitated aerosol precautions. The facility's failure to maintain documentation and provide education as required by regulations was evident, as Staff J admitted uncertainty about when the facility stopped offering vaccines and acknowledged the absence of records for staff education or vaccination status.
Failure to Address Resident Grievances Without Reprisal
Penalty
Summary
The facility failed to ensure that residents could file grievances without fear of reprisal and did not consistently resolve grievances promptly. This deficiency was evident in the cases of four residents who reported various issues, including staff ignoring call lights, inappropriate staff behavior, and poor food quality. Despite the facility's grievance policy, which allows residents to voice concerns orally, in writing, and anonymously, residents felt their grievances were not addressed timely, and some experienced retaliation from staff. Resident 40, who was cognitively intact, reported multiple grievances, including staff ignoring call lights and using resident areas as break rooms. Despite resolutions being documented, the resident continued to experience the same issues and felt retaliated against by staff. Similarly, Resident 31, also cognitively intact, reported rough handling by a nursing assistant and long wait times for assistance, yet continued to face delays in staff response, leading to unsafe situations where they had to manage without oxygen. Resident 10 and Resident 24 also reported grievances related to food quality and long wait times for assistance, respectively. Both residents felt their grievances were not adequately followed up on. Interviews with staff revealed a lack of understanding of the grievance resolution timeframe and inappropriate staff behavior that could be perceived as retaliation. The facility's failure to address these grievances effectively and ensure a safe environment for residents to voice concerns without fear of reprisal contributed to the deficiency.
Deficiencies in Resident Care and Monitoring
Penalty
Summary
The facility failed to provide care according to person-centered care plans and provider orders for several residents, leading to deficiencies in their care. Resident 36, who had Parkinson's disease and diabetes, was supposed to have their blood sugar monitored using a continuous glucose monitor (CGM). However, the CGM was broken by staff, and the resident's blood sugar was instead monitored using finger sticks, causing discomfort. There was no documentation of the CGM's status or notification to the provider, and the resident continued to have their blood sugar checked via finger sticks for several weeks. Resident 54, who required total assistance for activities of daily living, did not have a care plan for constipation despite being at risk. The facility's bowel protocol was not followed, as the resident did not receive the prescribed bowel management medications after not having a bowel movement for several days. This omission was not documented, and the Director of Nursing acknowledged the importance of administering bowel medication as ordered to prevent constipation and related complications. Resident 27, who had heart failure and was on a fluid restriction, received more fluids than allowed according to their care plan. The facility failed to monitor and maintain the resident's fluid intake, with records showing multiple instances of excess fluid consumption. Despite signage indicating the fluid restriction, the resident had access to a large cup of water at their bedside, and staff were unsure of the cup sizes used. Interviews with staff revealed a lack of awareness and adherence to the fluid restriction, which could potentially lead to medical complications for the resident.
Failure to Implement Timely Nutritional Interventions
Penalty
Summary
The facility failed to implement timely interventions to prevent weight loss for two residents, Resident 77 and Resident 54, which placed them at risk for further weight loss and health decline. Resident 77, who was cognitively intact and able to verbalize needs, experienced significant weight loss after admission, dropping from 182 lbs to 154.8 lbs over several months. Despite being on a regular diet and consuming a substantial portion of meals, the resident's weight loss was not addressed with appropriate interventions until several months later, when a nutritionally enhanced meal plan and calorie-dense supplements were introduced. The delay in implementing these interventions contributed to the resident's continued weight loss and subsequent malnutrition. Resident 54, who had severe cognitive impairments and dysphagia, also experienced a downward trend in weight, losing 15 lbs over several months. The resident was prescribed thickened liquids and required supervision during meals to prevent aspiration. However, observations revealed that the resident often consumed meals without the necessary supervision and used regular cups instead of the prescribed sippy cups, increasing the risk of choking or aspiration. Despite these issues, interventions such as the addition of a no-sugar-added shake were not implemented until December 2024, after significant weight loss had already occurred. Interviews with staff members revealed a lack of awareness and timely response to the residents' weight loss. Staff acknowledged that interventions, such as calorie-dense supplements and supervision during meals, were implemented only after significant weight loss was identified, rather than proactively. The facility's failure to address these issues promptly contributed to the residents' weight loss and potential health risks associated with malnutrition and aspiration.
