Salmon Creek Post Acute & Rehabilitation
Inspection history, citations, penalties and survey trends for this long-term care facility in Vancouver, Washington.
- Location
- 2811 Ne 139th Street, Vancouver, Washington 98686
- CMS Provider Number
- 505522
- Inspections on file
- 35
- Latest survey
- January 9, 2026
- Citations (last 12 mo.)
- 28
Citation history
Health deficiencies cited at Salmon Creek Post Acute & Rehabilitation during CMS and state inspections, most recent first.
The facility did not follow its own policy to provide at least two baths or showers per week for residents dependent on staff for ADLs. One resident with ESRD, incontinence, and moderate cognitive impairment missed multiple scheduled showers because bathing was routinely scheduled at the same times the resident was out of the facility for dialysis, and the TAR showed many of these showers were not provided. Another resident with cancer, severe cognitive impairment, and reduced mobility missed a scheduled shower with no explanation documented in the progress notes, despite the DON’s expectation that missed baths be documented.
Surveyors found that staff failed to follow prescriber orders and facility policy for two residents when multiple medications and treatments were omitted and not documented on the MAR/TAR. For one resident with metastatic cancer, chronic respiratory failure, and severe cognitive impairment, catheter care, urinary output documentation, bladder scans with straight catheterization, weekly skin observations, barrier cream applications, and heel boot use were not carried out or recorded as ordered. For another resident with metabolic encephalopathy, a UTI, and severely impaired cognition, ordered doses of levothyroxine and acetaminophen, orthostatic BP checks, weekly weights, barrier cream to the coccyx, and elevation of the head of the bed for SOB prevention were also missed or undocumented. The RN Director of Resident Services confirmed that blank MAR/TAR entries meant the interventions were not done or not documented.
A resident with moderate cognitive impairment and a history of rhabdomyolysis was discharged with medications that did not match the reconciled list in the discharge summary. The resident later discovered, with a case worker, that one of the four medications they were taking at home had another person’s name on the container, even though the MAR showed only three medications were ordered to be sent home. The DON confirmed that an incorrect medication belonging to another resident had been provided at discharge, indicating a failure to ensure accurate medication reconciliation and prescriptions at discharge.
A resident with diabetes and peripheral vascular disease, who had multiple open wounds, did not receive prescribed wound care treatments on several occasions. The MAR and TAR lacked documentation for these missed treatments, and progress notes did not explain the omissions, except for one instance where care was provided by an outside provider but not recorded. Facility policy required treatments to be administered and documented as ordered, but this was not followed.
A resident with acute kidney failure and pancreatitis experienced a significant episode of hypotension, but there was no documented notification to the physician about this change. Facility policy required such notification, and the DON confirmed that nurses are expected to inform the doctor of new or concerning symptoms, which did not occur in this case.
A resident with multiple acute medical conditions did not receive scheduled bathing assistance as required by facility policy, with documentation showing missed bathing opportunities and staff confirming that showers were not consistently provided according to the established schedule.
A resident with multiple medical conditions had an open coccyx wound documented on admission, but subsequent weekly skin assessments and progress notes failed to consistently address or document the wound's status. Despite facility policy requiring weekly documentation by a licensed nurse, several entries indicated no skin concerns, and there was no record of the wound's healing. The DON confirmed that ongoing documentation should have occurred.
A resident with multiple medical conditions did not receive several prescribed medications and treatments as ordered, including missed doses of psychiatric, cardiac, respiratory, and pain medications, as well as omitted catheter care and bladder scans. Facility policy requires administration and documentation of medications per provider orders, but this was not followed, as confirmed by the DON.
The facility failed to obtain informed consent before administering psychotropic medications to two residents. One resident received Wellbutrin for depression without being informed of the risks and benefits, while another was given Prochlorperazine Maleate for nausea related to end-stage renal disease without a signed consent. Staff acknowledged the oversight, highlighting a lapse in ensuring residents were fully informed about their treatment.
A resident with severe malnutrition and diabetes experienced significant weight loss, but the facility failed to accurately document and monitor this change. Despite a care plan and directives for weekly weight monitoring, weights were not recorded due to an order entry error, leaving the RD unable to review the resident's nutritional status.
