Shuksan Rehabilitation And Health Care
Inspection history, citations, penalties and survey trends for this long-term care facility in Bellingham, Washington.
- Location
- 1530 James Street, Bellingham, Washington 98225
- CMS Provider Number
- 505098
- Inspections on file
- 35
- Latest survey
- March 18, 2026
- Citations (last 12 mo.)
- 6
Citation history
Health deficiencies cited at Shuksan Rehabilitation And Health Care during CMS and state inspections, most recent first.
Surveyors found that the facility’s use of a broad flex-time medication pass system led to multiple residents receiving APAP, levetiracetam, carvedilol, carbidopa-levodopa, and fosfomycin at times that did not comply with prescriber orders, manufacturer guidelines, or the facility’s own one-hour-before/after policy. One resident’s seizure and pain medications were repeatedly given late or at inconsistent intervals; another resident’s Parkinson’s medication was not coordinated with meals as ordered and APAP doses were given too close together; and a third resident’s APAP and carvedilol were scheduled and administered without regard to ordered meal timing, with some APAP doses only minutes apart and an antibiotic order left unclear between “evening” and “with breakfast.” Staff interviews showed reliance on wide flex-time windows, lack of clear documentation of exact administration times on the MAR, and inconsistent understanding of how to space BID and TID medications, contributing to the cited deficiency for pharmaceutical services.
Surveyors identified that the facility lacked an effective medication administration system, resulting in missed doses, poor adherence to provider orders, and failure to follow the facility’s stated ten rights of medication administration. One resident on prophylactic Fosfomycin Tromethamine for UTI prevention had a 20‑day gap between documented doses, with no evidence the scheduled intermediate dose was given. During observed med passes, an LPN did not check medication expiration dates, did not knock before entering rooms, failed to verify resident identity, misidentified or failed to identify medications when questioned by residents, and only told residents, “this is your medication.” Multiple nurses could not accurately state the ten rights of medication administration. MAR reviews for several residents showed no documentation that scheduled evening or HS medications, including psychotropics, cardiovascular agents, pain medications, bladder medications, glaucoma drops, antivirals, and blood sugar monitoring, were administered, while the DON who worked that shift believed the medications had been given.
Surveyors found that a treatment cart on one unit was left unlocked while an LPN was away at another medication cart, with open Derma Fungal cream, an odor eliminator, and other treatments easily accessible in its drawers despite facility policy requiring carts to remain locked. On another unit, an open tube of Refresh eye drops was left in a medication cup on top of a medication cart while an RN was several feet away at a different cart, after a resident had refused the drops. The Administrator and DON later acknowledged that carts should not be left unlocked and medications should not be left unattended on top of carts.
Staff failed to consistently follow infection control practices, including hand hygiene, PPE use, and cleaning of resident care equipment. An LPN prepared and administered medications to a resident without performing hand hygiene before or after handling medication cups, then documented and moved on to another resident still without hand hygiene. For a resident on precautions, the same LPN checked blood glucose, left the room wearing PPE, handled a glucometer and medication cart in the hallway, removed PPE there, and continued care activities without performing hand hygiene or disinfecting the glucometer or vital sign cart. The glucometer was returned to its storage bag and cart drawer without cleaning, despite manufacturer instructions and facility handouts requiring cleaning and hand hygiene as part of standard infection prevention procedures.
The facility did not conduct comprehensive investigations into allegations of abuse and neglect involving two residents—one who reported delayed pain medication and verbal mistreatment by a nurse, and another who experienced a prolonged wait for incontinence care due to caregiver availability. Key investigative steps, such as interviewing involved staff and reviewing medical records, were omitted, and the needs of other residents with similar care preferences were not assessed.
The facility did not include agency staff hours in its PBJ submission, resulting in a significant underreporting of total staffing hours and failure to meet the required HPRD for the quarter. This led to inaccurate staffing data being reported to CMS.
Facility administration did not ensure timely payment to vendors, leading to the discontinuation of laboratory services and missed critical lab tests for several residents, including drug level monitoring and metabolic testing. Staff confirmed that unpaid bills caused the service disruption, and there was no alternative lab available for the required tests. The facility also experienced delayed payroll, affecting staff benefits and care continuity.
Multiple residents did not receive timely or complete laboratory testing as ordered, including missed urinalysis, Hemoglobin A1C, Depakote levels, CBC, and CMP tests. These failures were linked to a disruption in lab services caused by vendor non-payment, with staff interviews confirming missed draws and lack of follow-up or documentation.
A resident admitted with multiple pressure ulcers and at moderate risk for further skin breakdown did not receive a pressure offloading mattress in a timely manner. The care plan initially lacked pressure ulcer prevention interventions, and a low air loss mattress was not provided until about a month after the need was identified. This delay led to the development of a preventable stage 3 pressure ulcer on the coccyx, requiring advanced wound care and impacting the resident's rehabilitation.
The Governing Body did not ensure timely payment of vendor invoices, leading to discontinued lab services, missed essential lab tests for several residents, and threats of utility disconnection. Staff reported missed payroll and loss of benefits, while administration confirmed ongoing financial difficulties and delayed payments to vendors.