Failure to Complete Annual Staff Performance Reviews
Penalty
Summary
The facility failed to complete annual staff performance reviews as required, specifically for one of the five sampled staff members, identified as Staff F, a Nursing Assistant. Staff F's personnel file showed they were hired on November 3, 2022, and received a verbal warning on January 10, 2023, for not completing required training, and a written warning on July 29, 2024, for a verbal altercation with a peer involving profanity and threatening language. However, there was no documentation of a performance evaluation for Staff F. Interviews with various staff members, including a Nursing Assistant, a Registered Nurse, the Resident Care Manager, and the Director of Nursing, confirmed that staff evaluations were supposed to be conducted yearly, but acknowledged that the facility was behind on completing these evaluations as required. This deficiency placed residents at risk of receiving care from inadequately trained and/or underqualified care staff, potentially diminishing their quality of life.
Facility Fails to Provide Palatable Meals
Penalty
Summary
The facility failed to provide palatable meals to residents, as evidenced by multiple grievances and interviews with residents who reported dissatisfaction with the food quality. Residents complained about the food being tough, dry, flavorless, and served at inappropriate temperatures. Specific instances included clam chowder that smelled and tasted bad, beef that was too tough to chew, and meals that were lukewarm or cold. These issues were reported by several residents who were cognitively intact and able to clearly express their needs. Resident 77 experienced significant weight loss and malnutrition, which they attributed to the poor quality of the facility's food. Despite being on nutritional supplements, Resident 77's weight had only stabilized after a period of loss. The dietary manager acknowledged the complaints, citing under-seasoning due to dietary restrictions and a lack of menu changes as contributing factors. A test tray confirmed the food's lack of flavor and poor quality, further supporting the residents' grievances.
Failure to Implement Abuse and Neglect Policy in LTC Facility
Penalty
Summary
The facility failed to implement its Abuse and Neglect Policy and Procedure, which led to several deficiencies in handling potential abuse allegations. For Resident 98, who had severe cognitive impairment and required assistance for toileting, the facility did not conduct a thorough investigation following an unanticipated death. The incident report lacked comprehensive interviews, and the investigation summary did not rule out abuse or neglect. Additionally, there were no pictures of the resident's facial laceration in the medical record, despite being sent to the medical examiner. Resident 58, who had severe cognitive impairment, reported feeling uncomfortable with a staff member's behavior, which was perceived as rude and condescending. Despite the resident's willingness to have the facility informed, the allegation was not reported to the State Survey Agency, and the facility's grievance log initially lacked documentation of the incident. The investigation was inadequate, as it only involved interviewing the resident and did not include a comprehensive investigation or reporting to the appropriate authorities. Other residents, including Residents 40, 10, and 31, also reported issues related to staff behavior, such as ignoring call lights, rude communication, and rough handling. These concerns were not properly investigated or reported as potential abuse allegations. The facility's failure to follow its abuse policy and procedure resulted in a lack of thorough investigations and reporting, leaving residents at risk for abuse and neglect.
