Seattle Medical Post Acute Care
Inspection history, citations, penalties and survey trends for this long-term care facility in Seattle, Washington.
- Location
- 555 16th Avenue, Seattle, Washington 98122
- CMS Provider Number
- 505311
- Inspections on file
- 36
- Latest survey
- February 11, 2026
- Citations (last 12 mo.)
- 70
Citation history
Health deficiencies cited at Seattle Medical Post Acute Care during CMS and state inspections, most recent first.
A resident with aphasia, encephalopathy, and on chronic anticoagulation was care-planned and assessed as requiring two-person assistance for bed mobility. Despite this, a CNA attempted to reposition the resident alone, without adjusting the bed position or using bed controls, and did not call for help until after the resident slid off the bed and fell. The resident sustained a head laceration and was hospitalized, where imaging showed a new L frontal IPH with increased ventricular size compared to a prior scan. The nurse manager and DON confirmed the resident’s two-person assist requirement and stated the fall was an avoidable accident caused by failure to follow the plan of care.
The facility did not ensure appropriate care for pressure ulcers and failed to prevent new ulcers from developing, as evidenced by surveyor findings that necessary interventions were not consistently implemented for affected residents.
A resident did not receive enough food and fluids to maintain their health, as observed and documented by surveyors. The facility did not meet the nutritional and hydration needs required to support the resident's well-being.
A resident with a traumatic brain injury and persistent vegetative state experienced significant weight loss, but neither the physician nor the resident's representative was notified as required by facility policy. Staff interviews and record reviews confirmed the absence of notification and documentation regarding this change.
A resident experienced a significant decline, including progression of pressure ulcers and substantial weight loss, but the facility did not complete a Significant Change in Status Assessment (SCSA) MDS as required. Staff confirmed that the criteria for a significant change were met and the assessment should have been performed.
A resident with a history of stroke was evaluated and approved for a specific number of PT and OT sessions, but received significantly fewer sessions than planned due to staffing shortages. The Rehab Director confirmed the missed sessions, and the administrator acknowledged that the therapy staff were expected to provide the full course of treatment.
Three residents with documented goals to discharge to the community did not have comprehensive, person-centered discharge care plans developed or implemented, despite facility policy and assessment findings. Staff interviews confirmed that discharge planning was expected but not completed for these residents.
A resident in a persistent vegetative state, fully dependent and unable to consent, was subjected to nonconsensual sexual contact by a cognitively intact roommate with a history of aggressive and inappropriate behaviors. Despite documented incidents of threatening, grabbing, and wandering, no behavioral care plan or ongoing monitoring was in place for the roommate, leading to a failure to prevent sexual abuse.
A resident in a persistent vegetative state was the victim of a substantiated sexual assault by a roommate. Facility staff did not offer or arrange for immediate transfer to the ER for evaluation and evidence preservation, as required by policy and professional guidelines. The responsible party was not informed of the option for ER evaluation until two days after the incident, and clinical staff were not provided full details, resulting in delayed and incomplete care.
Two residents requiring substantial toileting assistance were left with unemptied bedside commodes and urinals for extended periods, despite staff and policy expectations for prompt care. Direct observations and resident interviews confirmed that toileting needs were not met in a timely manner, and staff acknowledged that equipment should have been emptied after each use.
A resident with schizophrenia did not receive clozapine for four days due to unavailability, and the facility failed to notify the physician. The resident exhibited increased anxiety and suicidal ideation, requiring hospitalization. Staff interviews confirmed the oversight in notification and the significant impact on the resident's condition.
A resident with schizophrenia did not receive clozapine for four days due to unavailability, leading to increased anxiety, behaviors, and suicidal ideation, requiring hospitalization. Nursing staff failed to notify the physician or take appropriate action, resulting in significant negative outcomes for the resident.
A resident with an indwelling urinary catheter experienced delays in a urology referral and urine analysis, leading to potential risks. Despite a physician's recommendation for a urology follow-up in October, the referral was not made until December, with an appointment scheduled for April. Additionally, a urine analysis ordered in December was not completed due to an improper specimen, and no follow-up was documented. Staff interviews revealed a lack of clarity and follow-up in the referral process.
A resident with a recent stroke diagnosis went missing from the facility, and the staff failed to notify the resident's Power of Attorney, despite being listed on the face sheet. The nursing notes showed law enforcement was informed, but not the representative. Interviews with staff confirmed the oversight, and the resident's representative expressed concern over the lack of communication.
A resident in a persistent vegetative state received enteral nutrition through an incorrect route and in incorrect amounts due to unclear physician orders and staff oversight. The facility's records showed inconsistencies in the administration route, and the resident received double the prescribed amount of feeding formula on multiple occasions.
A resident's narcotic medication, specifically 42 tablets of Oxycodone, went missing in the facility. Despite protocols requiring narcotics to be counted and secured, the medication was misplaced by an LPN and never found. The facility pharmacy replaced the missing medication.
The facility failed to properly label and store medications, including expired and controlled substances, in two medication carts and a storage room. Undated and expired medications were found, and a controlled substance was improperly stored in an unlocked refrigerator.
The facility failed to maintain food safety standards in the kitchen and resident personal refrigerators. Raw chicken was improperly thawed in the kitchen, exceeding safe temperature limits, and Resident 6's personal refrigerators were not maintained, with doors unable to close due to ice buildup and blank temperature logs. Staff were unsure of responsibilities, despite policies requiring daily checks.
The facility failed to follow infection control protocols, including Contact Precautions and Enhanced Barrier Precautions (EBP), for staff and residents. Staff MM and LL did not wear gloves in contact precaution rooms, and Resident 6 lacked EBP signage and PPE. Staff BB and GG did not perform hand hygiene between glove changes, and Staff R failed to disinfect medical equipment between uses.
The facility failed to provide written notices of transfer or discharge to residents and their representatives, and did not notify the LTC Ombudsman for four residents transferred to hospitals. Staff interviews and record reviews revealed reliance on verbal communication and lack of documentation, contrary to the facility's policy requiring written notices and Ombudsman notification.
The facility did not ensure survey results were accessible to residents and their representatives, as required. The survey result binder was not readily available in the designated area and lacked documentation for several complaint surveys over the past three years. Residents were unaware of their right to access these results, and staff confirmed the binder was kept behind the receptionist desk, requiring residents to request it.