The facility did not conduct complete investigations into incidents involving falls, potential abuse or neglect, and medication errors. In several cases, investigations lacked necessary witness statements, omitted key details about the events, and failed to determine root causes or whether care plans were followed. For example, a resident with dementia was found with a head injury, but the investigation was missing staff statements and details about care provided prior to the fall. Another resident experienced multiple falls without thorough review of environmental factors or staff actions. Additionally, a medication error involving duplicate orders was not fully investigated, with missing verification from the pharmacy and no assessment of system failures.
The facility did not ensure timely and accurate completion of PASRR assessments for several residents with mental health diagnoses, including missing preadmission screenings, failure to update assessments when residents' conditions changed, and incomplete documentation of relevant psychiatric conditions. Staff responsible for PASRRs expressed uncertainty about the process, and required Level II evaluations were not initiated when indicated.
Nine CNAs worked with expired OBRA verifications, and the facility did not have a process to ensure active OBRA status prior to employment or scheduling. The Business Office Manager and Administrator confirmed that staff with expired verifications had been working and that OBRA documentation was not obtained for agency staff.
Surveyors found that the facility did not ensure complete and accurate medical records for several residents, with multiple omissions in MARs and TARs, including missing documentation of medication administration, monitoring, and assessments. In one case, a resident's record retained an incorrect mental health diagnosis despite a PASRR evaluator's correction, and staff were unaware of the error or lacked documentation audits.
A resident with cognitive impairment who required supervision for toileting was found on the floor with a significant head laceration after being left unsupervised, in violation of their care plan. The incident, which involved substantial injury and was not witnessed, was not reported to the state hotline as required by facility policy and state guidelines. Staff interviews confirmed the expectation to report such injuries, but the event was not documented as reported.
Two residents receiving psychotropic medications did not have their care plans revised to include current symptoms, resident goals, or non-pharmacological interventions. The care plans only addressed medication administration and monitoring for adverse effects, omitting key individualized information required for effective care planning.
Nursing staff administered cardiac medications to several residents despite physician orders to hold these medications for low blood pressure or heart rate. Medication administration records showed repeated instances where Amlodipine and Metoprolol were given when vital signs were below the specified parameters. Staff interviews confirmed awareness of the hold parameters, but the medications were still administered inappropriately.
A resident with severe cognitive impairment and a history of UTIs did not consistently receive adequate fluids, with daily intake falling short of the estimated requirement. Fluids were often not available or out of reach, and staff did not consistently assist or document hydration, despite the resident's need for extensive help and observed signs of dehydration.
A resident with mild cognitive impairment repeatedly reported significant pain, especially in the gluteal area, during daily care and repositioning. Staff did not consistently assess pain before or after administering scheduled pain medication, and pain assessments were only performed weekly. The provider was not notified of increased pain, and physical findings included red areas and an open wound. Staff interviews confirmed that pain complaints were not always followed by proper assessment or provider notification.
Annual staff performance reviews were not completed or properly documented for a nursing assistant certified, with missing signatures, dates, and incomplete evaluation forms. Only one page of a two-page evaluation was available, and no additional documentation was provided.
A resident with osteoporosis received duplicate weekly doses of Alendronate due to two active orders for the same medication on different days. Both doses were documented as administered over several weeks, and staff were unaware of the duplication until it was identified during review. The facility's medication error investigation did not fully clarify whether the pharmacy supplied extra medication or resolve inconsistencies in staff accounts.
A resident with osteoporosis received duplicate doses of Alendronate due to a duplicate order, and the error was not identified by the facility's medication management system or during monthly pharmacist reviews. Additionally, the resident's ongoing use of Enoxaparin lacked a documented stop date or treatment clarification, and these issues were not addressed in pharmacy reviews.
A NAC did not receive all required training in dementia care, abuse/neglect, communication, QAPI, and annual education. Review of training records showed only partial completion, and staff interviews revealed a lack of tracking for agency NAC training and unclear responsibilities for monitoring education requirements. This issue was previously cited.
A staff member worked as a NAC without an active certification after their credential expired. Employment and timecard records confirmed the individual continued to provide care while uncertified, and the lapse was not identified due to a missed follow-up in the facility's license audit process. Leadership confirmed that all NACs are expected to maintain current certification.
A resident with Alzheimer's disease eloped from the facility due to inadequate supervision and failure to follow the facility's wandering risk policy. The resident's assessments initially showed no elopement risk, and their care plan was resolved without proper documentation. Staff interviews revealed a lack of awareness and communication regarding the resident's risk status and procedures, contributing to the incident.
The facility failed to maintain a safe, sanitary, and homelike environment, with issues such as loose wallboard, broken ceiling tiles, and overgrown outdoor spaces. Additionally, hot water availability problems prevented residents from receiving showers, with water temperatures recorded as low as 61.9°F.
The facility failed to provide adequate supervision and update the care plan for a resident identified as a high fall risk, resulting in 11 falls and multiple injuries. Despite the resident's medical conditions and history of falls, the facility did not implement new interventions after each fall, leading to recurrent incidents and injuries.
The facility failed to complete required annual performance evaluations for three CNAs who had been employed for more than one year. This deficiency was confirmed during an interview with the Administrator, who acknowledged that the evaluations were not conducted, placing residents at risk for diminished quality of care.