Infection Control Deficiencies in TBP and Hand Hygiene
Penalty
Summary
The facility failed to adhere to proper infection prevention and control protocols, specifically in the implementation of transmission-based precautions (TBP) and hand hygiene practices. Resident 61, who had shingles, was placed on contact precautions as per the facility's policy and provider orders. However, observations revealed that staff did not consistently follow these precautions. For instance, a nursing assistant entered Resident 61's room without donning the required personal protective equipment (PPE) such as gloves and a gown, and failed to perform hand hygiene. Additionally, the roommate of Resident 61 reported that staff did not clean the shared toilet after use, and the garbage, often filled with soiled gloves, was not emptied regularly by staff, leading the roommate to do it themselves. Interviews with various staff members, including nursing assistants, housekeeping, and the acting Infection Preventionist, highlighted a lack of understanding and adherence to TBP protocols. Some staff were unaware of the requirements for contact precautions, while others acknowledged the need for PPE but did not consistently apply it. The facility's policy required staff to wear gloves and gowns upon entering a contact precaution room and to clean and disinfect shared equipment, but these practices were not consistently observed. Hand hygiene practices were also deficient, as staff were observed delivering meal trays to multiple rooms without performing hand hygiene before and after each delivery. This was contrary to the facility's hand hygiene policy and CDC guidelines, which emphasize the importance of hand hygiene in preventing the spread of infections. Interviews with staff revealed a misunderstanding of when and how hand hygiene should be performed, with some staff indicating there was no way to wash hands during meal service. The failure to perform hand hygiene and adhere to TBP placed residents at risk of acquiring communicable diseases.
Failure to Maintain Dignity in Urinary Catheter Care
Penalty
Summary
The facility failed to maintain urinary catheters in a dignified manner for two residents, leading to potential embarrassment and risk of infection. Resident 36, who had Parkinson's disease and kidney disease, was observed with an indwelling urinary catheter. The urine collection bag was hanging on the wheelchair frame, uncovered, and dragging on the floor, which was visible to others. This observation was made by the Director of Nursing, indicating a lack of adherence to dignity protocols for catheter management. Resident 154, diagnosed with benign prostatic hyperplasia and urinary retention, also had an indwelling urinary catheter. The urine collection bag was repeatedly observed uncovered and resting on the floor, visible from the hallway. Despite care plan instructions to keep the bag covered and off the floor, these guidelines were not followed. Staff interviews confirmed the expectation for dignity covers and proper positioning of the urine collection bags, yet these were not consistently applied, compromising the residents' dignity and potentially increasing the risk of infection.
Failure to Implement Self-Administration of Medication Policy
Penalty
Summary
The facility failed to implement its self-administration of medication policy for Resident 24, who was clinically determined to be appropriate for self-administration of certain medications. The interdisciplinary team did not ensure that only provider-approved medications were kept at the resident's bedside, nor were they safely and securely stored. Resident 24, who had chronic obstructive pulmonary disease, muscle weakness, and reduced mobility, was cognitively intact and able to verbalize their needs. However, the resident had unsecured medications at their bedside, including Xylitol nasal sprays, Mentholatum ointment, cough drops, and Lidocaine creams, which were not all approved for bedside storage. Observations over several days showed that Resident 24 had unsecured medications at their bedside, and there were no provider orders for some of these medications, such as the Xylitol nasal spray and the liquid roll-on Lidocaine. The Mentholatum ointment, which was used by the resident to moisten dry nasal passages due to oxygen use, was not approved for bedside storage, and its use with oxygen therapy posed a potential safety issue. The facility's policy required that residents be assessed for their ability to self-administer medications and that provider orders specify which medications could be stored at the bedside. Interviews with staff revealed a lack of clarity and adherence to the facility's policy on self-administration of medications. Staff members, including a registered nurse and the resident care manager, acknowledged that medications stored at the bedside needed to be secured to prevent access by other residents. The director of nursing and assistant director of nursing confirmed that the use of petroleum-based products while wearing oxygen was a safety concern. The facility's failure to ensure proper assessment, provider approval, and secure storage of medications at the bedside placed residents at risk of medication errors and accidents.
Environmental Deficiencies in Resident Rooms and Facility
Penalty
Summary
The facility failed to maintain a clean, comfortable, safe, and homelike environment for two residents. Resident 23's personal refrigerator contained expired foods, which were not labeled with expiration dates, posing a risk for foodborne illness. The facility's policy required daily monitoring of refrigerator temperatures and discarding of expired food, but there were multiple omissions in the temperature logs, and expired food was not discarded. Staff interviews revealed that the responsibility for labeling, dating food, and monitoring refrigerator temperatures was not adequately fulfilled, compromising food safety. Additionally, Resident 28's room had a large hole in the drywall behind the door, which had been present for an extended period. Staff were aware of the hole but did not document it in the maintenance binder, and there was no documentation of wall penetration checks. The hole was identified as a potential fire hazard and not conducive to a homelike environment. Furthermore, an exit door was observed to be offset, not latching properly, and slamming, which was acknowledged as a potential safety issue. Staff were aware of the door's condition but had not addressed it, leaving residents at risk for injury and diminished quality of life.