A facility failed to follow PASARR Level II recommendations for a resident with Alzheimer dementia and major depression. The resident's cognition was not assessed, and the necessary Level II assessment by a mental health professional was not documented in the medical record. Although a request was sent to the evaluator, the facility did not follow up to ensure services were initiated.
The facility failed to initiate timely baseline care plans for two residents, one with fall risks and another with communication needs, within 48 hours of admission. A resident with cognitive impairment experienced multiple falls before a care plan was developed, and another resident with limited English proficiency had delayed communication support.
The facility failed to complete neurological assessments for a resident after an unwitnessed fall, did not manage weight monitoring for two residents with CHF, and did not initiate bowel protocols for two residents experiencing prolonged periods without bowel movements. Additionally, the facility did not coordinate dental services for a resident needing dentures.
The facility failed to implement Enhanced Barrier Precautions (EBP) for residents with indwelling medical devices or wounds, as staff only used gloves and did not wear gowns during care. Observations showed a lack of EBP signage and PPE at room entrances. Interviews revealed staff confusion about EBP requirements, contributing to the deficiency.
A resident tested positive for COVID-19, but the facility failed to notify the resident or their representative in a timely manner, as required by their policy. The resident was informed of the positive result three days later by a doctor. Staff acknowledged the oversight and stated that the notification should have occurred within 24 hours.
The facility failed to create comprehensive and individualized care plans for six residents, resulting in incomplete and non-specific plans. These deficiencies involved residents with various medical conditions, such as congestive heart failure, diabetes, and multiple sclerosis. The care plans lacked specific interventions and goals, leaving critical areas like ADLs, pain management, and discharge planning unspecified, placing residents at risk for unmet care needs.
A facility failed to administer medications as ordered for four residents, leading to significant medication errors. One resident with congestive heart failure and other conditions missed doses of Atorvastatin and Levo-T. Another resident with severe cognitive impairment and diabetes missed multiple medications after a hospital visit. A third resident did not receive prescribed Hydrocortisone cream, and a fourth resident's daily weight was not monitored as ordered. The DON acknowledged the omissions and noted that the MAR should indicate reasons for missed medications.
A resident at risk for falls due to impaired balance and cognitive deficits fell from bed because fall mats were not placed as required by the care plan. Staff confirmed the absence of fall mats at the time of the incident, contrary to the intervention initiated in the care plan.
Failure to Provide Scheduled Bathing Assistance for Dependent Residents
Penalty
Summary
The facility failed to provide required bathing assistance to residents dependent on staff for activities of daily living, specifically bathing, in accordance with its policy requiring at least two full baths or showers per week. One resident with end stage renal disease, weakness, reduced mobility, moderate cognitive impairment, and frequent bowel and bladder incontinence was care planned as dependent on staff for personal hygiene and bathing. Review of this resident’s Treatment Administration Records (TARs) for October and November 2025 showed that bathing was scheduled on specific days of the week but was only provided for a portion of the scheduled times. The TARs also showed the resident was routinely out of the facility three days per week for dialysis, and showers were scheduled on days and times that conflicted with these dialysis appointments, resulting in multiple missed showers. The resident reported frequently not being assisted with bathing because they were at their regularly scheduled dialysis appointments. Another resident with cancer, reduced mobility, weakness, severe cognitive impairment, and dependence on staff for bathing assistance was also care planned to require help with personal hygiene. Review of this resident’s October 2025 TAR showed they did not receive a scheduled shower on one date, and review of the progress notes for the same month showed no documentation explaining why the scheduled shower was not provided. During an interview, the DON stated that residents were scheduled for bathing assistance twice per week and that nurses were expected to document in the progress notes if a resident did not receive a scheduled bath. The DON acknowledged that the first resident’s bathing schedule had been set for the same days of the week as their dialysis appointments.
