Shelton Health And Rehabilitation
Inspection history, citations, penalties and survey trends for this long-term care facility in Shelton, Washington.
- Location
- 153 Johns Court, Shelton, Washington 98584
- CMS Provider Number
- 505507
- Inspections on file
- 25
- Latest survey
- January 16, 2026
- Citations (last 12 mo.)
- 3
Citation history
Health deficiencies cited at Shelton Health And Rehabilitation during CMS and state inspections, most recent first.
The facility failed to provide adequate supervision and effective fall prevention for several high-risk residents, leading to repeated unwitnessed falls and serious injuries. One resident with dementia and multiple comorbidities had eight unwitnessed bed-related falls; after early falls, staff either implemented limited measures such as a single fall mat or only monitored for latent injuries, and did not add meaningful preventive interventions despite subsequent imaging-confirmed lumbar and facial fractures. Later falls for this resident resulted in additional facial trauma and a laceration requiring sutures, while care plan interventions such as a soft-touch call light were not actually in place at the bedside. A second cognitively impaired resident with metastatic cancer and other conditions experienced numerous unwitnessed falls; post-fall responses often consisted only of monitoring or resident education, and even when 1:1 supervision was ordered, the resident was still observed crawling out of bed. A third resident with hemiplegia, epilepsy, and vascular dementia had multiple unwitnessed falls, with documentation of a bedside commode and fall mat that were not present in the room on observation, and no new interventions were added after repeated falls, despite ongoing fall monitoring.
Multiple residents with complex medical needs did not consistently receive scheduled showers or timely assistance with ADLs due to insufficient nursing staff. Residents and staff reported frequent staffing shortages, missed care opportunities, and delays in call light response and medication administration. Documentation and council minutes confirmed ongoing concerns about missed showers and inconsistent staffing assignments.
A resident with cognitive impairment and multiple health conditions was not afforded privacy during a private conversation, as housekeeping staff remained in the room and cleaned in close proximity despite the resident's discomfort. The resident expressed feeling that staff intentionally intruded, and staff interviews confirmed that privacy should have been respected during such interactions.
A facility failed to obtain physician-ordered lab values for a resident who was hospitalized with sepsis and a UTI. The resident, who was severely cognitively impaired, did not meet hydration needs and lacked consistent monitoring. Additionally, the facility did not follow the bowel protocol for two residents, leading to improper administration of treatments. Staff interviews revealed a lack of policy on vital signs and unmet expectations for documentation.
The facility failed to provide adequate nutritional care for three residents, leading to significant weight loss. One resident lost 14.89% of their weight over six months due to lack of nutritional supplements and improper meal intake recording. Another resident lost 11.09% in 34 days, with their nutritional supplement not implemented. A third resident lost 10.48% over six months, with no alternative meals offered when eating less than 50% of their meal. Staff were unaware of Nutritionally Enhanced Meals (NEM) requirements, and necessary interventions were not implemented.
The facility failed to maintain oxygen equipment and adhere to physicians' orders for three residents. Observations revealed empty humidifier bottles and debris-covered filters on oxygen concentrators. Staff were unclear about responsibilities for equipment maintenance, leading to potential risks for residents.
The facility failed to inform residents and their representatives about their rights regarding binding arbitration agreements. Three residents were not adequately informed about the optional nature of these agreements, their right to rescind within 30 days, and the implications of signing. Staff interviews revealed a lack of proper review and understanding of these agreements during admissions and readmissions.
The facility failed to implement effective infection control measures, as evidenced by staff not following standard precautions for residents with pressure ulcers, urinary catheters, and those on contact precautions. Staff were observed not wearing PPE, not performing hand hygiene, and improperly handling contaminated items, increasing the risk of infection.
The facility failed to transfer funds from resident trust accounts within 30 days after discharge for two residents. One resident was discharged with a $40.00 balance, and another passed away with a $189.51 balance. The Business Office Manager confirmed the delayed account closures, and the Administrator acknowledged the checks were not issued timely.
A resident with cognitive and mental health conditions reported an incident involving a nurse's inappropriate response after a fall, which was not reported or investigated by the facility at the time. The DNS and Administrator acknowledged the failure to report and investigate the incident as required.