The facility failed to maintain a safe and homelike environment, with several resident rooms and a hallway in disrepair. Observations showed damaged walls, loose baseboards, and a detached headboard, while the second-floor hallway had loose handrails. Staff interviews revealed a lack of awareness and communication regarding these issues, as they were not logged in the maintenance system, indicating a breakdown in the reporting and repair process.
A registered nurse in an LTC facility failed to follow professional standards for medication administration via G-tube and insulin administration for two residents. The nurse did not check gastric residuals or flush the G-tube properly and administered insulin against physician orders. Additionally, an unlabeled urine specimen was improperly stored in the facility's refrigerator.
The facility failed to provide consistent restorative services for six residents, leading to a risk of decline in range of motion. Residents with conditions such as hemiplegia, anoxic brain damage, and traumatic brain injury did not receive prescribed splint and ROM programs due to missing documentation and lack of staff coverage. Interviews revealed that restorative aides were not replaced during absences, resulting in non-compliance with care plans.
The facility failed to post daily nurse staffing information consistently and prominently across all floors. Observations showed missing postings on the Second and Third floors on multiple days, and on the First floor on one occasion. The staffing coordinator only posted the information at the reception desk, and the weekend supervisor, responsible for posting on weekends, was off for two weekends. This led to a lack of accessible staffing information for residents and visitors.
Two residents with feeding tubes did not receive proper checks for gastric residual volumes or tube placement before feeding and medication administration, as required by physician orders. A nurse failed to perform these checks, contrary to facility policy, placing the residents at risk for complications.
The facility failed to ensure proper enteral tube feeding management for two residents, as staff did not check gastric residual volumes or verify feeding tube placement before administering medications or connecting to enteral formula. This was against physician orders and facility policy, as confirmed by interviews with staff and management.
The facility did not complete the required annual performance evaluations for two CNAs, Staff T and Staff MM, which were last conducted shortly after their hiring dates. This failure to adhere to the annual evaluation requirement placed residents at risk of receiving care from potentially underqualified staff.
A resident who was dependent on staff for transfers was not assisted in getting out of bed and into a wheelchair, despite documented needs and requests from the resident's representative. Observations showed the resident remained in bed, and staff interviews confirmed the care plan was not followed, leading to a deficiency in providing necessary ADL assistance.
The facility did not conduct required reference checks for a newly hired CNA, Staff W, as per their policy to prevent abuse and neglect. Despite the policy requiring at least two reference checks before employment, none were completed for Staff W. This oversight was confirmed by the Executive Director during interviews.
A resident's admission MDS was completed four days late, beyond the required 14-day period. This delay was confirmed by the MDS Coordinator and the DON, who acknowledged the assessment should have been timely. The delay risked unmet care needs and diminished quality of life.
A resident experienced a significant change in condition after the removal of a G-tube, transitioning from tube feeding to oral intake. The facility failed to complete the required SCSA MDS within the 14-day timeframe, completing it 16 days late. This delay in assessment placed the resident at risk for unmet care needs. The MDS Coordinator and DON acknowledged the oversight and the expectation to adhere to the RAI Manual guidelines.
The facility failed to accurately assess three residents in their MDS, leading to deficiencies in care. A resident under hospice care was not marked as such, another was incorrectly documented as receiving pressure ulcer care, and a third was inaccurately coded as being in a persistent vegetative state with incorrect pressure ulcer staging. These errors were acknowledged by the MDS Coordinator and DON, highlighting lapses in accurately reflecting residents' conditions.
A resident's care plan was not updated to include PT and OT recommendations, despite being admitted with traumatic brain injury and right-sided weakness. The care plan lacked current restorative nursing program services, placing the resident at risk for unmet care needs. This was confirmed during a review with the Resident Care Manager and DON.
A resident with hemiparesis following a stroke had their call light placed out of reach, contrary to their care plan, which required it to be accessible on their right side. Observations showed the call light was consistently placed on the left side or on the bedside table, leading to a risk of delayed care. Staff confirmed the expectation for the call light to be within reach, highlighting a deficiency in accommodating the resident's needs.
A resident with a fractured lumbar vertebra expressed a desire to increase caloric intake but received less food than requested, leading to dissatisfaction with meals. Observations showed untouched breakfast trays not aligning with menu offerings. Staff interviews revealed a breakdown in the process of collecting and fulfilling meal preferences, with the Dietary Manager unable to locate menu orders for the resident for five weeks.
A resident with moderate cognitive impairment and a history of encephalopathy eloped from the facility unsupervised to buy cigarettes. Despite being on the elopement risk list, the resident left unnoticed and required assistance from a nearby kidney center to return. Staff confirmed the resident's fluctuating orientation and the need for supervision.
The facility failed to follow CDC guidelines for COVID-19 infection control, as room doors of four COVID-19 positive residents were left open, and staff did not use full PPE as required. Staff members were observed entering and exiting rooms without proper PPE, including N95 respirators, gowns, gloves, and eye protection. Interviews confirmed that staff were expected to adhere to posted isolation precautions, but these were not followed, risking the spread of infection.
A facility failed to administer enteral nutrition per physician's order for a resident with a feeding tube. The prescribed rate was 90 cc/hr, but the pump was set at 80 cc/hr. The discrepancy was not noticed by the nurse on duty, and there was no communication about any changes in the feeding rate.
Failure to Provide Required Two-Person Assist for Bed Mobility Resulting in Fall and Head Injury
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident received required two-person assistance for bed mobility, resulting in an avoidable accident and injury. The resident had diagnoses including aphasia following cerebral infarction and encephalopathy, and chronically received anticoagulant medication for valvular atrial fibrillation. Her Activities of Daily Living care plan, revised on 03/22/2023, and her quarterly MDS dated 12/26/2025 both documented that she was dependent on two or more helpers for bed mobility, including rolling and repositioning in bed. On the date of the incident, a nursing progress note documented that the resident fell from the bed, hit the back of her head, sustained a 2 cm laceration, and was sent to the hospital for further evaluation. Hospital records showed that she presented to the emergency department after a fall from bed at the SNF and was found to have a new left frontal intraparenchymal hemorrhage that increased slightly in size on a four-hour repeat CT scan, with increased ventricular size compared to a prior scan from 2019. A nurse practitioner stated that, based on the notes, after the fall the resident was found to have new bleeding in the brain and that the ventricles had increased in size, showing swelling to the brain, and that her anticoagulant medication was held because it can cause bleeding. The facility’s investigation and staff interviews showed that the CNA providing care repositioned the resident in bed without obtaining the required second person assist and did not adjust the bed position before attempting the task. The CNA reported noticing the resident at the edge of the bed, pushing her upper body toward the middle, then moving to the opposite side and using the draw sheet to pull her, without lowering the head of the bed or using bed controls, and without calling for help until after the resident slid off the bed. The CNA acknowledged that the incident could have been prevented if another staff member had been present to assist and act as a barrier. The weekend nurse manager and the DON both confirmed that the resident required two-person assistance for bed mobility per her plan of care, that staff were expected to follow this plan, and that the fall was an avoidable accident because the CNA did not obtain a second person to assist.