Failure to Provide Timely Bed-Hold Notice
Penalty
Summary
The facility failed to provide a bed-hold notice to a resident and/or their representative within 24 hours of the resident's transfer to the hospital, as required. This deficiency was identified for one of the two sampled residents, Resident 54, who was hospitalized due to a rapid heart rate and low oxygen levels. Resident 54 had a significant change in condition assessment with diagnoses including high blood pressure, diabetes, and dementia, and was noted to have severe cognitive impairments. The bed-hold notice was not provided until four days after the transfer, which did not comply with the regulatory requirement. Staff K, the Admissions Director, acknowledged that bed holds were typically offered upon admission and within 24 hours of discharge to the hospital, except when the transfer occurred on a Friday, in which case it was delayed until Monday.
Inconsistent Restorative Care Leads to Decline in Resident's ADLs
Penalty
Summary
The facility failed to ensure that a resident's abilities in activities of daily living (ADLs) did not diminish without a medical reason. Resident 36, who was cognitively intact and diagnosed with Parkinson's disease and muscle weakness, required partial assistance for various ADLs. Despite having a restorative nursing program established after being discharged from occupational therapy, the resident's participation in restorative activities was inconsistent. The facility's records showed that the resident's restorative nursing aide (RNA) sessions were frequently missed or reduced, particularly during a period when one of the three RNA staff was reassigned to direct care duties multiple times. The resident's care plan included a restorative program to maintain mobility and independence, but the facility's staffing issues led to a lack of consistent restorative care. During the period from December 2024 to January 2025, the resident's participation in restorative activities was sporadic, with several weeks showing no participation at all. This inconsistency was compounded by the resident's illness with a urinary tract infection, which further impacted their ability to participate in restorative activities. Interviews with staff revealed that the resident's restorative activities were often deprioritized due to staffing shortages, and the resident expressed concern about the lack of therapy, stating it was important to prevent stiffness. The facility's failure to provide consistent restorative care resulted in a documented decline in the resident's ability to perform ADLs. By January 2025, the resident required more assistance with mobility and personal care tasks than previously documented. Staff interviews indicated that the resident's decline was noted, but the facility's staffing challenges hindered the ability to provide the necessary restorative care. The Director of Rehabilitation acknowledged the decline and indicated that therapy would be resumed for the resident, highlighting the impact of the facility's failure to maintain consistent restorative services.
Inadequate Mealtime Assistance for Resident with Traumatic Brain Injury
Penalty
Summary
The facility failed to provide adequate assistance during mealtimes for Resident 90, who was reviewed for activities of daily living. Resident 90 had a traumatic brain injury, lack of coordination, and muscle weakness, and required set-up or clean-up assistance for eating. Despite being cognitively intact for decision-making, Resident 90 had difficulty grasping utensils and consumed less than 25% of their meals during multiple observations. The resident was observed eating with their fingers and taking long breaks between bites, with no staff present to assist or provide cues. The care plan for Resident 90 indicated varying levels of assistance needed during meals, from independent to set-up assistance, and instructed staff to refer to physical or occupational therapy as appropriate. However, during several observations, Resident 90 was left without adequate assistance, leading to difficulties in eating and drinking. Staff L, a Certified Occupational Therapist Assistant, acknowledged that stand-by assistance during meals would have been more appropriate for Resident 90, and the care plan should have been updated to reflect this need. This deficiency was a repeat issue from a previous survey.