The facility failed to accurately assess MDS for four residents, leading to discrepancies in care plans. A resident's MDS did not reflect the use of a Wander Guard, despite documentation and staff confirmation. Another resident's MDS omitted refusals of care, and two residents' MDS assessments failed to identify significant weight loss due to incorrect date usage.
The facility failed to ensure accurate PASRR documentation for three residents. One resident's PASRR omitted diagnoses of MDD and Unspecified Psychosis, another's failed to include a psychotic disorder despite treatment with antipsychotics, and a third resident's PASRR incorrectly listed an anxiety disorder. Staff acknowledged these inaccuracies.
The facility failed to update and accurately reflect care plans for several residents, leading to unmet care needs. A resident with neurogenic bladder had an incomplete care plan, while another required more assistance with oral care than documented. A third resident's wander guard placement was inaccurately recorded, and their nutritional needs were not updated. Additionally, a resident's shower schedule was incorrect, and another's nutrition plan was outdated, lacking interventions for weight loss and food refusal.
The facility failed to provide scheduled bathing assistance to five residents, including those with cognitive impairments and those requiring substantial assistance. Records showed inconsistencies in bathing schedules, with some residents not receiving showers for extended periods. Staff confirmed the lack of adherence to care plans, indicating a deficiency in care.
A facility failed to document pre and post dialysis assessments and medications for a resident with end stage renal disease. The resident had specific orders for dialysis, including midodrine and Ceftazidime administration, but there was a lack of documentation and communication with the dialysis center. This deficiency led to uncertainty about the resident's care and medication administration during dialysis sessions.
The facility experienced a 46.88% medication error rate, with late administration for two residents and omitted medication for another. An RN administered medications late, and an LPN failed to provide a resident's prescribed medication for three days due to unavailability, without notifying the pharmacy or provider.
The facility failed to secure medications properly, with instances of unattended medication on a cart and at a resident's bedside. An RN left a MiraLAX bottle and an unlabeled pill on a medication cart, while an LPN disposed of an unlabeled pill found on the cart. An insulin pen was also left unattended. Additionally, an RN left an insulin pen on a resident's bedside table. These actions did not meet the facility's expectations for medication security.
The facility failed to maintain complete and accurate medical records for three residents, leading to potential risks. A resident's death was not documented, another resident's return from the hospital lacked documentation, and a third resident's pressure ulcer was improperly assessed by an LPN without RN confirmation. Staff acknowledged these documentation gaps, which were against expected standards.
A resident with a full resuscitation order was found unresponsive, and staff initiated chest compressions but failed to provide respirations due to missing equipment. The involved staff had expired CPR certifications, and the facility acknowledged the deficiency, which posed a risk to residents requiring CPR.
The facility failed to ensure timely physician visits within the first 30 days after admission for two residents. One resident with multiple diagnoses did not receive a physician's visit for 112 days after readmission, while another resident with Chronic Systolic Heart Failure did not receive a visit for 50 days. The facility's Administrator and DON acknowledged the issue, citing the facility physician's leave and lack of coverage as reasons for the deficiency.
A resident with dementia and a history of falls experienced an unwitnessed fall resulting in a fracture. The facility did not update the care plan with new interventions to prevent further falls, despite policy requirements. Staff acknowledged the care plan was not revised.
A resident with dementia and depression was allegedly abused by a CNA, who grabbed and slapped the resident. The incident was witnessed by two other CNAs but was not reported until the following day, delaying the investigation and allowing the alleged abuser to continue working.