Failure to Provide and Prevent Pressure Ulcer Care
Penalty
Summary
The facility failed to provide appropriate care for pressure ulcers and did not implement effective measures to prevent the development of new ulcers. This deficiency was identified through surveyor observations and documentation review, which indicated that the necessary interventions to manage existing pressure ulcers and prevent additional ones were not consistently provided to affected residents.
Failure to Provide Adequate Food and Fluids
Penalty
Summary
The facility failed to provide sufficient food and fluids to maintain a resident's health. This deficiency was identified by surveyors based on observations and records indicating that the nutritional and hydration needs of at least one resident were not adequately met. The lack of appropriate provision of food and fluids resulted in a failure to support the resident's overall health status.
Failure to Notify Physician and Representative of Significant Weight Loss
Penalty
Summary
The facility failed to notify both the physician and the resident's representative of a significant change in a resident's condition, specifically a substantial weight loss. According to the facility's policy, licensed nurses are required to notify the physician and the resident's responsible party of significant weight changes and document this notification in the progress notes. For one resident with a history of traumatic brain injury and persistent vegetative state, weight records showed a loss of over 25% of body weight within a short period. However, a review of the resident's progress notes from the time of the weight loss did not show any documentation that the physician or the resident's representative had been notified. Interviews with facility staff, including the Registered Dietitian and the Assistant Director of Nursing, confirmed that it was the responsibility of the Resident Care Manager to notify the physician and the resident's representative in such cases, and that this should be documented in the medical record. The resident's representative also stated they were not informed of the significant weight loss. The lack of notification and documentation was confirmed through joint record reviews and staff interviews.
Failure to Complete SCSA MDS After Significant Resident Decline
Penalty
Summary
The facility failed to complete a Significant Change in Status Assessment (SCSA) Minimum Data Set (MDS) for a resident who experienced multiple significant declines in health status. According to the Long-Term Care Resident Assessment Instrument (RAI) manual, an SCSA is required when a resident has a major decline or improvement affecting more than one area of health. The resident in question was admitted with a stage 2 pressure ulcer and no significant weight loss. Subsequent assessments documented a progression to an unstageable pressure ulcer on the sacrum, which later advanced to a stage 4 pressure ulcer with exposed bone and additional unstageable pressure ulcers on the left lower leg. The resident also experienced a significant weight loss of 25.6% over a short period. Despite these documented changes, which met the criteria for a significant change in status, there was no evidence that an SCSA MDS was completed for the resident. Staff interviews confirmed that the facility followed the RAI manual and that an SCSA should have been completed within 14 days of the significant change. Both the MDS Coordinator and the Assistant Director of Nursing acknowledged that the resident had two areas of decline and that the required assessment was not performed.
Failure to Provide Required Rehabilitative Therapy Sessions
Penalty
Summary
The facility failed to provide the required specialized rehabilitative services for one resident who had been readmitted with a primary diagnosis of stroke. According to the resident's physical therapy (PT) and occupational therapy (OT) evaluations, the plan of care required three sessions per week for eight weeks, totaling 24 sessions each for PT and OT. Insurance authorization was obtained for the full course of therapy. However, documentation showed that only 16 PT sessions and 14 OT sessions were completed during the treatment period. Interviews with the Rehab Director confirmed that the shortfall in therapy sessions was due to staffing issues, which prevented adherence to the scheduled number of sessions. The resident's collateral contact also reported that the resident did not receive enough therapy services while in the facility. The facility's administrator stated that the expectation was for therapy staff to provide the required treatment sessions as outlined in the resident's care plan.
Failure to Develop and Implement Discharge Care Plans
Penalty
Summary
The facility failed to develop and implement comprehensive, person-centered discharge care plans for three residents who had expressed goals to discharge to the community. Review of the Minimum Data Set (MDS), Care Area Assessment (CAA), and care conference notes for these residents confirmed that their discharge goals were documented, but the corresponding care plans did not include individualized discharge planning. The facility's policy and the Long-Term Care Resident Assessment Instrument (RAI) User's Manual require that discharge care plans be completed within seven days of the CAA, incorporating the resident's goals, preferences, and needs. Interviews with the Director of Nursing and Social Service Director revealed that the expected process was to include a discharge plan of care as part of the comprehensive care plan upon admission and after the comprehensive MDS was completed. However, record reviews and staff interviews confirmed that no such discharge care plans were present for the three residents in question, despite their stated goals and the facility's policy. The Executive Director also confirmed that the expectation was for discharge care plans to be completed per policy.
Failure to Protect Resident from Sexual Abuse Due to Inadequate Behavioral Monitoring
Penalty
Summary
The facility failed to protect a resident's right to be free from sexual abuse, resulting in a substantiated incident of nonconsensual sexual contact. A resident with anoxic brain damage and in a persistent vegetative state, who was completely dependent on staff and unable to consent, was found by a CNA to be the victim of a sexual act performed by their roommate. The CNA observed the roommate with their head and face in the resident's private area, with the resident's incontinence brief unfastened and their private area exposed. The incident was immediately reported to the Resident Care Manager, who confirmed the resident's condition and lack of awareness or ability to respond. Prior to the incident, the roommate had a documented history of behavioral symptoms, including threatening, scratching, grabbing others, wandering, and physical aggression, as recorded in December and January. Despite these behaviors, there was no evidence that a behavioral care plan was developed or implemented to address these risks. Behavioral monitoring for the roommate was discontinued after a hospital stay and was not reactivated upon readmission, and the social services director and DON were unaware of the extent of the documented behaviors. The facility's policy required assessment and intervention for residents exhibiting behaviors towards others, but the roommate's behaviors were not addressed in their care plan. The lack of ongoing monitoring and intervention for the roommate's aggressive and inappropriate behaviors contributed to the failure to prevent the sexual abuse of a vulnerable, non-responsive resident.