Failure to Implement Toileting Care Plan for a Resident
Penalty
Summary
The facility failed to consistently implement a care plan for Resident 81, who had diagnoses including stroke and hemiplegia, and was frequently incontinent of bowel and bladder. The care plan instructed staff to use a bedpan for toileting and to observe patterns of incontinence to initiate a toileting schedule if indicated. However, observations showed that staff did not offer or provide a bedpan to Resident 81 during toileting, as care planned. Interviews with staff revealed that the use of a bedpan was not part of the routine care provided to Resident 81, despite the care plan's instructions. Resident 81 expressed a preference for continence and reported not using a bedpan for toileting. Staff interviews confirmed that a bedpan was not used, and the resident was only checked and changed using briefs. The Director of Nursing acknowledged that a bedpan should have been available and offered to Resident 81, as per the care plan. This failure to follow the care plan placed Resident 81 at risk for a decline in urinary and/or bowel function, embarrassment, and diminished quality of life.
Failure to Implement BIPAP as Ordered for Resident
Penalty
Summary
The facility failed to ensure that a bi-level positive airway pressure (BIPAP) machine was used as ordered by the physician for a resident identified as Resident 81. This resident, who was moderately cognitively impaired and dependent on nursing staff for activities of daily living, had a care plan developed to address their sleep apnea. The care plan specified that the BIPAP machine should be worn by the resident while sleeping, including during naps. However, multiple observations were made where Resident 81 was found sleeping without the BIPAP machine, contrary to the physician's orders. Interviews with staff and the resident's spouse highlighted the importance of the BIPAP machine for the resident's health, particularly due to the risk of another stroke and decreased alertness from poor sleep. Despite this, a nursing assistant indicated that the resident only used the BIPAP at night and not during daytime naps. The Director of Nursing confirmed that the resident was required to wear the BIPAP whenever sleeping, including naps, as per the care plan. This oversight placed the resident at risk for impaired sleep and unmet care needs.
Delayed Response to Pharmacist's Recommendations for Resident's Medication Monitoring
Penalty
Summary
The facility failed to act promptly on the pharmacist's monthly medication regimen review recommendations for Resident 24, who was on a cholesterol-lowering medication. The pharmacist had recommended obtaining baseline and yearly liver function tests (LFTs) and lipid panel blood work to monitor the medication's therapeutic effects and side effects. Despite these recommendations being made in July, August, September, and October 2024, the facility did not ensure the timely completion of the lipid panel, which was only conducted on November 25, 2024, 95 days after it was initially ordered by the resident's provider. Interviews with facility staff revealed a lack of clarity and understanding of the monthly pharmacy medication review process, particularly in cases involving outside providers. Staff E, a Registered Nurse, and Staff D, a Resident Care Manager, were unsure of how the pharmacist's recommendations were communicated and reviewed by outside providers. The Director of Nursing and Assistant Director of Nursing acknowledged the delay in obtaining the lipid panel and expected pharmacy recommendations to be completed by the end of the month. The Administrator confirmed the delay in the lipid panel order and emphasized the expectation for staff to follow the facility's medication review process.
Failure to Prevent Significant Medication Errors
Penalty
Summary
The facility failed to ensure that significant medication errors were prevented for Resident 156, who was cognitively intact and had diagnoses including bone infection of the hip, ankylosing spondylosis, and depression. The resident was prescribed amitriptyline for depression and Enbrel for osteoarthritis. However, the medication administration records (MAR) showed that the resident did not receive Enbrel on three occasions and amitriptyline on three separate occasions. The MAR indicated that the medications were on order from the pharmacy, but there were no progress notes related to the missed doses. Interviews with staff revealed that there was a breakdown in the process of obtaining and administering the medications. Staff Y, the Resident Care Manager, explained the protocol for obtaining medications, which included checking the medication cart, the Cubex storage unit, and notifying the pharmacy and provider if the medication was unavailable. However, neither Enbrel nor amitriptyline was found in the Cubex, and the pharmacy required authorization for Enbrel due to its cost. Staff Z, an LPN, confirmed that the amitriptyline had been ordered but not received, possibly due to an insurance issue. The Director of Nursing, Staff B, acknowledged signing the authorization for Enbrel only on the day of the interview, indicating a delay in the process. This deficiency was a repeat citation from previous surveys.