Failure to Implement and Maintain Effective Fall Prevention and Supervision
Penalty
Summary
The deficiency involves the facility’s failure to provide adequate supervision and effective fall prevention interventions for multiple residents assessed as high fall risk, resulting in repeated unwitnessed falls and injuries. Facility policy required licensed nurses to update care plans with individualized interventions to reduce or prevent falls, to review care plans after each fall to determine intervention effectiveness, and to complete a systematic post-fall review with root cause identification. The policy also stated that while a new intervention was not required after every fall, each fall required review of current interventions and consideration of discontinuing ineffective ones. Despite this, residents with high fall risk scores experienced numerous unwitnessed falls where either no new preventive interventions were implemented, or interventions documented in the care plan were not put into place. One resident with dementia, seizures, atrial fibrillation, cognitive impairment, and dependence on staff for transfers had a fall risk score of 105 and sustained eight unwitnessed falls from their bed. After an unwitnessed fall on 10/26/2025, the only intervention documented was placement of a fall mat. Following another unwitnessed fall on 11/27/2025, the intervention was limited to lab testing and urinalysis. After a fall on 11/30/2025, the facility documented only monitoring for latent injuries and did not implement any new intervention to prevent further falls. Subsequent imaging on 12/03/2025 revealed an acute to subacute L2 vertebral body fracture and multilevel compression fractures, and the resident reported severe sharp, stabbing back pain. On 12/12/2025, the resident had another unwitnessed fall when attempting to get out of bed to use the toilet, resulting in facial trauma with bleeding from the right nostril and mouth, headache, and back pain; hospital CT imaging showed acute maxillofacial fractures involving the right orbital wall and floor, right maxillary sinus walls, and associated edema and hematoma. The same resident continued to experience additional unwitnessed falls after these injuries. Later on 12/12/2025, the resident had another unwitnessed fall in their room, striking their face and having blood in the nostrils; the only new interventions documented were a pharmacy review and a bedside commode. On 12/25/2025, the resident had an unwitnessed fall in their room without injury, and staff documented education to wait for assistance, despite the resident’s cognitive impairment; the care plan revised on 12/26/2025 showed no new supervision intervention. After another unwitnessed fall on 12/26/2025 with a bruised left knee, the care plan was revised on 12/29/2025 only to add a soft-touch call light. Following an unwitnessed fall on 01/06/2026 with a laceration above the right eyebrow requiring hospital evaluation and sutures, the resident’s room was changed to increase supervision. However, subsequent observations on 01/14/2026 and 01/15/2026 showed the resident using a regular call bell instead of the soft call light specified in the care plan, and an LPN acknowledged the resident did not have the soft call light in place. Another resident with prostate cancer with metastasis, diabetes, bipolar disorder, severe cognitive impairment, wheelchair use, incontinence, and a fall risk score of 65 had 11 falls without injury over a short period. After an unwitnessed fall on 11/25/2025, the only intervention was to monitor for latent injuries. Following an unwitnessed fall outside the dining room on 11/28/2025, after staff had placed the resident outside the dining room post-meal, the intervention was to provide training to the resident to stay in the dining room, despite the resident’s severe cognitive impairment. Later that same day, the resident had another unwitnessed fall from bed, and no new intervention was implemented to prevent further falls. After an unwitnessed fall near the nursing station on 12/19/2025, the DON reported that the intervention was to place the resident on 1:1 supervision; however, on 12/20/2025, while on 1:1 supervision, the resident was observed crawling out of bed. The DON acknowledged that the resident had multiple falls during this period and that education was not an appropriate intervention given the resident’s cognitive impairment. A third resident with hemiplegia, hemiparesis, epilepsy, vascular dementia, cognitive impairment, wheelchair and walker use, incontinence, and a fall risk score of 55 had five falls without injury. After an unwitnessed fall on 12/30/2025 in the resident’s room, the documented intervention was a bedside commode. Following another unwitnessed fall on 01/12/2026 in the room, no new intervention was implemented to prevent further falls, and documentation only noted that a fall mat was placed at the bedside. After a subsequent unwitnessed fall on 01/14/2026, documentation again showed no new intervention, stating only that the resident was already on fall monitoring. During observation on 01/16/2026, the resident was found resting in bed without a fall mat or bedside commode in the room, and an LPN acknowledged that these items were not present despite being documented as interventions. The administrator and DON later acknowledged that residents had falls with injuries and that new fall interventions were not implemented after falls for these residents, even though facility policy required review of falls and interventions.