Failure to Administer and Document Ordered Medications and Treatments
Penalty
Summary
The deficiency involves the facility’s failure to ensure medications and treatments were administered and documented in accordance with prescriber orders and facility policy, resulting in multiple omissions for two residents. The facility’s medication administration policy dated January 2023 required that medications be administered per written prescriber orders and that the individual administering the medication immediately record the administration on the MAR. During review of October and November 2025 MARs and TARs, surveyors identified numerous blank entries, which the Director of Resident Services confirmed meant the medications or treatments were not done or not documented, and stated those areas should not be blank. For one resident with metastatic cancer, chronic respiratory failure, hypertension, reduced mobility, weakness, and severe cognitive impairment, the October and November 2025 MAR/TAR showed multiple omitted treatments and monitoring tasks. These included missed catheter care and failure to document urinary output on several shifts, missed weekly skin observations, and omitted application of Triad barrier cream and other barrier creams to the buttocks and posterior thighs for skin breakdown and redness. Additional omissions included ordered bladder scans every six hours with straight catheterization for post-void residuals greater than 350 cc at several scheduled times, and failure to ensure bilateral heel boots were in place while the resident was in bed. For another resident with metabolic encephalopathy, a UTI, and severely impaired cognition, the October and November 2025 MAR/TAR also showed omitted medications and treatments. These included missed doses of levothyroxine and acetaminophen at scheduled administration times, as well as failure to complete ordered orthostatic blood pressure measurements and weekly weights. The records further showed omissions in applying barrier cream to the coccyx every shift and as needed for redness, and failure to elevate the head of the bed every shift as ordered to alleviate or prevent shortness of breath while lying flat. The Director of Resident Services confirmed that the blank MAR/TAR entries for these residents indicated the orders were not carried out or not documented.
Incorrect Medication Sent Home at Discharge Due to Failed Medication Reconciliation
Penalty
Summary
Surveyors identified a deficiency in the facility’s discharge process related to medication reconciliation and accuracy of prescriptions provided at discharge. The facility’s own Discharge Planning policy, dated 10/01/2021, required that when discharge is anticipated, the facility prepare a discharge summary that includes reconciliation of all pre-discharge medications with the resident’s post-discharge medications. For one resident with a diagnosis including rhabdomyolysis and moderate cognitive impairment, the admission MDS dated 11/28/2025 documented this cognitive status. The resident reported that after discharge they were taking four medications daily, and later discovered with their case worker that one of the medications provided by the facility had another person’s name on the container. Record review of the resident’s December 2025 MAR showed only three prescribed medications ordered to be sent home at discharge, indicating a discrepancy between the reconciled medication list and what was actually provided. During an interview, the DON acknowledged the facility had been made aware that an incorrect medication, belonging to another resident, was sent home with this resident at discharge. The DON also stated that the nurse who provided the wrong medication had been identified. This sequence of events demonstrated that the prescriptions and medications supplied at discharge did not accurately reflect the reconciled medication list in the discharge summary for this resident.
Failure to Administer and Document Wound Care Treatments as Ordered
Penalty
Summary
The facility failed to ensure that medications and treatments were administered in accordance with provider orders for a resident with multiple chronic conditions, including Diabetes Mellitus II and Peripheral Vascular Disease. The resident had documented skin impairments, including open areas on the lower extremity, buttocks, and right heel, with care plan interventions specifying that wound care treatments be provided as ordered. Review of the Medication Administration Record (MAR) and Treatment Administration Record (TAR) revealed that the resident did not receive prescribed wound care treatments on several specific dates. There was no documentation on the MAR/TAR or in the resident's progress notes explaining why the treatments were missed, except for one instance where wound care was provided by an outside provider but not recorded appropriately. Facility policy required that medications and treatments be administered according to prescriber orders and documented immediately after administration. The interim Director of Nursing confirmed that the expectation was for nurses to follow provider orders for medications and treatments. The lack of administration and documentation for the resident's wound care treatments constituted a medication and/or treatment error, as the facility did not follow its own policy or provider orders, and failed to document reasons for missed treatments.
Failure to Notify Physician of Significant Change in Condition
Penalty
Summary
The facility failed to notify a resident's physician about a significant change in the resident's physical condition. Specifically, a resident with a history of acute kidney failure and acute pancreatitis experienced a clinically significant episode of hypotension, with a recorded blood pressure of 73/48. Despite this event, there was no documented communication to or with the provider regarding the hypotensive episode, as confirmed by a review of the resident's progress notes and the electronic provider communication tool. The facility's policy requires nurses to notify the attending physician or practitioner when there is a significant change in a resident's physical, mental, or psychosocial status, including clinical complications. The care plan for the resident included monitoring for cardiac complications, but there was no evidence that the physician was informed of the low blood pressure event. The Director of Nursing stated that nurses are expected to assess and notify the doctor of any new or concerning symptoms, but this did not occur in this instance.