Medication Management and Storage Deficiencies
Penalty
Summary
The facility failed to ensure proper medication management and storage practices, as observed during a survey. In the Oak Hall Medication Room, an undated vial of Tuberculosis screening solution was found, which should have been discarded 30 days after opening. Additionally, expired bottles of mineral oil were identified in both the Oak Hall and Transitional Care Unit (TCU) Medication Rooms. The staff acknowledged these medications were expired and should have been discarded. Furthermore, the facility did not consistently monitor refrigerator temperatures for vaccine storage, with missing temperature logs for several days and incomplete documentation of freezer temperatures. This oversight was acknowledged by the acting Infection Preventionist. The survey also identified unsanitary conditions in the Oak Hall Medication Cart, with extensive dry stains and medication residue observed inside the drawers and on the cart's exterior. The night shift was responsible for cleaning the carts weekly, but this was not done. Additionally, medications were found unsecured in a resident's room without proper orders or evaluations for bedside storage. A tube of Triamcinolone acetonide cream and a bottle of ammonium lactate 12% lotion were found on the resident's bed and bedside table, respectively, without documented orders for their use or storage. Staff acknowledged the need for proper orders and evaluations for these medications.
Deficiency in Dietary Staff Credentialing
Penalty
Summary
The facility failed to ensure that dietary staff had the required training, which was identified during a review of credentialing for four of the seventeen sampled dietary staff members. Specifically, Staff P did not possess a valid Washington State Food Workers card, as their certificate was expired and not provided. Additionally, Staff M, N, and O had certificates from Food Handler Solutions, a program not approved for credentialing in the State of [NAME]. This program was intended only for personal development and preparation for state-provided training. During an interview, the Dietary Manager, Staff Q, admitted to being unaware that the Food Handler Solutions program did not meet the state's credentialing requirements. This oversight had the potential to lead to unsafe food handling practices, thereby placing all residents at risk for developing foodborne illnesses.
Failure to Ensure Understanding of Arbitration Agreements
Penalty
Summary
The facility failed to ensure that the arbitration agreements were presented in a form, manner, and language understood by the residents or their legal representatives. This deficiency was identified for two residents who were severely cognitively impaired and unable to comprehend the arbitration agreements they signed. The facility's policy required that arbitration agreements be explained and understood by the parties involved, but this was not adhered to in these cases. Resident 13, who was admitted with severe cognitive impairment and non-Alzheimer's dementia, signed the arbitration agreement without the involvement of their legal representative. Despite being able to make basic needs known, Resident 13 was not capable of understanding the arbitration process due to their cognitive condition. Similarly, Resident 88, also severely cognitively impaired, signed the arbitration agreement without their spouse's knowledge or involvement. Interviews with staff revealed that both residents were confused and unable to comprehend the arbitration process. The staff responsible for explaining and offering the arbitration agreements lacked adequate training and understanding of the arbitration process. Staff JJ, who assisted with the completion of the agreements, was primarily a transportation driver and did not have the necessary knowledge to explain the legal implications of the agreements. This lack of proper training and assessment of residents' cognitive abilities led to the residents signing agreements they did not understand, without the involvement of their legal representatives.
Failure to Safeguard Resident Information and Maintain Complete Medical Records
Penalty
Summary
The facility failed to ensure that resident records were complete, accurate, and safeguarded against unauthorized use, specifically for Resident 98. The deficiency was identified during a review of the facility's practices and interviews with staff. Resident 98, who had severe cognitive impairment and required assistance with toileting, was admitted with diagnoses including muscle weakness and chronic pain. An incident occurred where Resident 98 was found unresponsive on the toilet with a laceration above the left eyebrow, leading to an unanticipated death. The medical examiner requested photographs of the injury, which were taken by a staff member using a personal cell phone. The facility's employee handbook prohibits the use of personal cell phones in resident care areas and emphasizes the need to follow state and federal regulations regarding the use of such devices. Despite this, a Licensed Practical Nurse (LPN) used their personal phone to take and send pictures of Resident 98's injury to the medical examiner. These photographs were not included in the resident's medical record, violating the Health Insurance Portability and Accountability Act (HIPAA) standards. Interviews with various staff members, including the Director of Nursing and a Corporate Licensed Nurse, confirmed that the photographs were deleted from the personal phone after being sent and were not documented in the medical record. The deficiency highlights a lack of adherence to the facility's policies regarding the use of personal electronic devices and the safeguarding of resident information. Staff interviews revealed inconsistencies in understanding the proper procedures for photographing residents for medical purposes. The facility's failure to maintain complete and accurate medical records, as well as to protect resident-identifiable information, placed residents at risk of unauthorized access to confidential health information and compromised the quality of care provided.