Failure to Provide Timely Post-Assault Care and ER Transfer
Penalty
Summary
The facility failed to act in a timely manner and ensure that a resident received necessary care and services following a substantiated incident of sexual assault. The incident involved a resident in a persistent vegetative state, fully dependent on staff for all care, who was observed by a staff member to be the victim of an unwanted sexual act performed by a roommate. Facility policy and CDC guidelines require immediate medical evaluation and evidence preservation in such cases, including prompt transfer to the emergency room (ER) for examination and possible collection of forensic evidence. Despite these requirements, the facility did not offer or arrange for the resident to be transferred to the ER immediately after the incident. Documentation and interviews revealed that the responsible party was not offered the option to transfer the resident to the ER until two days after the event, at which point the offer was declined. Staff interviews confirmed that the on-call provider was notified but only advised monitoring the resident, and that the responsible party was not informed of the option for ER evaluation at the time of the incident. Further, the on-call provider and physician assistant were not given full details of the incident, which limited their ability to make appropriate clinical recommendations. The facility's Director of Nursing and Executive Director both stated that the expected protocol would have been to send the victim to the ER immediately to preserve evidence and provide appropriate care, but this did not occur. The failure to follow established protocols resulted in a delay in care and services for the resident following the sexual assault.
Failure to Provide Timely Toileting and Hygiene Assistance
Penalty
Summary
The facility failed to provide necessary assistance with toileting care for two residents who required substantial or maximal help with toileting and hygiene. One resident, who had intact cognition and required moderate assistance, was observed to have a bedside commode (BSC) containing a large, formed bowel movement that had not been emptied for several hours despite the resident's requests to staff. Staff interviews confirmed that the BSC should be emptied after each use, but this was not done. The facility's investigation could not substantiate abuse or neglect due to uncertainty about whether the resident had informed staff, but direct observation and resident statements indicated the BSC remained unemptied for an extended period. Another resident, also with intact cognition and requiring substantial assistance, reported waiting one to two hours for care after activating the call light and typically relied on staff to empty their urinals. Observations showed two urinals at the bedside, one full and one half full, which had not been emptied since the morning. Staff interviews confirmed that urinals should be emptied frequently and not left to fill. The facility's policy required individualized care plans and prompt toileting assistance, but these were not followed, resulting in residents' toileting needs not being met in a timely manner.
Failure to Notify Physician of Missed Medication Doses Leads to Resident Hospitalization
Penalty
Summary
The facility failed to ensure timely notification of the primary care physician when medications were not administered to a resident diagnosed with schizophrenia. The resident was prescribed clozapine, a medication critical for managing their condition, but it was not administered for four consecutive days due to unavailability. During this period, the resident exhibited increased anxiety, behaviors, and suicidal ideation, ultimately requiring hospitalization. The medication administration record indicated that clozapine was not given on four specific days, and the facility's investigation revealed that the responsible nursing staff did not notify the physician or place the resident on alert monitoring. Despite the resident's escalating symptoms, including anxiety and pacing, the physician was not informed of the missed doses until the resident's condition worsened significantly. Interviews with facility staff confirmed that the missed doses of clozapine were a significant concern, and the lack of timely notification to the physician was a critical oversight. The resident's condition deteriorated, leading to hospitalization for suicidal ideation and other related symptoms, highlighting the serious impact of the facility's failure to adhere to proper medication administration and notification protocols.
Failure to Administer Clozapine Leads to Resident Hospitalization
Penalty
Summary
The facility failed to administer clozapine, a medication significant to the health of a resident diagnosed with schizophrenia, for four consecutive days. This lapse occurred from February 22 to February 25, 2025, during which the medication was unavailable and not administered. The resident's Medication Administration Record (MAR) indicated that the medication was on order from the pharmacy, but no further action was taken by the nursing staff to address the unavailability. The nursing staff, including Staff H and Staff G, did not notify the physician or place the resident on alert monitoring despite the missed doses. As a result, the resident exhibited increased anxiety, behaviors, and suicidal ideation, which ultimately required hospitalization. The facility's investigation revealed that the nursing staff failed to follow the facility's policy on medication error reporting and adverse drug reaction prevention, which mandates notifying the physician and taking appropriate steps when a medication is unavailable. Interviews with facility staff, including the Consultant Pharmacist, Licensed Practical Nurse, Physician, and Resident Care Manager, confirmed the significance of the missed doses and the resulting negative outcomes for the resident. The resident experienced symptoms such as anxiety, insomnia, racing thoughts, confusion, irritability, and suicidal ideation, which were attributed to the missed doses of clozapine. The Director of Nursing acknowledged that the facility could not manage the resident's behaviors, leading to the decision to send the resident to the hospital for further evaluation and treatment.
Failure in Timely Urology Referral and UTI Management
Penalty
Summary
The facility failed to ensure timely action for a urology referral and urine analysis for a resident with an indwelling urinary catheter. The resident, who was admitted with neuromuscular dysfunction of the bladder, had ongoing issues with catheter blockage and cloudy urine. Despite a physician's note in October recommending a urology follow-up, the referral was not made until December, and the appointment was not scheduled until April of the following year. Interviews with staff revealed a lack of clarity and follow-up regarding the referral process, contributing to the delay. Additionally, the facility did not properly manage the resident's urinary tract infection (UTI) concerns. A nursing progress note indicated that a urine analysis was ordered in December due to cloudy and strong-smelling urine. However, the lab results showed that the test was not performed due to an improper specimen. Although staff noted the need to collect another specimen, there was no documentation of a follow-up or collection of a new sample in the resident's records. The deficiency highlights a breakdown in the facility's processes for managing specialty referrals and ensuring timely follow-up on medical orders. The lack of documentation and follow-up on both the urology referral and the urine analysis placed the resident at risk for further complications related to their urinary care management.
Failure to Notify Resident's Representative of Missing Resident
Penalty
Summary
The facility failed to notify the responsible parties of a resident's change in status, specifically when the resident went missing. The resident, who had a recent diagnosis of stroke and did not possess a cellphone, left the facility and did not return. The nursing progress notes indicated that law enforcement was notified, but there was no documentation showing that the resident's representative, who was listed as the Power of Attorney, was informed of the situation. This lack of communication was confirmed during interviews with the facility staff, including the Infection Preventionist/Resident Care Manager, Social Services, and the Director of Nursing, all of whom acknowledged that the representative should have been notified. The resident's representative expressed concern during an interview, stating they were unaware of the resident's admission to the facility and their subsequent disappearance. The representative emphasized the importance of being informed, especially given the resident's medical condition. The Executive Director of the facility also stated that it was expected for all responsible parties to be notified of changes in the resident's care. The failure to notify the resident's representative placed the resident at risk of not having their representative make timely decisions for their care and services.