Failure to Provide Sufficient Nursing Staff for Resident Care Needs
Penalty
Summary
The facility failed to provide sufficient nursing staff to meet the needs of residents, as evidenced by multiple resident interviews, record reviews, and staff schedules. Several residents with varying medical conditions, including dementia, diabetes, post-traumatic stress disorder, asthma, chronic pain, major depressive syndrome, spinal stenosis, chronic obstructive pulmonary disease, stroke, and pressure ulcers, did not consistently receive scheduled showers or timely assistance with activities of daily living (ADLs). Documentation showed that residents often missed scheduled bathing opportunities, and staff did not always reattempt or document refusals as required by care plans. Residents reported long waits for call light responses, late medication administration, and staff rushing through care tasks. Some residents specifically noted that showers did not occur on their preferred or scheduled days, and that staff did not spend adequate time with them. Observations included residents appearing disheveled and in poor hygiene, with visible sores and scabs. Resident council minutes and grievance forms further documented ongoing concerns about short staffing, inconsistent assignment of nursing assistants, missed showers, and lack of communication regarding medication needs. Staff interviews confirmed that staffing shortages were frequent, with bath aides (BAs) often being reassigned to cover other shifts, leaving nursing assistants (NAs) responsible for both floor duties and showers. Staff described feeling overwhelmed and unable to complete all required care, particularly when high-acuity residents were present or during periods of increased absenteeism. Leadership acknowledged the ongoing issues with staffing and the impact on resident care, including missed showers and delayed medication passes.
Failure to Respect Resident Privacy During Private Conversation
Penalty
Summary
Staff failed to honor a resident's right to privacy and dignity during a private conversation. The resident, who had dementia, post-traumatic stress syndrome, and diabetes mellitus, required substantial assistance with activities of daily living and was dependent on staff to meet emotional, intellectual, physical, and social needs. During an interview with the resident, housekeeping staff remained in the room, cleaning in close proximity to the resident and the interviewer, despite the resident's expressed discomfort and request for privacy. One staff member stood at the entrance while another cleaned around the resident's bed and bedside table, and only moved to the bathroom after being asked by the resident. The resident reported feeling that staff intentionally intruded to overhear conversations and described the behavior as uncaring and lacking empathy. Staff interviews confirmed that housekeeping staff should respect residents' privacy when they have guests and that cleaning should not occur near residents during private conversations. The Director of Nursing Services acknowledged the privacy issue, stating that staff should not have been cleaning near the resident and interviewer during their discussion.
Failure to Follow Physician Orders and Bowel Protocol
Penalty
Summary
The facility failed to ensure physician-ordered laboratory values were obtained for a resident who was declining, found unresponsive, and had to be hospitalized. This resident, who was severely cognitively impaired and dependent on staff for care, was admitted with diagnoses including epilepsy and surgical aftercare following genitourinary surgery. Despite being placed on a fluid restriction and a no added salt diet, the resident did not meet their daily hydration needs for 8 out of 10 days. The facility did not obtain a urinalysis or complete blood count as ordered, and there was a lack of consistent monitoring and documentation of the resident's condition. The resident was eventually found unresponsive with abnormal vital signs and was hospitalized with a urinary tract infection and sepsis. The facility also failed to follow the bowel protocol for two residents. One resident did not have a bowel movement for 10 days, and the facility administered an enema out of order from the bowel protocol without documenting the results or any refusals of less invasive treatments. There was no alert charting or documentation regarding the lack of bowel movement or the intervention of the enema. Another resident did not receive Milk of Magnesia as ordered on the fourth day without a bowel movement, as per the bowel protocol. Interviews with staff revealed that there was no policy on vital signs, and expectations for alert charting and documentation were not met. The Director of Nursing Services acknowledged that the facility did not prevent the hospitalization by failing to obtain the necessary laboratory tests. The Resident Care Manager confirmed that the bowel protocol was not followed, and there was a lack of documentation and alert charting for the residents involved.
Failure to Provide Adequate Nutritional Care
Penalty
Summary
The facility failed to ensure proper nutritional care for three residents, leading to significant weight loss and potential harm. Resident 14 experienced a severe weight loss of 14.89% over six months, with the facility failing to provide nutritional supplements as ordered, accurately record meal intake, and obtain weekly weights despite clear indicators of nutritional decline. Observations showed that Resident 14 was not provided with whole milk as part of their Nutritionally Enhanced Meals (NEM) diet, and staff were unaware of the NEM requirements. The resident's significant weight loss was not effectively addressed, and interventions were not reassessed for effectiveness. Resident 49 experienced an 11.09% weight loss in 34 days, which went unidentified by the facility staff. The resident's nutritional supplement, Ensure Plus, was not transcribed or implemented, and the resident was not reviewed in the facility's weekly nutrition meeting due to the absence of the Registered Dietician. Observations revealed that the resident was not provided with the NEM diet, and staff did not recognize the significance of the weight loss or implement necessary interventions. The resident's lack of appetite was not adequately addressed, and there was no follow-up on nutritional recommendations. Resident 29 experienced a 10.48% weight loss over six months, with the facility failing to provide the prescribed NEM diet and calorie-dense supplements. Observations showed that the resident was not offered alternative meals or supplements when eating less than 50% of their meal, contrary to the care plan. The resident's weight loss was not identified or addressed by the facility, and there was a lack of communication with the resident's Power of Attorney regarding the weight loss and dietary needs. Staff were unaware of the NEM diet requirements, and the facility did not document or implement the necessary interventions to address the resident's nutritional needs.