The facility failed to maintain sanitary conditions in the kitchen, including issues with hot water supply, improper cooling of foods, and lapses in hand hygiene practices. These deficiencies placed residents at risk for foodborne illnesses.
The facility failed to ensure that three CNAs had the required 12 hours per year of in-service education and annual dementia training. The administrator acknowledged challenges in retrieving older training records and admitted that dementia training had not been conducted for a while, with no tracking of the required education hours.
The facility failed to honor a resident's choice regarding bathing frequency, resulting in the resident being bathed less often than desired. Documentation and staff interviews revealed a lack of follow-up when the resident refused a bath, and the resident reported missing a shower due to no hot water.
The facility failed to follow the PASRR process for two residents, resulting in incomplete documentation and unimplemented recommendations for their care. One resident's Level II PASRR report was not incorporated into their medical record, while another resident's Level II PASRR evaluation was not completed due to an administrative error.
The facility failed to fully develop baseline care plans and provide written summaries for three residents, leading to incomplete documentation on critical health information and potential unmet care needs. The residents had various diagnoses, including fractures, Alzheimer's, diabetes, hypertension, bipolar disorder, and schizoaffective disorder, but their care plans lacked essential details.
The facility failed to develop and implement a comprehensive care plan for a resident who required daily weights. Despite an order for daily weights, only one weight was documented from admission to over a month later. An LPN admitted to not always receiving or reviewing discharge summaries and did not notify the physician of the resident's refusals to be weighed. This issue was a repeat citation from previous surveys.
The facility failed to ensure the cleanliness of respiratory care tubing for three residents, leading to the use of potentially soiled equipment. Staff interviews confirmed the absence of specific orders and documentation for changing or cleaning the equipment, and the tubing was not dated.
The facility failed to ensure a resident was free from unnecessary psychotropic medications by not obtaining consent for an antianxiety medication and not conducting gradual dose reductions for antipsychotic and antidepressant medications. Despite staff indicating processes for audits and consents, the facility did not follow through, resulting in a repeat citation.
The facility failed to store medications in a safe place for a resident who had Lantus and Humalog insulin pens stored in their room. The insulins were observed on the resident's windowsill, and the DON was unable to explain why they were stored there. This placed residents at risk for compromised or ineffective medications and unintended access to drugs.
The facility failed to ensure complete and accurate clinical records for a resident with skin conditions. The resident, who was on a blood thinner medication, had bruising that was not documented in weekly skin assessments or monitored correctly in the Treatment Administration Record. Staff interviews confirmed the documentation lapses.
The facility failed to use adequate infection control practices during wound and incontinent care for a resident. Staff did not change gloves or perform necessary hand hygiene, leading to contamination of the resident's bedding, clothing, and light pull cord. This incident is a repeat citation from previous surveys.
Failure to Administer Medications per Orders and Standards Under Flex-Time System
Penalty
Summary
The deficiency involves the facility’s failure to consistently provide pharmaceutical services that ensured medications were acquired, scheduled, and administered in accordance with prescriber orders, manufacturer guidelines, and the facility’s own policies. The facility’s “Medication and Flexible Pass Time” policy allowed broad administration windows (AM 6:00–11:00, noon 11:00–2:00, evening 2:00–7:00, HS 7:00–10:00) and defined routine medications as time-specific orders that could be given one hour before or after the scheduled time. Surveyors found that, in practice, medications were not administered within these parameters and were not consistently spaced according to general medication guidelines. Staff interviews showed that nurses relied on the flex-time windows and did not always know or document the exact administration times on the MAR, requiring separate reports to determine when doses were actually given. For one resident receiving acetaminophen (APAP) 1000 mg three times daily for pain and levetiracetam 1000 mg twice daily for seizures, the MAR showed APAP scheduled at AM flex pass, 11:00, and 8:00 p.m., and levetiracetam at AM flex pass and 4:00 p.m. The Medication Administration Audit Report (MAAR) documented multiple late or irregular doses. On several dates, the 11:00 APAP dose was given significantly late (e.g., at 1:41 p.m. and 1:34 p.m.), outside the one-hour window after the scheduled time. Levetiracetam doses were also given late or too close together, including a 4:00 p.m. dose administered at 8:46 p.m. and another day when the two daily doses were only five hours and 24 minutes apart, deviating from consistent interval guidelines. For a second resident receiving APAP three times daily and multiple daily doses of carbidopa-levodopa for Parkinson’s disease, the MAAR showed that carbidopa-levodopa was not administered in accordance with orders specifying dosing one hour before breakfast and one hour before or after meals. Morning doses ordered one hour before breakfast were given around 5:00 a.m., while breakfast was served between 7:50 and 8:00 a.m. Midday doses ordered one hour before or after lunch were administered approximately one hour before the scheduled lunch time, and an afternoon dose scheduled at 3:30 p.m. was set two hours before dinner, contrary to the order to give one hour before or after the meal. Evening doses ordered one hour before or after