Failure to Provide Scheduled Bathing Assistance
Penalty
Summary
The facility failed to provide adequate bathing assistance to a resident who was admitted with acute kidney failure, muscle weakness, and acute pancreatitis, and was assessed as cognitively intact. According to facility policy, residents are to be offered at least two full baths or showers per week, with refusals documented and reported to a licensed nurse. Review of the resident's records showed that bathing was not provided as scheduled, with only a few documented instances of bathing during the resident's stay. Staff interviews confirmed that showers were expected to be performed according to a set schedule, but this was not consistently followed for the resident in question.
Failure to Accurately Document and Assess Pressure Ulcer
Penalty
Summary
The facility failed to assess and accurately document a resident's wound, specifically a coccyx wound, for one of three residents sampled for wound care. According to the facility's policy, licensed nurses are required to conduct and document weekly skin observations, including the status of any pressure injuries. The resident in question was admitted with multiple diagnoses, including acute kidney failure, muscle weakness, and acute pancreatitis, and was cognitively intact. Medical records showed an order for weekly skin assessments, and initial documentation noted an open area on the coccyx. However, subsequent weekly skin observations and progress notes failed to consistently address the presence or status of the coccyx wound, with several entries indicating no skin concerns despite the initial finding. There was no documentation indicating that the coccyx wound had healed, and later observations described a red blanchable area and scar tissue at the same location. The Director of Nursing confirmed that nurses should have been documenting the wound each week or providing evidence of healing. This lack of consistent and accurate documentation regarding the resident's wound status constituted a failure to follow facility policy and placed residents at risk.
Failure to Administer Medications and Treatments as Ordered
Penalty
Summary
The facility failed to ensure that medications and treatments were administered in accordance with provider orders for one resident. Review of the Medication Administration Record (MAR) and Treatment Administration Record (TAR) for this resident revealed multiple instances where prescribed medications and treatments were omitted or not administered as ordered. These included missed doses of Quetiapine Fumarate, Rosuvastatin Calcium, Vitamin C, Fluticasone Propionate, Spiriva Respimat, Metoprolol Succinate, Potassium Chloride, as well as missed daily weights, catheter care, hydromorphone for pain, and scheduled bladder scans. The facility's policy requires medications to be administered according to prescriber orders and documented immediately after administration, but this was not followed in these cases. The resident involved had diagnoses including acute kidney failure, chronic obstructive pulmonary disease, and acute pancreatitis, and was assessed as cognitively intact. The omissions were identified through review of the resident's records for April and May, which showed specific dates and times when medications and treatments were not given as ordered. During an interview, the DON confirmed that the expectation is for nurses to administer medications and treatments according to provider orders.
Failure to Obtain Informed Consent for Psychotropic Medications
Penalty
Summary
The facility failed to ensure that residents were fully informed and provided with the necessary information to give informed consent before administering psychotropic medications. This deficiency was identified for two residents. Resident 32, who was admitted with a diagnosis of depression, received Wellbutrin, an antidepressant, on 10/25/2024, without having been informed of the risks and benefits, and without signing a consent form. Staff J, a Unit Manager and LPN, acknowledged that the medication was administered before obtaining the necessary consent. Similarly, Resident 78, who was alert and oriented, was prescribed Prochlorperazine Maleate, an antipsychotic, for nausea related to end-stage renal disease. The medication was administered without an informed consent form being signed. Staff B, the Director of Nursing Services and RN, confirmed that any use of psychotropic medication should have a consent form signed by the resident or their representative. These failures placed the residents at risk of not being fully informed about their care and treatment.
Failure to Accurately Document Resident's Weight Loss
Penalty
Summary
The facility failed to accurately assess and document significant weight loss for a resident diagnosed with severe malnutrition and Diabetes Mellitus. The resident was admitted with a care plan goal to maintain stable weights within 3-5 pounds, with interventions including diet as ordered, weights per protocol, and supplements as ordered. However, a Nutrition/Dietary progress note documented a significant weight loss of 11.73% of total body weight, and a subsequent nutritional assessment recommended weekly weight monitoring. Despite these directives, the facility did not record the resident's weights as requested by the Registered Dietician (RD), due to an order not being correctly entered, which led to the absence of weight records for review. Staff interviews revealed that the weights were not recorded in the medical record as required, and the RD was unable to provide missing weights for the resident. The Director of Nursing Services confirmed the absence of recorded weights after a certain date. The facility's policy indicated that weight changes of 10% are significant, and greater than 10% are severe, necessitating accurate weight documentation to prevent, monitor, or intervene with undesirable weight changes. The failure to record and monitor the resident's weight placed them at risk for nutritional and functional decline.