Failure to Maintain Oxygen Equipment and Adhere to Orders
Penalty
Summary
The facility failed to provide appropriate respiratory care for three residents by not adhering to physicians' orders and neglecting the maintenance of oxygen equipment. Resident 51 was observed receiving oxygen at incorrect flow rates and using an oxygen concentrator with a filter covered in debris and an empty humidifier bottle. The staff did not have orders or directions to check or replace the humidifier bottle or clean the concentrator filter, and the Resident Care Manager was unaware of who was responsible for these tasks. Similarly, Resident 32 was found with an empty humidifier bottle and a heavily matted filter on their oxygen concentrator. Staff members were unaware of the need to clean the filter, indicating a lack of clarity regarding responsibilities. Resident 38 also had an empty humidifier bottle, and there were no orders to check or replace it. The Director of Nursing later stated that staff should clean the concentrator filters weekly, but this was not being done, leading to potential risks for the residents involved.
Failure to Inform Residents of Arbitration Agreement Rights
Penalty
Summary
The facility failed to ensure that residents or their representatives were adequately informed about the binding arbitration agreements they were signing. This deficiency was identified for three residents who were reviewed for binding arbitration agreements. Resident 32 was unaware that signing the agreement meant giving up the right to litigation in court and believed signing was mandatory for admission. Resident 51 did not remember signing the agreement and was not informed about the option to terminate or withdraw from it within 30 days. Resident 54's Power of Attorney (POA) was not aware of the implications of the agreement, including its applicability to future admissions and the right to rescind within 30 days. Staff interviews revealed that the facility's process for reviewing arbitration agreements was inadequate. Staff V, responsible for admissions, indicated that arbitration agreements were reviewed within 72 hours of admission, but there was no specific process to ensure residents or their representatives understood the agreements. The facility relied on the assumption that if someone was designated as a POA, they were capable of understanding the agreement. Additionally, during readmissions, the facility did not re-review the arbitration agreements, assuming prior consent was still valid. The facility administrator expected residents or their representatives to be fully aware of the optional nature of the agreements and the 30-day rescission period, but this expectation was not met in practice.
Infection Control Deficiencies in LTC Facility
Penalty
Summary
The facility failed to operationalize an effective Infection Prevention and Control Program (IPCP) as evidenced by multiple instances of non-compliance with standard precautions, enhanced barrier precautions, and transmission-based precautions. For Resident 13, who was severely cognitively impaired and dependent on staff for care, staff members were observed not changing gloves or performing hand hygiene during catheter and wound care. Staff entered the resident's room without wearing gowns, and contaminated items were handled improperly, increasing the risk of infection. Resident 14 was on contact precautions, yet a staff member entered the room without wearing personal protective equipment (PPE) and handled the resident's food and water pitcher. Although another staff member noticed the breach and instructed the first staff member to wash hands and don PPE, the initial failure to follow protocol was a significant lapse in infection control practices. For Resident 12, who was cognitively intact and receiving insulin injections, a registered nurse administered the injection without wearing gloves, contrary to facility expectations. The nurse believed that regular handwashing negated the need for gloves, indicating a misunderstanding of infection control protocols. The Director of Nursing Services confirmed that wearing gloves for insulin administration is expected, highlighting a gap in staff training and adherence to infection control measures.
Delayed Transfer of Resident Trust Funds
Penalty
Summary
The facility failed to ensure the timely transfer of funds from resident trust accounts within 30 days following discharge for two residents. Resident 165 was discharged with a remaining account balance of $40.00, and Resident 166 passed away with a balance of $189.51. Both accounts were not closed within the required 30-day period. Staff Q, the Business Office Manager, confirmed the closure dates of the accounts, and Staff A, the Administrator, acknowledged the delay in issuing checks within the expected timeframe.