Inappropriate Diabetes Management Leads to Aspiration
Penalty
Summary
The facility failed to provide necessary care and services for a resident with diabetes, leading to a critical incident. The resident, who had diabetes and lung disease, was found unresponsive with a dangerously low blood sugar level of 39 mg/dl. Despite the facility's policy for hypoglycemia management, which advises against oral administration of glucose gel to unresponsive residents, a Licensed Practical Nurse (LPN) administered glucose gel orally, resulting in the resident's aspiration. The resident's care plan included insulin administration and regular blood sugar monitoring. On the day of the incident, the resident's blood sugar was recorded at 189 mg/dl before receiving insulin. However, the resident became unresponsive shortly after, and the LPN administered a Glucagon injection followed by glucose gel, despite the resident's inability to swallow. This action was contrary to the facility's policy, which recommends Glucagon injections for residents unable to swallow. Staff interviews and statements revealed that the LPN continued to administer glucose gel even after being advised against it by another staff member. Emergency medical personnel intervened, noting the inappropriate administration of glucose gel to an unresponsive resident and performed suctioning due to suspected aspiration. The resident was subsequently diagnosed with aspiration pneumonia at the hospital.
Failure to Protect Resident from Sexual Abuse
Penalty
Summary
The facility failed to protect a resident from sexual abuse by a staff member, resulting in harm to the resident. The resident, who was alert and oriented, reported that a staff member had engaged in sexual intercourse with them, and a subsequent sexual assault exam confirmed abrasions consistent with penile penetration. The resident had a history of making sexually inappropriate comments during medical changes such as a urinary tract infection (UTI), but there was no documentation of further sexual behaviors after treatment. The incident came to light when a staff member reported the resident's allegations to the facility's administration. The resident described the staff member involved but could not provide a name. The facility's investigation led to the suspension of three staff members who matched the description given by the resident. The resident's family was informed, and the resident was eventually sent to the hospital for a sexual assault exam, which confirmed the presence of trauma. Interviews with facility staff and the Sexual Assault Nurse Examiner (SANE) corroborated the resident's account of the abuse. The SANE nurse found two external abrasions on the resident's genitalia, consistent with the reported sexual activity. The facility's failure to prevent this abuse placed the resident at risk for further harm and violated their right to be free from abuse.
Failure to Supervise Resident Leads to Fatal Fall
Penalty
Summary
The facility failed to provide adequate supervision for Resident 2, who was at high risk for falls due to severe cognitive impairment, dementia, and osteoporosis. The care plan for Resident 2 included specific interventions to prevent falls, such as keeping the bed in a low position, using a fall mat, and ensuring the resident was not left unattended during transfers. However, on the morning of July 15, 2024, these interventions were not followed, leading to Resident 2 falling out of bed and sustaining a head laceration and skull fracture. On the day of the incident, two nursing assistants were preparing to transfer Resident 2 from their bed to a wheelchair using a mechanical lift, which required two staff members to operate. The bed was elevated, and the fall mat was removed to accommodate the lift. One of the nursing assistants, Staff G, left the resident unattended to retrieve the mechanical lift and inform the nurse about an empty oxygen tank. During this brief absence, Resident 2 rolled out of the elevated bed and fell to the floor, resulting in a head injury. The fall incident investigation concluded that facility protocols were followed, and abuse was ruled out. However, it was noted that leaving the resident unattended with the bed elevated was against safe transfer practices. The emergency room visit confirmed a skull fracture and an 8-centimeter scalp laceration. Despite being treated, Resident 2's condition deteriorated, and they passed away later that day. Interviews with staff revealed that the incident was considered an accident, and Staff G acknowledged the mistake of leaving the resident unattended with the bed elevated.