a meal were given at various times not clearly aligned with meal times. This resident’s APAP doses were also administered with very short intervals between the morning and 11:00 doses, sometimes less than three hours apart. For a third resident receiving APAP 1000 mg three times daily and carvedilol 6.25 mg twice daily ordered after meals, the MAR scheduled APAP at AM flex pass, 11:00, and 8:00 p.m., and carvedilol at AM flex pass and 4:00 p.m., without aligning carvedilol with meals as ordered. The MAAR showed instances where APAP doses were given late or too close together, including one day when the AM dose was given at 11:32 and the 11:00 dose at 11:59, resulting in 2000 mg of APAP administered 27 minutes apart. Carvedilol doses were also given late relative to the scheduled times. Additionally, this resident had an order for fosfomycin tromethamine “every 10 days in the evening…give with breakfast,” but the MAR scheduled it at 4:00 p.m., and there was no documentation in the EMR clarifying whether it should be given in the evening or with breakfast. During interview, the DON acknowledged the order was written in a confusing manner and would need clarification, and also recognized that the MAR did not show exact administration times, which could only be determined by running a separate report. Staff interviews further demonstrated inconsistent understanding and application of flex-time and dosing intervals. LPNs and an RN stated that AM flex time allowed administration between 6:00 and 11:00 a.m. and that for twice-daily or three-times-daily medications they would “spread out” doses as best they could, but they did not reference specific intervals or manufacturer guidelines. When asked how nurses would know the exact time a flex-time dose was given before administering the next scheduled dose, the DON initially stated it was documented on the MAR, then acknowledged that the MAR did not show exact times and that a separate report was needed. The survey report states that these failures to administer drugs and biologicals per physician orders and standards of nursing practice placed residents at risk for medication errors, unmet health care needs, and decreased quality of life.
Widespread Medication Administration Errors and Omissions
Penalty
Summary
The deficiency involves the facility’s failure to maintain a functioning medication administration system that ensured medications were given according to provider orders, not omitted, and administered in accordance with the facility’s stated ten rights of medication administration. The facility’s policy on medication pass required all morning medications to be administered between 6:00 AM and 11:00 AM and referenced ten rights to medication administration, but did not define what those ten rights were. The facility’s policy on medication incidents and errors defined an omission as any dose of medication not delivered to the resident. For one resident receiving Fosfomycin Tromethamine 10 grams every 10 days for UTI prophylaxis, the MAR showed doses given on 02/10/2026 and 03/02/2026, with a code on 02/20/2026 directing staff to see the nurse’s notes. The nurse’s note documented a call to the pharmacy about the medication and that the pharmacy would send as much as insurance allowed, but there was no evidence the 02/20/2026 dose was administered, resulting in a 20‑day gap between doses. The administrator and DON were not aware of this omitted dose. During a continuous medication pass observation, an LPN prepared six morning medications for another resident, including duloxetine, Tylenol, thyroid medication, a stimulant laxative, a gout medication, and a medication for an autoimmune disease. The LPN separated the duloxetine into one cup and the remaining medications into another, did not check expiration dates, entered the resident’s room without knocking, did not verify the resident’s identity, and addressed the resident only by first name. When the resident asked what the first cup of medications contained, the LPN first stated it was duloxetine and Tylenol, then, after the resident did not understand and asked again, stated it was Tylenol; the resident then took the two pills. When handing the second cup, the LPN again told the resident it was Tylenol when asked what the medications were. In a subsequent observation with a different resident, the same LPN took an acidophilus capsule from a house‑supply bottle without checking the expiration date, admitted they did not check expiration dates because the cart was filled at the beginning of the year, and then prepared additional medications. The LPN entered the resident’s room without knocking, did not verify the resident’s name, administered medications one by one with a spoon, and each time only stated, “this is your medication,” without identifying the medication name or purpose. Interviews with multiple nursing staff showed they could not correctly state the facility’s ten rights of medication administration, each listing only five or six rights, and the DON stated they would have to follow up on what the ten rights were. Review of MARs for several residents showed no documentation that scheduled 8:00 PM or HS medications were administered on 03/15/2026. One resident had no documentation of receiving a cholesterol‑lowering medication, a pain medication, and a probiotic; another had no documentation of an anti‑anxiety medication and an overactive bladder medication; another had no documentation of a cholesterol‑lowering medication, stimulant laxative, antipsychotic, and blood pressure medication; another had no documentation of an antiviral, glaucoma eye drops, a cholesterol‑lowering medication, and a nerve pain medication; and another had no documentation of an overactive bladder medication or blood sugar monitoring. When interviewed, the administrator and DON initially stated there had been no medication errors since surveyors arrived, and the DON, who passed medications on the PM shift on 03/15/2026, believed they had administered the HS and/or 8:00 PM medications. They were informed that the sampled residents’ MARs showed omitted medications and that only a small sample of residents on that hallway had been reviewed.