Failure to Report Allegation of Abuse for a Resident
Penalty
Summary
The facility failed to report an allegation of abuse, neglect, or mistreatment involving Resident 18, who was cognitively intact and had diagnoses including bipolar disorder, borderline personality disorder, major depressive disorder, and unspecified dementia. The incident occurred after Resident 18 experienced a fall approximately 7-8 weeks prior to the report, during which a nurse allegedly told the resident to get up despite their recent surgery and used the bed remote to make them sit up straight. Resident 18 did not report the incident at the time due to fear of getting into trouble. The Director of Nursing Services (DNS) was informed of the allegation on March 11, 2025, and acknowledged that the incident should have been reported and investigated at the time it occurred. A nursing progress note from July 20, 2024, documented an interaction where Resident 18 felt attacked during education on repositioning in bed, which may have been related to the incident. However, the facility's Accident and Incident log for July 2024 showed no entry regarding this incident. The Administrator confirmed that the expectation was for such incidents to be reported immediately for investigation.
Inaccurate MDS Assessments for Residents
Penalty
Summary
The facility failed to accurately assess the Minimum Data Sets (MDS) for four residents, leading to discrepancies in their care plans and assessments. Resident 29 was documented as not using a wander/elopement alarm on their MDS, despite having a Wander Guard attached to their wheelchair as per the care plan and physician's order. Staff acknowledged the error in the MDS. Similarly, Resident 49's Admission MDS did not reflect the use of a wander guard, although it was documented in the electronic health record and confirmed by staff. Resident 13's Significant Change MDS failed to document refusals of care, despite progress notes and medication administration records indicating multiple refusals during the assessment period. Staff admitted there was no reason for the omissions. Resident 14's MDS assessments did not correctly identify significant weight loss, with staff using incorrect dates for weight comparisons. The errors were acknowledged by staff, who confirmed that the weight loss should have been coded on the MDS.
Inaccurate PASRR Documentation for Residents
Penalty
Summary
The facility failed to ensure the Level I Preadmission Screening and Resident Reviews (PASRR) were complete and accurate for three residents. Resident 53 was admitted with diagnoses including Major Depressive Disorder (MDD), Unspecified Psychosis, and Post Traumatic Stress Disorder (PTSD). However, the PASRR Level I only documented PTSD, omitting the other diagnoses. Staff D and Staff B acknowledged the omissions and confirmed that the PASRR was incorrect and should have been corrected. Resident 49's PASRR Level I documented a diagnosis of major depressive disorder but failed to include a diagnosis of psychotic disorder, despite the resident being treated with antipsychotic medication. Staff F acknowledged the inaccuracy and the need for a Level II evaluation referral. Resident 13's PASRR inaccurately included an anxiety disorder diagnosis, which was not present in the resident's health record. Staff D and Staff F confirmed the error, acknowledging that the anxiety disorder should not have been checked.
Care Plan Deficiencies in LTC Facility
Penalty
Summary
The facility failed to ensure that care plans were reviewed, revised, and accurately reflected the care needs of five residents. Resident 51, who was cognitively intact and had diagnoses of schizophrenia and neurogenic bladder, had an indwelling catheter care plan that did not address the neurogenic bladder diagnosis. Additionally, the anxiety behavior monitoring care plan for Resident 51 lacked specificity regarding the resident's delusions and the appropriate staff response. Staff acknowledged that these care plans should have been more detailed and resident-specific. Resident 41, who required moderate assistance with oral care due to a right upper extremity deformity, reported being unable to brush their teeth without assistance. The care plan directed staff to set up oral care supplies and cue the resident, but it did not reflect the resident's increased need for physical assistance. Staff confirmed that the care plan needed updating to accurately reflect the resident's needs. Resident 49 had a care plan indicating a wander guard on the left wrist, but it was actually attached to the right ankle. Additionally, the care plan did not document the resident's need for nutritionally enhanced meals, despite a recommendation and order for such meals. Resident 38's care plan inaccurately documented their shower schedule, and Resident 14's nutrition care plan contained outdated interventions and lacked specific interventions for significant weight loss and food refusal. Staff interviews revealed that the care plans for these residents were not updated to reflect current needs and interventions. The deficiencies in care planning placed residents at risk for unmet care needs and diminished quality of life.