Failure to Follow PASARR Level II Recommendations
Penalty
Summary
The facility failed to ensure the recommendations of the Preadmission Screen and Resident Review (PASARR) Level II were followed for a resident reviewed for PASARR. The resident was admitted with diagnoses including Alzheimer dementia and major depression. The Quarterly Minimum Data Set assessment indicated that the resident's cognition was not assessed. The PASARR Level I indicated the need for a Level II assessment by a licensed mental health professional or mental health agency for individual services. However, the PASARR Level II recommendations were not found in the resident's medical record. The facility had a fax confirmation for a PASARR Level II request sent to the evaluator, but did not follow up to ensure services were started.
Failure to Initiate Timely Baseline Care Plans for Fall Risk and Communication Needs
Penalty
Summary
The facility failed to develop a baseline care plan to address fall risks and communication needs for two residents within 48 hours of their admission, as required. Resident 66, who was severely cognitively impaired and had a history of cerebrovascular accident, experienced three falls after admission, with the first two occurring before a fall risk care plan was initiated. The care plan was only developed after the second fall, despite the resident being assessed for falls upon admission. The Director of Nursing Services acknowledged that the fall risk care plan should have been initiated at the time of admission. Similarly, Resident 82, who was alert and oriented but had limited English proficiency, did not have a communication needs care plan initiated until several days after admission. The resident was observed having difficulty communicating in English and requested assistance with a phone. Staff used a translator service to communicate with the resident, but the communication care plan was delayed. The Director of Nursing Services confirmed that the communication needs care plan should have been initiated upon admission.
Deficiencies in Neurological Assessments, Weight Management, Bowel Protocol, and Dental Services
Penalty
Summary
The facility failed to perform ongoing neurological assessments for a resident who experienced an unwitnessed fall. The resident, who was severely cognitively impaired and had a history of cerebrovascular accident, did not receive complete neurological checks as required. The Director of Nursing Services acknowledged that the neuro checks were incomplete, which was against the facility's expectations for handling unwitnessed falls. The facility also failed to manage weight monitoring for two residents with congestive heart failure. One resident had a physician's order for weekly weights, but several weekly weights were missing from the electronic health record. Another resident had an order for daily weights, but numerous daily weights were not recorded. Staff members, including the Unit Manager and Director of Nursing Services, recognized the lack of documentation and stated that it was expected for CNAs to weigh residents as ordered. Additionally, the facility did not initiate bowel protocols for two residents who experienced extended periods without bowel movements. Despite having physician orders for laxatives to be administered after specific durations without bowel movements, the medication administration records showed no interventions were initiated. Staff admitted that the bowel protocol was not followed, and there was inconsistency in documentation. Furthermore, the facility failed to coordinate dental services for a resident who expressed a need for dentures, with no documentation of attempts to address the resident's dental care needs.
Failure to Implement Enhanced Barrier Precautions
Penalty
Summary
The facility failed to implement Enhanced Barrier Precautions (EBP) for four out of five residents reviewed for infection prevention and control. These residents had indwelling medical devices or wounds, which required the use of gowns and gloves during high-contact care activities as per the facility's policy. Observations revealed that staff only used gloves and did not wear gowns when providing care to these residents. Additionally, there was no EBP signage or personal protective equipment (PPE) available at the entrances of the residents' rooms. Resident 62, who had an indwelling urinary catheter, was observed multiple times without EBP signage or PPE at their room entrance. Similarly, Resident 240, with an abdominal drain, and Resident 241, with a peripherally inserted central catheter (PICC line), reported that staff only used gloves during care, and no EBP signage or PPE was present at their room entrances. Resident 339, who used a suprapubic catheter, was also observed without EBP signage or PPE, and staff were seen entering and exiting the room without applying PPE. Interviews with staff, including the Infection Control Nurse and Director of Nursing Services, revealed a lack of understanding and implementation of EBP. Staff members incorrectly equated EBP with standard precautions and believed gowns were unnecessary unless an infection was present. The Infection Control Nurse stated that EBP should be initiated by the admission nurse and verified by the nurse manager, but this process was not effectively carried out, leading to the observed deficiencies.