Unlocked Treatment Cart and Unattended Medications on Medication Cart
Penalty
Summary
The deficiency involves failure to keep medication and treatment carts locked and medications properly stored and labeled as required by facility policy and professional standards. The facility’s policy titled “Medication and Flexible Pass Time,” dated 10/27/2023, required that medication carts be locked at all times. On the morning of 03/16/2026, surveyors observed the [NAME] Lane treatment cart unlocked on two separate occasions while the responsible nurse, an LPN identified as Staff D, was down the hallway at a different medication cart. During this time, unidentified staff were seen walking past the unlocked cart on their way to the dining room. When informed, Staff D acknowledged responsibility for the cart and confirmed it should have been locked, stating that the prior shift, which ended at 6:00 AM, must not have locked it. Upon inspection of the unlocked [NAME] Lane treatment cart with Staff D, surveyors found an open tube of Derma Fungal cream and a bottle of simple odor eliminator in the top drawer, both labeled under their warning sections to be kept out of reach of children, along with other drawers containing various treatments, ointments, and creams that could be easily removed. Additionally, on the Artist Lane medication cart, surveyors observed a small open tube of Refresh eye drops placed in a plastic medication cup on top of the cart while the assigned RN (Staff C) was approximately 10 feet away at another medication cart preparing medications. Staff B later acknowledged that the eye drops should not have been left there and that the resident had refused the drops. In separate interviews, the Administrator (Staff A) and the DON/RN (Staff B) both stated that treatment and medication carts should not be left unlocked and that medications should not be left unattended on top of the cart.
Failure to Follow Hand Hygiene, PPE, and Glucometer/Vital Sign Equipment Cleaning Protocols
Penalty
Summary
The deficiency involves the facility’s failure to follow standard infection prevention and control practices, including hand hygiene, PPE use, and cleaning of resident care equipment such as vital sign (VS) equipment and a glucometer. Facility handouts from the Infection Prevention Manual for Long Term Care, revised 02/2018, directed staff to perform hand hygiene as part of donning PPE and to remove PPE at the doorway before leaving a resident’s room, followed immediately by hand hygiene. Despite these written procedures, staff actions during medication administration and resident care did not align with these guidelines. During continuous observation, one LPN prepared medications for a resident without performing hand hygiene, placing multiple pills into small plastic medication cups and handling the cups in the palm of unclean hands before entering the resident’s room. After the resident ingested the medications, the LPN discarded the cups, exited the room, returned to the medication cart, documented medication administration, and proceeded to another resident’s room without performing hand hygiene. Later, the same LPN was observed to perform hand hygiene before entering another resident’s room, but then inconsistently applied hand hygiene practices before and after subsequent resident care tasks. For a resident on precautions requiring gown and gloves for high-contact care, the LPN performed a blood glucose check, exited the room wearing PPE, walked down the hall, discarded an item in the sharps container, placed the glucometer on top of the medication cart, removed gown and gloves in the hallway, and returned to the cart without performing hand hygiene. The LPN then re-gowned and re-gloved without hand hygiene, entered the resident’s room with the VS cart, and later exited with PPE still on, parked the VS cart by the medication cart, removed PPE at a hallway trash can, and began preparing the resident’s medications without hand hygiene or sanitizing the VS cart or its components. The glucometer, which manufacturer guidelines required to be cleaned with soap and water or 70–80% isopropyl alcohol after use, was placed on the medication cart, then returned to its storage bag and cart drawer without being cleaned. The LPN acknowledged they were supposed to clean the glucometer with an alcohol pad after use but did not do so. Additionally, the administrator noted the lack of trash cans inside rooms of residents on precautions and stated this was unusual.
Failure to Conduct Thorough Abuse and Neglect Investigations
Penalty
Summary
The facility failed to conduct thorough investigations into allegations of abuse and neglect for two residents. For one resident with multiple sclerosis and anxiety, who was cognitively intact and experienced constant pain, the facility did not fully investigate an allegation that a nurse withheld pain medication and made derogatory comments. The investigation did not include a review of the resident's medical record to confirm medication administration times, nor did it include an interview with the nurse involved or with other residents regarding their experiences with medication administration or verbal abuse. The investigation summary instead focused on the resident's history of making allegations and ruled out abuse and neglect without substantiating the facts. For another resident with demyelination of the central nervous system, anxiety, and depression, who was dependent on staff for toileting and preferred female caregivers, the facility did not thoroughly investigate an allegation of neglect after the resident waited over an hour and a half for incontinence care. The investigation acknowledged the delay but did not identify it as potential neglect, nor did it assess whether other residents with similar care preferences were at risk. The investigation also failed to interview another resident who preferred female caregivers to determine if their needs were unmet. Interviews with facility leadership revealed a lack of awareness regarding key documentation and investigative steps, such as not reviewing relevant progress notes or interviewing involved staff. The Director of Nursing confirmed that essential investigative actions were omitted, including not checking medication administration times and not interviewing other potentially affected residents. The facility's investigations did not meet the minimum requirements outlined in their own abuse prevention policy, which mandates interviews with alleged perpetrators and thorough record reviews.
Failure to Accurately Report Staffing Hours in PBJ Submission
Penalty
Summary
The facility failed to ensure accurate submission of Payroll Based Journal (PBJ) data to CMS for Fiscal Year Quarter 4, 2024. The PBJ report submitted included only hours worked by facility-employed staff and omitted hours worked by agency or contracted staff, resulting in 28,907.80 hours unaccounted for in the report. This omission led to the facility not meeting the minimum required 3.4 Hours Per Resident Day (HPRD) and being short by 920 hours. The process for PBJ reporting involved the corporate office preparing the report, sending it to the administrator for review and approval, and then submitting it, but the failure to include agency staff hours was confirmed by the Chief Operating Officer. The inaccurate data submitted to CMS affected the reported staffing levels for the entire facility.