Failure to Prevent Pressure Ulcer Development
Penalty
Summary
The facility failed to prevent the development of a pressure ulcer in a resident who was at increased risk due to conditions such as Diabetes and paraplegia. Upon admission, the resident was assessed to be at risk for pressure ulcers and had Moisture Associated Skin Damage (MASD). The care plan included interventions like floating the resident's heels, frequent repositioning, and skin inspections during care. However, from the time of admission until the resident's transfer to the hospital, there was no documentation regarding the resident's skin condition, including the previously identified MASD. The deficiency was identified when the resident was admitted to the hospital with an unstageable pressure ulcer, which had not been detected while the resident was in the facility. Interviews revealed that the facility had a process for skin evaluations by nurses upon admission and weekly checks, as well as documentation by shower aides. However, this process was only implemented after the facility became aware of the resident's pressure ulcer upon hospital admission.
Failure to Ensure Resident Dignity in Dressing for Appointment
Penalty
Summary
The facility failed to provide care that promoted resident dignity for a resident who was reviewed for dignity. The resident, who had diagnoses including blindness, a fracture, and dementia, required moderate assistance for dressing their upper body and was dependent on staff for dressing their lower body. On the day of the incident, the resident was taken to an appointment in the community dressed inappropriately in a nightgown, without undergarments or socks, and with uncombed hair. The resident was also without their hearing aids, which further compromised their dignity and self-worth. Staff interviews revealed that the resident was particular about their clothing and appearance, and the family was very involved in their care. Staff were expected to notify a nurse if a resident refused to change clothes and to re-approach the resident. However, on the day of the appointment, the staff failed to ensure the resident was dressed appropriately despite being instructed to do so by a Resident Care Manager. The resident was seen in the same inappropriate attire upon returning from the appointment, indicating a lack of follow-through by the staff.
Failure to Notify Resident's Representative of Change in Condition
Penalty
Summary
The facility failed to notify the resident's representative of a change in condition for one of the residents, identified as Resident 2, who was part of a sample reviewed for notification of change. Resident 2 had a spinal cord dysfunction and was unable to move their lower extremities but was capable of communicating their needs. Despite this, the resident's representative was not informed of the resident's worsening condition until the resident was being sent to the hospital. The representative had attended a care conference earlier and was told the resident was doing well. However, they became concerned when the resident stopped making daily phone calls and appeared listless during a visit. Progress notes indicated that the resident had been experiencing nausea and a lack of appetite for several days, but there was no documentation showing that the resident's representative or family was notified of these changes until the day the resident was transferred to the hospital. Staff F, the facility physician, noted the resident's lethargy and inability to respond well during a follow-up visit, which led to the decision to send the resident to the hospital. The Director of Nursing, Staff E, mentioned that the facility did not have a specific policy for notifying changes in condition but followed standards of care, which included notifying the provider and family at the time of change.
Failure to Monitor and Document Change in Resident's Condition
Penalty
Summary
The facility failed to consistently monitor and document a change in condition for one resident, who had a spinal cord dysfunction and was unable to move their lower legs. The resident was dependent on staff for mobility and was able to communicate their needs. On 04/04/2024, nursing progress notes indicated the resident was experiencing nausea and had not been eating well for several days. However, there was no further documentation of the resident's condition until 04/08/2024, when the resident was seen by a physician and subsequently sent to the hospital due to lethargy and inability to respond well to questions. Interviews with facility staff revealed that there was a lack of consistent monitoring and documentation following the initial report of the resident's nausea. Staff members stated that the standard procedure for a change in condition involved notifying the provider and family, placing the resident on alert charting, and documenting changes in the progress notes. Despite these procedures, there was a gap in documentation and monitoring from 04/04/2024 to 04/08/2024, which contributed to the deficiency identified in the report.
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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