Failure to Provide Scheduled Bathing Assistance
Penalty
Summary
The facility failed to provide adequate assistance with bathing for five residents, leading to a deficiency in care. Resident 163, who was moderately cognitively impaired, had not received a shower for nine days despite requesting one and having a care plan that specified showers twice a week. The facility's records did not document any showers for this resident, and staff confirmed the lack of documentation and adherence to the care plan. Similarly, Resident 51, who was cognitively intact and required substantial assistance, reported not receiving scheduled baths, with records showing inconsistencies in the bathing schedule. Resident 41, who was cognitively intact, also experienced missed scheduled showers, with records indicating that bathing was offered on only five out of nine scheduled days. Resident 38, scheduled for showers twice a week, was only offered bathing on two out of nine scheduled days, with no refusals documented. Lastly, Resident 14, who was severely cognitively impaired and dependent on staff for personal hygiene, had not received a shower since February 24, 2025, despite being scheduled for showers twice a week. Staff confirmed the lack of adherence to the bathing schedule for these residents, indicating a systemic issue in providing necessary care.
Inadequate Documentation and Communication for Dialysis Care
Penalty
Summary
The facility failed to consistently document pre and post dialysis assessments and medications for a resident with end stage renal disease who required dialysis. The resident, who was moderately cognitively impaired, had specific orders for dialysis on Mondays, Wednesdays, and Fridays, including the administration of midodrine and Ceftazidime at the dialysis center. However, there was a lack of documentation for pre-dialysis evaluations on certain dates, and it was unclear whether the resident received the prescribed medications during dialysis sessions. The facility's contract with the dialysis center was outdated, and there was a lack of consistent communication and follow-up with the dialysis center regarding the resident's care. Staff members acknowledged the absence of necessary documentation and communication, which led to uncertainty about the resident's medication administration and care during dialysis. This deficiency placed the resident at risk for unmet care needs and potential medical complications.
High Medication Error Rate and Omitted Medication Administration
Penalty
Summary
The facility failed to maintain a medication error rate of less than five percent, resulting in a 46.88% error rate during medication administration. This was observed in 15 out of 32 medication administration opportunities, affecting three residents. For Resident 6, medications such as Polyethylene Glycol, Duloxetine, Meloxicam, Doxycycline, and Loratadine were administered more than 60 minutes past their scheduled times. Similarly, Resident 12 received medications like Famotidine, Metoprolol, Vitamin D3, Eliquis, Gabapentin, Glipizide, Novolin N, Potassium Chloride, and Torsemide later than the allowed time frame. Staff R, an RN, was observed administering these medications late, and the Director of Nursing Services confirmed that this did not meet the facility's expectations. Additionally, Resident 57 did not receive the prescribed Breo Ellipta Inhalation Aerosol Powder for three consecutive days due to the medication being unavailable. Staff S, an LPN, was unable to locate the medication during a medication pass, and the Resident Care Manager acknowledged the omission without documentation of pharmacy contact or provider notification. These failures placed residents at risk for ineffective treatment and potential adverse outcomes.
Medication Security Lapses in Facility
Penalty
Summary
The facility failed to ensure medications were secured in a locked storage area and inaccessible to unauthorized staff and residents. During an observation of the Team 3 medication cart, a bottle of MiraLAX and a white pill in an unlabeled medication cup were found unattended on the cart. Staff R, an RN, admitted to leaving the MiraLAX out while using it and acknowledged that the pill should have been stored and labeled properly. On a separate occasion, a pill was observed on the cart in an unlabeled cup, which Staff S, an LPN, later disposed of in a sharps container. Additionally, an insulin pen was left unattended on the cart. Both the Resident Care Manager and the Director of Nursing Services confirmed that these practices did not meet the facility's expectations for medication storage. Furthermore, during a medication administration, Staff R placed an insulin pen on a resident's bedside table and left the room, leaving the medication unattended. Staff C, another Resident Care Manager, confirmed that medications should not be left at the bedside. These actions placed residents at risk for unauthorized access to medications, which could lead to medical complications and a diminished quality of life.