Failure to Maintain Financial Obligations Resulting in Disruption of Essential Resident Services
Penalty
Summary
Facility administration failed to maintain effective financial management, resulting in overdue payments to multiple vendors, including laboratory services, utilities, staffing agencies, and medical supply companies. The administration was aware of the outstanding balances and received multiple demand notices and service discontinuation warnings from vendors. Despite this awareness, the facility did not ensure timely payment, leading to a disruption in essential services. On a specific date, the laboratory services provider placed the facility on a non-payment hold, which resulted in the discontinuation of laboratory services. As a direct consequence, four residents did not receive critical laboratory tests as ordered. These included Depakote levels for two residents, which are necessary to monitor therapeutic drug levels and prevent toxicity, a Comprehensive Metabolic Panel and Complete Blood Count for another resident, and a Hemoglobin A1C test for a fourth resident. Staff interviews confirmed that the missed laboratory services were due to the vendor not coming to the facility because of unpaid bills, and there was no alternative laboratory available for these tests. Additionally, staff reported that the facility had experienced a delayed payroll, resulting in a temporary loss of staff benefits and out-of-pocket expenses for medical needs. The business office manager and administrator both indicated that invoices were forwarded to the corporate office for payment, but payments were not made in a timely manner. The failure to pay vendors on time directly impacted the facility's ability to provide necessary care and services to all residents, as evidenced by the missed laboratory tests and the risk of further service interruptions.
Removal Plan
- Ensured resident lab testing had been completed.
- Ensured an active laboratory services vendor was in place.
- Provided evidence of vendor contract payments to ensure continuity of essential services.
- Audited resident laboratory orders.
- Obtained ordered laboratory testing for affected residents.
Failure to Provide Timely Laboratory Services Due to Vendor Non-Payment
Penalty
Summary
The facility failed to provide timely laboratory services for five residents, resulting in missed or delayed lab tests as ordered by physicians. For one resident, a urinalysis was ordered to rule out a urinary tract infection due to new delusions and hallucinations, but the sample was not collected, and there was no documentation of follow-up or physician notification regarding the missed test. Another resident did not have a Hemoglobin A1C test completed as ordered, with no documentation in the medical record or treatment administration record indicating the lab was drawn or any result received. Two residents receiving Depakote for mood and behavioral management did not have their Depakote levels drawn as ordered. The orders specified that the Depakote level should be drawn on the night shift, but the tests were not completed on the specified dates. In one case, the Depakote level was eventually obtained two days after the order, and the result was reported as low. Additionally, a complete metabolic panel (CMP) was ordered for one of these residents but was not documented as completed. Another resident with a history of diabetes had an order for a Hemoglobin A1C, but there was no evidence the test was performed or results obtained. A further resident with a recent toe amputation and gangrenous tissue was to have a CBC and CMP drawn for ongoing monitoring, but these labs were not collected as ordered. Instead, a basic metabolic panel (BMP) was drawn several days after the order, and there was no documentation that the correct labs were obtained. Staff interviews confirmed that the facility experienced issues with laboratory services due to vendor non-payment, resulting in missed lab draws and lack of follow-up or documentation regarding the missed tests.
Failure to Timely Provide Pressure Offloading Mattress Resulting in Stage 3 Pressure Ulcer
Penalty
Summary
A facility failed to ensure timely ordering and implementation of a pressure offloading mattress for a resident who was at moderate risk for pressure ulcer (PU) development and admitted with existing wounds. Upon admission, the resident had stage 2 PUs on the right and left buttocks and an unstageable PU on the left foot, but no skin breakdown on the coccyx. The initial care plan did not address existing pressure ulcers or include prevention interventions, and there was no documentation of a higher-level mattress being provided at admission. Despite the resident's risk factors and care needs, the care plan was not updated to include pressure ulcer prevention interventions until a week after admission, when a slit was first noted on the coccyx. The resident developed a stage 3 PU on the coccyx, which progressed to require wound vacuum treatment. Documentation showed inconsistent wound assessments and delayed implementation of a low air loss (LAL) mattress, which was not provided until approximately 30 days after the need was identified and the RCM was notified. Interviews with staff confirmed that there was no standard protocol for pressure ulcer prevention interventions upon admission, and staff were unclear about the process for ordering specialty mattresses. The delay in providing appropriate pressure relief measures contributed to the development and worsening of the resident's coccyx wound, which impacted the resident's rehabilitation and discharge potential.