Failure to Administer Enteral Nutrition as Ordered
Penalty
Summary
The facility failed to administer enteral nutrition in accordance with physician's orders and professional standards of practice for a resident in a persistent vegetative state. The resident was supposed to receive enteral feeding through a specific route, either a G-tube or J-tube, as per the physician's order. However, the facility's records showed inconsistencies in the administration route, with the order not clearly specifying whether the feeding should be through a G-tube or J-tube. This lack of clarity led to the resident receiving the feeding formula through the incorrect route. Additionally, the facility did not adhere to the prescribed amount of enteral feeding formula. The resident was ordered to receive 600 cc of Nutren 2.0 formula per 24 hours, but records indicated that the resident received 1200 cc on multiple occasions. This discrepancy in the amount administered was not identified or corrected by the staff, despite the Director of Nursing's expectation that staff should follow physician orders and document the amount of formula administered. These failures placed the resident at risk for adverse health outcomes and complications.
Misappropriation of Resident's Narcotic Medication
Penalty
Summary
The facility failed to protect a resident from the misappropriation of their property, specifically involving the loss of a narcotic medication. The incident involved a resident who was admitted with a diagnosis that included pain and multiple fractures. During an investigation, it was reported that a bingo card containing 42 tablets of Oxycodone, a narcotic pain reliever, was missing. The floor nurse, identified as Staff D, admitted to possibly misplacing the medication and only realized it was missing during the end-of-shift narcotic count. Despite efforts to locate the missing medication, it was never found. Interviews with various staff members, including LPNs and the Director of Nursing Services, revealed that the facility had protocols in place for counting and securing narcotic medications. However, these protocols were not effectively followed, as evidenced by the missing medication. Staff members confirmed that narcotics should never be left unattended and should be counted at the beginning and end of each shift. The Director of Nursing Services and the Administrator acknowledged the medication as the resident's property and confirmed that it was replaced by the facility pharmacy after it could not be located.
Medication Storage and Labeling Deficiencies
Penalty
Summary
The facility failed to properly label and store medications, as well as dispose of expired medications in a timely manner, which was observed in two medication carts and one medication storage room. On the second floor, an open and undated bottle of Milk of Magnesia with an expiration date of August 2024 was found in a medication cart, and staff acknowledged it should have been discarded. On the third floor, two open and undated bottles of Chlorhexidine Gluconate and an expired bottle of Fish Oil gel capsules were found in another cart. Staff admitted that the mouthwash bottles should have been dated when opened and the expired Fish Oil should have been removed. In the second floor medication storage room, an unlocked refrigerator contained an unopened bottle of lorazepam, a controlled substance, which should have been stored in a locked compartment. Additionally, an open and unlabeled vial of tuberculin was found, which should have been labeled with the date it was opened. Staff interviews confirmed the expectations for proper labeling and storage of medications, including the requirement for controlled substances to be stored in locked compartments.
Food Safety Deficiencies in Kitchen and Resident Refrigerators
Penalty
Summary
The facility failed to adhere to professional standards of food safety in the kitchen and in resident personal refrigerators, leading to potential risks of foodborne illness. During an observation, raw chicken breasts were found thawing in a sheet pan under running water in the kitchen preparation sink without a time sticker to indicate when the thawing process began. The temperature of the chicken was measured at 64.9°F, which did not meet the food safety preparation standards, as it exceeded the safe temperature of 41°F. Staff members acknowledged the failure to maintain the required temperature and decided to discard the chicken. Additionally, the facility did not maintain the personal refrigerators of Resident 6 according to their policy. Observations revealed that Resident 6 had two personal refrigerators with doors that would not close due to ice buildup, and the temperature logs on the refrigerators were blank. The resident confirmed that the facility staff never cleaned, maintained, or checked the temperature of their refrigerators. Staff members were unsure who was responsible for maintaining these refrigerators, despite the facility's policy requiring daily checks. Interviews with staff, including the Dietary Manager and Registered Dietician Nutritionist Consultant, confirmed that the facility followed the FDA 2022 Food Code and expected staff to adhere to these standards. However, the lack of proper monitoring and maintenance of both the kitchen and resident personal refrigerators demonstrated a failure to comply with these standards, placing residents at risk for foodborne illnesses.
Infection Control Deficiencies in LTC Facility
Penalty
Summary
The facility failed to adhere to Contact Precautions for two staff members, Staff MM and Staff LL, who did not wear gloves when entering rooms designated for contact precautions. Observations showed Staff MM entering a contact precautions room without gloves to deliver and pick up meal trays, despite signage indicating the requirement to wear gloves. Similarly, Staff LL was observed entering a contact precautions room without gloves on two separate occasions. Interviews with both staff members and the Infection Preventionist confirmed the expectation to follow signage instructions, which included wearing gloves before entering such rooms. The facility also failed to implement Enhanced Barrier Precautions (EBP) for Resident 6, who had an indwelling catheter. Observations over several days revealed the absence of EBP signage and a PPE cart outside Resident 6's room. Interviews with staff, including the Resident Care Manager and the Infection Preventionist, confirmed that EBP should have been initiated with appropriate signage and PPE availability. However, there was no order or care plan in place for EBP for Resident 6, indicating a lapse in infection control measures. Additionally, the facility did not ensure proper hand hygiene practices and glove use among staff. Staff BB and Staff GG were observed failing to perform hand hygiene between glove changes during resident care activities. Staff BB did not perform hand hygiene between glove use while attending to a resident's foot care, and Staff GG failed to perform hand hygiene between glove changes while administering medication and handling a feeding tube. Furthermore, Staff R did not disinfect medical equipment between resident use, using regular wipes instead of the required disinfectant wipes. Interviews with staff confirmed the expectation to perform hand hygiene and disinfect equipment as per facility policy and CDC guidelines.
Failure to Provide Written Transfer/Discharge Notices
Penalty
Summary
The facility failed to provide written notices of transfer or discharge to residents and their representatives, as well as to notify the Office of the State Long Term Care Ombudsman, for four residents who were transferred to hospitals. This deficiency was identified through interviews and record reviews, which revealed that the facility did not adhere to its own policy requiring written notices and notifications to the Ombudsman. The policy mandates that residents receive a written notice of transfer or discharge, including the reason for the transfer, at least 30 days in advance, except in urgent medical situations where notice should be given as soon as practical. For Resident 9, there was no documentation of a written notice of transfer or discharge provided to the resident or their representative, nor was there evidence that the Ombudsman was notified. Staff interviews confirmed that while a change in condition was documented, the required notices were not issued. Similarly, for Resident 75, the facility failed to provide written notices, relying instead on verbal communication via phone calls to families, with no documentation of Ombudsman notification. Resident 52's representative reported not receiving written notices for hospital transfers in August and September, and staff interviews corroborated the lack of written documentation. Additionally, Resident 15 was discharged to a hospital without a written notice, and staff were unaware of the requirement to provide such notices. Throughout the interviews, staff acknowledged the expectation to follow the facility's policy and state regulations, yet failed to provide the necessary documentation to demonstrate compliance.