Failure to Notify Resident of Positive COVID-19 Test
Penalty
Summary
The facility failed to notify a resident's family and/or representative of a positive COVID-19 test result, which was a requirement according to their policy. The policy, dated May 15, 2020, stated that the facility must inform residents, their representatives, and families by 5:00 p.m. the next calendar day following a confirmed COVID-19 infection. Resident 75, who was alert and oriented, tested positive for COVID-19 on September 27, 2024, as documented in their Treatment Administration Record. However, there was no documentation in the resident's Electronic Health Record indicating that the resident or their representative was informed of the positive result. Interviews with the resident and staff revealed that the resident was not notified of the positive COVID-19 test until about three days later, when a doctor mentioned it in passing. Staff D, the Infection Preventionist and RN, stated that the facility's practice was to notify residents and their representatives as soon as possible, ideally within 24 hours of the test. Staff B, the Director of Nursing Services and RN, acknowledged that the facility failed to notify Resident 75 as per the policy, admitting that they missed this notification.
Incomplete and Non-Specific Care Plans for Residents
Penalty
Summary
The facility failed to develop comprehensive and individualized care plans for six residents, which resulted in incomplete and non-specific care plans. These deficiencies were identified during a review of the care plans for residents with various medical conditions, including congestive heart failure, diabetes mellitus, aortic valve stenosis, urinary tract infection, multiple sclerosis, and obesity. The care plans lacked specific interventions and goals tailored to each resident's needs, leaving critical areas such as assistance with activities of daily living (ADLs), pain management, mobility, cognitive function, and discharge planning unspecified. For instance, one resident with moderate cognitive impairment and mobility issues had a care plan that did not specify the level of assistance required for ambulation, toileting, and eating. Another resident with severe cognitive impairment and diabetes had a care plan that failed to detail pain management strategies and discharge arrangements. Similarly, a resident with aortic valve stenosis and muscle weakness had a care plan that omitted specific interventions for communication problems, behavior issues, and intravenous medication management. The lack of individualized care plans placed residents at risk for unmet care needs and diminished quality of life. The Director of Nursing Services acknowledged that the Resident Care Managers were responsible for writing these care plans and recognized the need for education to address the incomplete segments. However, the report does not detail any corrective actions taken to rectify the deficiencies.
Medication Administration Errors in LTC Facility
Penalty
Summary
The facility failed to ensure that residents were free from significant medication errors, as medications were not administered according to provider orders for four of the six sampled residents. Resident 1, who had diagnoses including congestive heart failure, hypothyroid, and hyperlipidemia, did not receive Atorvastatin Calcium and Levo-T as ordered. Resident 2, with severe cognitive impairment and conditions such as type 1 diabetes mellitus and hypertension, experienced a significant lapse in medication administration after returning from the hospital, missing multiple doses of critical medications including Losartan Potassium, Namenda, Basaglar KwikPen, and Humalog, among others. Resident 5, diagnosed with multiple sclerosis and paraplegia, did not receive Hydrocortisone External Cream as ordered for a facial rash. Resident 6, with congestive heart failure and class III obesity, did not have their daily weight monitored as ordered, which is crucial for managing their heart condition. The Director of Nursing Services acknowledged the omissions and indicated that the MAR should reflect valid reasons for any missed medications, which was not the case in these instances.
Failure to Implement Fall Prevention Measures
Penalty
Summary
The facility failed to ensure that fall mats were in place on either side of a resident's bed as directed in the comprehensive care plan. This deficiency was identified for a resident who was at risk for falls due to a history of falls, impaired balance, poor coordination, potential medication side effects, unsteady gait, and cognitive deficits. The resident's care plan, initiated in November 2020, included an intervention to place fall mats on either side of the bed at all times. However, during a facility investigation, it was found that on May 14, 2024, the resident fell from the bed onto the floor, and there were no fall mats present at the time of the fall. Staff members confirmed the absence of fall mats, which was contrary to the care plan requirements.
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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