Governing Body Failed to Maintain Financial Oversight, Resulting in Discontinued Lab Services and Missed Resident Care
Penalty
Summary
The facility's Governing Body failed to maintain oversight of the facility's finances, resulting in significant unpaid balances to multiple vendors, including laboratory services, utilities, staffing agencies, and medical supply companies. The Governing Body was aware of overdue payments and notices for discontinuation of services but did not ensure that these financial obligations were met. As a result, the laboratory services provider discontinued services due to non-payment, and other vendors issued urgent notices threatening to cease services or disconnect utilities. Due to the discontinuation of laboratory services, necessary lab tests for several residents were not obtained as ordered. Specifically, residents who required Depakote levels, comprehensive metabolic panels, complete blood counts, and hemoglobin A1C tests did not receive these services. Staff confirmed that the laboratory did not come to the facility as scheduled, and there was no documentation explaining the missed lab draws. Additionally, staff were not aware if providers had been notified about the missed labs, and alternative laboratory options were limited. Interviews with facility staff and administration revealed that invoices were processed and sent to the corporate office for payment, but payments were delayed or not made, leading to daily calls from vendors regarding overdue balances. Payroll was also delayed on one occasion, resulting in staff temporarily losing benefits and having to pay out of pocket for medical expenses. The facility was also behind on required Safety Net Assessment payments, which had been referred for collection, further impacting cash flow and the ability to pay vendors.
Failure to Conduct Thorough Investigations of Incidents and Medication Errors
Penalty
Summary
The facility failed to conduct thorough investigations into incidents involving accidents, potential abuse, neglect, and medication errors for several residents. In multiple cases, investigations lacked comprehensive documentation, including missing or incomplete witness statements, insufficient details about the circumstances of the incidents, and failure to determine the root cause or contributing factors. For example, after a resident with Alzheimer's dementia was found on the floor with a head injury, the investigation did not include statements from the assigned nursing assistant, lacked information on the resident's care prior to the fall, and omitted a summary of the incident's cause or necessary corrective actions. Additionally, post-fall monitoring was incomplete, and the incident was reported late to the state. Another resident with multiple sclerosis and severe cognitive impairment experienced multiple falls, yet investigations did not include statements from all relevant staff, failed to assess environmental or equipment factors, and did not address whether care plan interventions were implemented. In one case, a resident was found on the floor after their wheelchair rolled back during a haircut, but the investigation did not review the wheelchair's condition or the environment. In another, a resident with significant cognitive impairment was found on the floor in the dining room, but the investigation did not address positioning or follow-up care. The facility also failed to thoroughly investigate a medication error involving duplicate orders for Alendronate, resulting in the resident potentially receiving double doses. The investigation did not verify the number of tablets dispensed by the pharmacy, nor did it determine how the duplicate order was entered without system or pharmacy alerts. Across all incidents, there was a consistent lack of comprehensive review, failure to identify involved staff, and absence of summaries detailing the who, what, where, when, and how of each event, as well as missing documentation of whether care plans were followed.
Failure to Complete and Update PASRR Assessments as Required
Penalty
Summary
The facility failed to ensure that Pre-Admission Screening and Resident Review (PASRR) assessments were accurately completed prior to or upon admission, or updated when residents' conditions changed, for four out of five residents reviewed. Specifically, two residents were admitted without a Level I PASRR completed preadmission, with the assessments being performed only after admission. Another resident's PASRR did not accurately reflect all relevant diagnoses, such as psychotic or delusional disorders, and was not revised upon admission. Additionally, a resident who began experiencing hallucinations and delusions did not have their PASRR updated to reflect these significant changes in condition. Record reviews and staff interviews revealed that the social worker responsible for PASRR completion and accuracy was uncertain about the process and acknowledged errors in the documentation. One resident's PASRR indicated depression but did not trigger a required Level II evaluation, contrary to PASRR instructions. The administrator confirmed awareness of the requirement for preadmission Level I PASRRs but was unsure why they were not completed as required. These deficiencies were identified through observation, interview, and record review, and were in violation of the facility's own policy and state regulations.
Failure to Verify Active OBRA Status for CNAs
Penalty
Summary
The facility failed to ensure that nine Certified Nursing Assistants (CNAs) had active Omnibus Budget Reconciliation Act (OBRA) verifications at the time of their employment and while working in the facility. Employment records showed that one CNA was hired and worked with an expired OBRA verification, and a review of all facility staff revealed a total of nine staff members with expired OBRA verifications. The Business Office Manager acknowledged awareness of the expired OBRA status for at least one CNA and provided documentation showing the expiration. The manager also stated that OBRA verifications were only being updated as they expired and that there was no plan in place to update expired verifications prior to employment. Additionally, the facility did not have OBRA documentation for any agency staff. Interviews with facility staff confirmed that the identified CNAs with expired OBRA verifications had been scheduled and working in the facility. The Business Office Manager expressed uncertainty about how to address the expired verifications and indicated that staff would need to be removed from the schedule until their OBRA status could be verified as active. The Administrator confirmed that there had been a period when OBRA verifications were not processed in a timely manner, resulting in staff being taken off the schedule. The Administrator also stated that agency staff should have OBRA verifications and that CNAs without current OBRA documentation should not work until the issue is resolved.