Failure to Provide Accessible Survey Results
Penalty
Summary
The facility failed to ensure that survey results were posted in a location that was easily accessible to residents and their legal representatives. This deficiency was identified through observations, interviews, and record reviews. Residents and staff were unaware of the location of the survey results, and the survey result binder was not readily available in the designated area. Instead, it was kept on a small shelf behind the receptionist desk, and residents had to request access to it. Furthermore, the binder was missing results from several complaint surveys that resulted in citations over the past three years. During a Resident Council meeting, two residents expressed that they were not informed of their right to access the facility's survey results or where to find them. Observations confirmed that the survey results were not displayed in the main lobby as indicated. The Executive Director acknowledged that the survey result binder should be accessible to residents and their representatives, but it lacked the necessary documentation for complaint surveys from 2021, 2022, and two from 2023. This oversight prevented residents and their representatives from exercising their right to review past survey results and the facility's plan of correction.
Facility Fails to Maintain Safe and Homelike Environment
Penalty
Summary
The facility failed to maintain a safe, clean, and homelike environment for residents, as evidenced by the poor condition of several resident rooms and a hallway. Observations revealed that rooms had scraped and damaged walls, exposed drywall, and loose baseboards. In one instance, a room had a hole in the wall below the bathroom light switch, and another room had a detached headboard and a hole in the wall behind the bed. These conditions were not logged in the maintenance system, indicating a lapse in communication and adherence to the facility's preventative maintenance policy. Interviews with staff, including the Maintenance Director and Executive Director, highlighted a lack of awareness and communication regarding the disrepair in resident rooms. Staff members stated that issues should be logged in a maintenance log for non-emergent repairs, but this was not consistently done. The Maintenance Director was unaware of the specific damages until they were pointed out during joint observations, suggesting a breakdown in the reporting and repair process. Additionally, the facility's second-floor hallway had loose handrails, with exposed screws and anchors coming out of the wall. These issues were observed during multiple inspections, and staff acknowledged the need for repairs. The Executive Director expressed expectations that such environmental issues should be communicated to the maintenance department and addressed promptly, but this was not effectively implemented, leading to the deficiencies noted in the report.
Medication and Specimen Handling Deficiencies
Penalty
Summary
The facility failed to ensure proper medication administration via a gastrostomy tube (G-tube) for one resident and did not adhere to insulin administration orders for another. A registered nurse, identified as Staff GG, was observed administering medications to a resident through a G-tube without checking the gastric residual volume or verifying the tube placement. The nurse also failed to administer water flushes before, between, and after each medication, as required by the facility's policy and professional standards. Instead, the nurse mixed all the medications together and administered them simultaneously, contrary to the guidelines that specify each medication should be given separately. In another instance, Staff GG administered insulin to a resident despite the physician's order to hold the medication if the resident's capillary blood glucose level was below 100 mg/dL. The nurse checked the resident's blood sugar, which was 81 mg/dL, but proceeded to administer the insulin regardless. This action was against the physician's directive and placed the resident at risk of hypoglycemia. Additionally, the facility failed to properly label and store a urine specimen in the second-floor specimen refrigerator. Observations over several days revealed an unlabeled urine specimen in the refrigerator, which was not expected to be held for more than 24 hours. Staff members acknowledged the oversight, indicating that specimens should be labeled with at least two patient identifiers and not stored beyond the specified time frame.
Failure to Provide Consistent Restorative Services
Penalty
Summary
The facility failed to consistently provide restorative services to maintain or improve the range of motion (ROM) for six residents, leading to a risk of decline in ROM and unmet care needs. Resident 14, diagnosed with hemiplegia, was on a restorative program requiring the use of a left elbow and hand splint for up to six hours daily. However, documentation showed missing records of splint use for 11 out of 30 days, and observations confirmed the absence of splints on specific days. Interviews with staff revealed that the restorative aide responsible for applying the splints was not covered when absent, leading to lapses in care. Resident 59, with anoxic brain damage, was also on a restorative program requiring bilateral hand/wrist splints for six to eight hours daily. Similar to Resident 14, documentation was missing for 11 out of 30 days, and observations confirmed the absence of splints. Staff interviews indicated that the restorative aide was solely responsible for applying the splints, and no coverage was provided during their absence, resulting in non-compliance with the care plan. Other residents, including Residents 37, 28, 35, and 10, experienced similar deficiencies in their restorative programs. Resident 37, with upper extremity impairments, received passive ROM only three out of 29 days, and no splint use was documented for 30 days. Resident 28, with a traumatic brain injury, reported not receiving ROM exercises for two to three weeks, and documentation was lacking. Resident 35, with hemiparesis, did not have a left elbow splint applied as required, and Resident 10, in a persistent vegetative state, did not receive the prescribed splint program. Staff interviews consistently highlighted issues with staffing and documentation, leading to the failure to implement the restorative programs as outlined in the care plans.
Failure to Post Daily Nurse Staffing Information
Penalty
Summary
The facility failed to ensure that the daily nurse staffing information was posted consistently and in prominent locations across the building. Observations on multiple occasions revealed that the nurse staffing information was not visible on the Second and Third floors on specific days. Additionally, the staffing information was not posted on the First floor on one occasion. Interviews with staff indicated that the staffing coordinator was responsible for creating the nurse staffing forms after checking for call-outs and preparing schedules for the weekend supervisor to post. However, the weekend supervisor had been off for the last two weekends, leading to a lack of posting on those days. The staffing coordinator admitted to only posting the nurse staffing information in a glass case by the reception desk and not throughout the building. The administrator confirmed the expectation for daily posting of nurse staffing information but acknowledged the absence of the weekend supervisor. This oversight placed residents, their representatives, and visitors at risk of not being fully informed of the current staffing levels, as the information was not readily accessible in the designated areas.