Incomplete and Inaccurate Medical Records for Residents
Penalty
Summary
The facility failed to maintain complete, accurate, and accessible medical records for three residents, which placed them at risk for medical complications and unmet care needs. For Resident 60, who was moderately cognitively impaired and dependent on staff for all activities of daily living, there was no documentation in the electronic health record regarding the events leading up to his death or the notification of his family and provider. Staff members acknowledged the absence of necessary documentation, which was expected to be present. Resident 35, who was severely cognitively impaired, was taken to the hospital, but there was no progress note documenting his return to the facility. Staff confirmed the lack of documentation and stated that it was expected for nursing staff to document when a resident returned from the hospital, including any new diagnoses and orders. For Resident 13, who was severely cognitively impaired and dependent on staff, there was a lack of consistent skin assessments to monitor a documented pressure ulcer. The staging of the pressure ulcer was incorrectly done by an LPN, and there was a lack of clarification with an RN, leading to inaccurate documentation.
Failure to Perform Complete CPR Due to Expired Certifications and Missing Equipment
Penalty
Summary
The facility failed to ensure that staff performed complete Cardio-Pulmonary Resuscitation (CPR) for a resident who was found unresponsive and had a physician's order for CPR. The deficiency was identified when a resident, who had a POLST form indicating full resuscitation, was found not breathing. Staff initiated chest compressions but failed to provide respirations due to missing equipment on the emergency cart, specifically the ambu bag. This failure to perform complete CPR placed residents at risk for serious injury, harm, impairment, or death and was determined to be an Immediate Jeopardy situation. The resident involved was admitted with diagnoses including a fracture of the left femur, Chronic Obstructive Pulmonary Disease, and Hypertension. The resident was alert and oriented and required staff assistance for activities of daily living. On the day of the incident, the resident was found unresponsive by a CNA who then called for help. Licensed staff responded and initiated chest compressions but did not administer breaths due to the absence of necessary equipment. Paramedics arrived and took over CPR, but the resident was pronounced dead shortly after. The investigation revealed that the CPR certifications for the staff involved had expired, and the facility had not ensured that all required staff maintained current certifications. Interviews with staff confirmed the lack of respirations during CPR and the absence of the ambu bag on the crash cart. The facility's administration acknowledged the deficiency and the risk it posed to residents who required CPR.
Failure to Ensure Timely Physician Visits
Penalty
Summary
The facility failed to ensure timely physician visits within the first 30 days after admission for two residents, which is a requirement according to the facility's policy. Resident 11, who had diagnoses including Diabetes Mellitus, Chronic Kidney Disease (Stage 4), and Acquired Absence of the left lower leg, was readmitted to the facility but did not receive a physician's visit for 112 days after readmission. Resident 14, diagnosed with Chronic Systolic Heart Failure, was also readmitted to the facility and did not receive a physician's visit for 50 days after readmission. The deficiency was acknowledged by the facility's Administrator and Director of Nursing, who stated that the facility physician had been on leave and they were unable to secure physician coverage during that time. As a result, residents were seen by Nurse Practitioners or Physician's Assistants instead of a physician, leading to the failure to meet the required physician visit schedule for Residents 11 and 14.
Failure to Update Care Plan After Resident Fall
Penalty
Summary
The facility failed to update the care plan and implement new interventions after a resident experienced a fall. The resident, who was admitted with diagnoses including dementia, psychosis, and a fractured right femur, was identified as being at high risk for falls. Despite this, after an unwitnessed fall resulting in a right femoral neck fracture, the care plan was not revised with interventions to prevent further falls. The facility's falls policy required post-fall actions to include reviewing and updating the care plan with newly identified interventions, which was not done in this case. Staff acknowledged the oversight in not updating the care plan.
Failure to Timely Report Abuse Allegation
Penalty
Summary
The facility failed to ensure an abuse allegation was reported timely for a resident with dementia and depression. The incident involved a CNA, Staff C, who allegedly grabbed the resident by the shirt, pulled him forward, and slapped him on the left upper arm. The incident was witnessed by two other CNAs, Staff D and Staff E, who did not report the incident until the following day. This delay in reporting prevented immediate investigation and intervention. The resident was admitted with cognitive impairment and did not exhibit behaviors or have extremity impairments according to the Quarterly Minimum Data Set. Despite the serious nature of the allegation, the facility's investigation and staff interviews were not conducted until the day after the incident. Staff C continued to work in the facility until the incident was reported to administration. The Director of Nursing confirmed that the expectation was for all staff to report abuse allegations immediately, which did not occur in this case.
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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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