Failure to Verify Tube Feeding Placement
Penalty
Summary
The facility failed to ensure appropriate treatment and services related to enteral tube feeding for two residents, which placed them at risk for medical complications and a diminished quality of life. Resident 54, who was admitted with a diagnosis of laryngeal cancer, had a gastrostomy tube and physician orders to check gastric residual volumes (GRV) and verify feeding tube placement prior to each tube feeding or flush. However, on observation, a registered nurse administered medications via the G-tube without checking the GRV or verifying the tube placement. Similarly, Resident 36, admitted with dysphagia, also had physician orders to check residuals and feeding tube placement before each feeding or flush. During observation, the same registered nurse connected the resident's feeding tube to their enteral formula without performing the required checks. Interviews with the staff revealed a lack of adherence to the facility's policy and standard practices, as the nurse only checked tube placement at the start of their shift or if they suspected displacement. The Director of Nursing and Resident Care Manager confirmed the expectation for staff to check tube placement prior to feeding and medication administration.
Failure to Verify Feeding Tube Placement and Residuals
Penalty
Summary
The facility failed to ensure appropriate treatment and services related to enteral tube feeding for two residents, leading to a deficiency. Resident 54, who was admitted with laryngeal cancer and had a gastrostomy tube, did not have their gastric residual volumes (GRV) checked or feeding tube placement verified before medication administration by a registered nurse. Similarly, Resident 36, admitted with dysphagia and also with a feeding tube, did not have their GRV checked or tube placement verified before being connected to their enteral formula. These actions were contrary to the physician's orders and the facility's policy, which required checking residuals and verifying tube placement prior to each feeding or medication administration. Observations revealed that Staff GG, a registered nurse, did not perform the necessary checks for both residents before administering medications or connecting the feeding tube to the enteral formula. Interviews with Staff GG indicated a misunderstanding of the procedure, as they only checked tube placement once per shift unless they suspected displacement. The Resident Care Manager and the Director of Nursing both confirmed that staff were expected to check tube placement before each feeding and medication administration, highlighting a lapse in adherence to the facility's standards and procedures.
Failure to Conduct Annual CNA Performance Evaluations
Penalty
Summary
The facility failed to conduct the required annual performance evaluations for two Certified Nursing Assistants (CNAs), identified as Staff T and Staff MM. Staff T was hired on January 22, 2022, and their last performance review was completed on February 23, 2022. Staff MM was hired on February 23, 2022, and their last performance review was completed on December 8, 2022. This oversight was identified during an interview and record review, where it was noted that the facility did not adhere to the expectation of completing performance evaluations annually. The absence of these evaluations placed residents at risk of receiving care from potentially underqualified staff, leading to unmet care needs and a diminished quality of life.
Failure to Assist Resident with ADLs and Transfers
Penalty
Summary
The facility failed to provide necessary assistance with Activities of Daily Living (ADL) for Resident 14, who was dependent on staff for transferring from bed to a wheelchair. According to the quarterly Minimum Data Set (MDS) and the resident's care plan, Resident 14 was supposed to be assisted in getting out of bed and into a tilt-in-space wheelchair for positioning and pressure reduction. Despite these documented needs and the resident's representative's request for chair time, observations over several days showed that Resident 14 remained in bed, and the wheelchair was unused in the room. Interviews with staff, including a Certified Nursing Assistant, a Licensed Practical Nurse, and the Director of Nursing, confirmed that Resident 14 had not been transferred to the wheelchair as required by the care plan. The staff acknowledged the expectation to follow the care plan and provide necessary ADL assistance, including transfers for dependent residents. The failure to implement the care plan and provide the required assistance with transfers was identified as a deficiency, as it placed Resident 14 at risk for unmet needs and pressure-related complications.
Failure to Conduct Reference Checks for New Hire
Penalty
Summary
The facility failed to implement its abuse policy and procedure by not conducting reference checks prior to hiring a staff member, identified as Staff W, a Certified Nursing Assistant. The facility's policy, updated in October 2022, mandates that prospective employees undergo screening, including at least two reference checks, to prevent abuse, neglect, exploitation, or misappropriation of resident property. However, upon review of Staff W's employee records, there was no evidence of such reference checks being conducted before their hire date of September 15, 2023. Interviews with the Executive Director, Staff A, confirmed that reference checks were not completed for Staff W during the onboarding process, which should have been done prior to their start date.
Delayed MDS Completion for a Resident
Penalty
Summary
The facility failed to complete the admission Minimum Data Set (MDS) for one resident within the required 14-day period following admission. Specifically, Resident 26 was admitted to the facility, and their admission MDS was completed four days late, on 07/08/2024. This delay was confirmed during interviews and joint record reviews with the MDS Coordinator and the Director of Nursing, who acknowledged that the assessment should have been completed within the stipulated timeframe. The failure to complete the MDS on time placed the resident at risk for delayed and/or unmet care needs, potentially affecting their quality of life.
Failure to Timely Complete SCSA MDS After Significant Change
Penalty
Summary
The facility failed to complete a Significant Change in Status Assessment (SCSA) Minimum Data Set (MDS) within the required 14-day timeframe for a resident who experienced a significant change in condition. The resident, who was initially receiving more than 51% of their total calories via tube feeding, underwent a gastrostomy tube (G-tube) removal and began eating orally. This change in the resident's nutritional status required a timely SCSA MDS to reassess and potentially revise the care plan to meet the resident's new needs. The MDS Coordinator, Staff L, acknowledged that the SCSA MDS for the resident was completed 16 days late, beyond the 14-day requirement from the determination date of the G-tube removal. The Director of Nursing, Staff B, confirmed the expectation that staff should adhere to the RAI Manual guidelines and complete the SCSA MDS within the specified timeframe. The delay in completing the assessment placed the resident at risk for unmet care needs and a diminished quality of life.
Inaccurate Resident Assessments in MDS
Penalty
Summary
The facility failed to accurately assess three residents, leading to deficiencies in their care. Resident 84, who was admitted with a diagnosis of malignant neoplasm of the larynx, was not marked for hospice care in the Minimum Data Set (MDS) despite being under hospice care since March 2024. This oversight was acknowledged by the MDS Coordinator and the Director of Nursing during interviews, indicating a lapse in accurately coding the resident's status. Resident 82's admission MDS inaccurately reflected the provision of pressure ulcer care, despite no evidence of pressure ulcers or related treatment in the resident's records. The MDS Coordinator admitted to the error, noting that the resident had no pressure ulcers, and the Director of Nursing emphasized the expectation for accurate MDS assessments reflecting the resident's condition and treatment. Resident 26 was incorrectly coded as being in a persistent vegetative state in the MDS, although records showed the resident was alert and oriented. Additionally, the MDS inaccurately documented the presence of Stage 3 and Stage 4 pressure ulcers, with the actual condition being two Stage 4 pressure ulcers. The MDS Coordinator confirmed these inaccuracies, and the Director of Nursing reiterated the importance of accurate coding based on the resident's medical condition.
Failure to Revise Comprehensive Care Plan for Resident
Penalty
Summary
The facility failed to revise the comprehensive care plan for one resident, identified as Resident 28, who was reviewed for care plan revision. This deficiency was identified during an interview and record review, where it was found that the care plan did not include current and specific restorative nursing program (RNP) services recommended by physical therapy (PT) and occupational therapy (OT). Resident 28, who was admitted with diagnoses including traumatic brain injury and right-sided weakness, had an existing care plan intervention for passive range of motion (PROM) to the right arm, which was last revised in January 2024. However, the care plan did not reflect the PT and OT recommendations made in September 2024, which included passive/active range of motion exercises for the lower extremities and specific exercises for the upper extremities. During a joint record review and interview with the Resident Care Manager and the Director of Nursing, it was confirmed that the care plan had not been updated to include the PT and OT recommendations from September 2024. The Director of Nursing acknowledged that the care plan was not revised to incorporate these recommendations until the day of the review. This oversight placed Resident 28 at risk for unmet care needs and a diminished quality of life, as the care plan did not align with the current therapeutic recommendations necessary for maintaining the resident's physical condition.
Failure to Ensure Call Light Accessibility for Resident
Penalty
Summary
The facility failed to ensure that a call light was within reach for a resident, identified as Resident 35, who was reviewed for accommodation of needs. Resident 35 was readmitted to the facility with hemiparesis following a cerebral infarction, affecting their left non-dominant side. The resident's care plan specified that a soft touch call light should be placed within reach on their right side, near their right hand, to accommodate their condition. However, multiple observations revealed that the call light was consistently placed out of reach, either next to or below the resident's left hand, or on the bedside table. During a joint observation and interview, the Resident Care Manager, Staff F, confirmed that the call light was not within reach and acknowledged the expectation for it to be placed near the resident's right hand. The Director of Nursing, Staff B, also stated that staff were expected to place call lights within reach according to each resident's needs and preferences. This oversight placed the resident at risk for delayed care, accidents, falls, and a diminished quality of life, as the call light was not accessible to them as required by their care plan.
Failure to Honor Resident Meal Preferences
Penalty
Summary
The facility failed to honor the meal preferences of a resident, identified as Resident 76, which led to dissatisfaction with the food served and a diminished quality of life. Resident 76, who was admitted with multiple diagnoses including a fractured lumbar vertebra, expressed a desire to increase their caloric intake to gain weight. However, they reported receiving less food than requested, specifically noting that their breakfast often consisted of only a sausage patty and toast, despite their preference for items like waffles and pancakes. Observations confirmed that Resident 76's breakfast trays were often untouched, and the meals did not align with the menu offerings, such as waffles on one occasion. Interviews with staff revealed a breakdown in the process of collecting and fulfilling meal preferences. The activities department was responsible for distributing and collecting menu orders, but Resident 76 did not receive assistance with this task when they were unable to get out of bed. The Dietary Manager was unable to locate menu orders for Resident 76 for the past five weeks, and there was confusion about why their preference for wheat toast resulted in the omission of other menu items. The Administrator confirmed that food preferences were collected upon admission and that residents should receive what was on the menu, indicating a failure in the system to ensure Resident 76's meal preferences were met.
Resident Elopement Due to Inadequate Supervision
Penalty
Summary
The facility failed to provide adequate supervision for a resident at risk for elopement, resulting in the resident leaving the facility unnoticed. The resident, who had moderate cognitive impairment and was identified as an elopement risk, left the facility to purchase cigarettes and was unable to return without assistance. The resident was found at a nearby kidney center, which contacted the facility for help in returning the resident. The resident's medical history included encephalopathy, muscle weakness, and pain in the right hip, which contributed to their risk of elopement and falls. Despite being on the elopement list, the resident was able to leave the facility unsupervised, highlighting a lapse in the facility's supervision and monitoring procedures. Staff interviews confirmed that the resident's cognitive condition fluctuated, and they should not have been allowed to leave the facility without supervision.
Failure to Follow COVID-19 Infection Control Protocols
Penalty
Summary
The facility failed to adhere to CDC guidelines for infection prevention and control, specifically regarding COVID-19 precautions. Observations revealed that the room doors of four residents with confirmed COVID-19 infections were left open, contrary to the CDC's directive to keep such doors closed to prevent the spread of the virus. This oversight was noted for Residents 1, 2, 3, and 4, all of whom had tested positive for COVID-19. The facility's policy also required these doors to remain closed, yet this was not followed. Additionally, staff members did not comply with PPE requirements when entering the rooms of COVID-19 positive residents. Staff D, E, and F were observed entering and exiting rooms without wearing the full PPE as mandated by the CDC and the facility's policy. This included the improper use of N95 respirators and the absence of gowns, gloves, and eye protection. Staff D and E acknowledged their failure to follow the posted PPE requirements, while Staff F was unaware of the isolation status of Resident 3. Interviews with facility staff, including the Infection Preventionist and the Assistant Director of Nursing, confirmed that the expectation was for staff to follow the posted isolation precautions. However, the observations indicated a lack of adherence to these protocols, placing residents, staff, and visitors at risk of COVID-19 infection.
Failure to Administer Enteral Nutrition Per Physician's Order
Penalty
Summary
The facility failed to ensure that enteral nutrition was provided per the physician's order for a resident with a feeding tube. The resident, who had diagnoses including diabetes and a persistent vegetative state, was prescribed a tube feeding supplement at a rate of 90 cc/hr for 20 hours per day. However, during an observation, it was found that the resident's tube feeding pump was set at 80 cc/hr. The discrepancy was not noticed by the registered nurse on duty, who admitted to not checking the pump's rate during their morning rounds. The nurse also stated that there was no communication from the night nurse about any changes in the tube feeding rate. Further interviews with the Resident Care Manager and the Director of Nursing Services confirmed that staff are expected to follow the physician's orders and monitor the tube feeding pump's rate. The failure to adhere to the prescribed rate placed the resident at risk for inadequate nutrition and related complications. The facility's policy on enteral feeding, which requires the licensed nurse to administer feedings per physician order, was not followed in this instance.
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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