Incomplete and Inaccurate Medical Record Documentation
Penalty
Summary
The facility failed to maintain complete, accurate, and systematically organized medical records for several residents, as required by policy and regulatory standards. For three residents reviewed, there were multiple omissions in Medication Administration Records (MAR) and Treatment Administration Records (TAR), including missing documentation of medication administration, behavior and side effect monitoring, anti-coagulant bleeding monitoring, hours of sleep, weekly skin checks, and pain assessments. These omissions were noted across several months and shifts, making it unclear whether prescribed care and monitoring were provided as ordered by physicians. Additionally, for one resident, the facility did not follow up on a PASRR evaluator's identification of an erroneous diagnosis of bipolar disorder, which originated from a hospital record. The incorrect diagnosis remained in the resident's medical record, MAR, and care plan, despite the evaluator's findings. Interviews with staff revealed a lack of awareness regarding the documentation errors and the absence of ongoing documentation audits at the time of the survey.
Failure to Immediately Report Potential Neglect and Substantial Injury
Penalty
Summary
The facility failed to immediately report a potential case of neglect involving a resident with significant cognitive impairment who required supervision for toileting. The resident was found on the floor with a 2-inch laceration on the forehead, labored breathing, and signs of distress after being left unsupervised on the toilet, contrary to their care plan. The incident was unwitnessed, and the assigned nursing assistant did not provide the required supervision. The facility's investigation identified contributing factors such as poor lighting, confusion, drowsiness, impaired memory, and gait imbalance. The injury was substantial, occurring in an area not generally vulnerable to trauma. Despite facility policy and state guidelines requiring immediate reporting of suspected abuse, neglect, or substantial injuries to the state hotline, the incident was not documented as reported. Staff interviews confirmed the expectation to report such injuries, but the state reporting log did not reflect that the incident was reported as required. The failure to report the potential neglect and injury was identified during the survey and cited as a deficiency.
Failure to Revise Care Plans for Residents on Psychotropic Medications
Penalty
Summary
The facility failed to ensure that care plans were revised as required for two residents who were receiving psychotropic medications. For one resident with moderate dementia, depression, and anxiety, the care plan did not include the symptoms the resident was experiencing, resident goals, or non-pharmacological interventions, despite the use of anti-anxiety and antidepressant medications. The care plan only listed administering medication as ordered and monitoring for adverse effects. Similarly, another resident with major depressive disorder, who was experiencing hallucinations and delusions and was being treated with multiple antidepressants and an antipsychotic, had care plans that also lacked documentation of symptoms, resident goals, and non-pharmacological interventions. The deficiency was identified through interviews and record reviews, which showed that the care plans for both residents were not updated to reflect their current symptoms or needs, as required by the Resident Assessment Instrument (RAI) manual. The administrator acknowledged awareness of care planning issues and stated that work had begun to address them. The lack of comprehensive and updated care plans was found to have the potential to impact staff knowledge of resident needs.
Failure to Hold Cardiac Medications per Physician Orders
Penalty
Summary
The facility failed to follow physician orders and professional standards of care for medication management in three out of five residents reviewed. Specifically, nursing staff administered cardiac medications, including Amlodipine and Metoprolol, to residents despite physician orders to hold these medications if certain blood pressure (BP) or heart rate (HR) parameters were not met. For example, one resident with a history of atherosclerosis, prosthetic heart valve, hypertension, and hyperlipidemia received these medications on multiple occasions when their HR or diastolic BP was below the ordered threshold. Another resident with congestive heart failure, atherosclerotic heart disease, and a cardiac pacemaker was given Amlodipine when their systolic BP was below the ordered limit. A third resident with hypertension also received Amlodipine when their BP or HR was below the specified parameters. Interviews with nursing staff confirmed that they were aware of the need to check vital signs and hold medications per parameters, yet the medication administration records (MARs) showed repeated instances where medications were given despite abnormal vital signs. The administrator also confirmed the expectation that medications should be held according to the parameters set by the physician orders. These findings were based on record reviews and staff interviews, and reference was made to WAC: 388-97-1060 (1).
Failure to Ensure Adequate Hydration for Cognitively Impaired Resident
Penalty
Summary
The facility failed to ensure that a resident with severe vascular dementia and a history of UTIs consistently received adequate fluids to meet their daily estimated needs of 1900 cc. Despite the resident's significant cognitive impairment and need for extensive assistance with eating, multiple observations over several days revealed that fluids were not consistently available at the bedside, and when present, were often out of reach. Documentation showed that the resident's daily fluid intake ranged from 336 cc to 1056 cc, never meeting the required amount. Family members expressed concern about the lack of fluids at the bedside during visits, and staff interviews confirmed that the resident rarely initiated drinking independently and required cues and hand-held assistance. Clinical records and care plans lacked specific documentation or interventions regarding hydration, aside from general encouragement for good nutrition and hydration. There were no recent laboratory assessments to monitor hydration status, and staff were not aware of any hydration concerns. Observations also noted physical signs of dehydration, such as a dry tongue. The administrator stated that the expectation was for nursing to provide water regularly and for dietary to supplement fluids as needed, but these practices were not consistently implemented or documented for this resident.
Failure to Provide Effective Pain Management and Timely Assessment
Penalty
Summary
A deficiency occurred when staff failed to adequately reassess, report, or provide effective pain management for a long-term resident who was mildly cognitively impaired. The facility's policy required staff to identify situations that increase pain, understand the rationale for pain medication, and document pain levels when pain increases. Despite this, the resident repeatedly expressed significant pain, particularly in the gluteal region, during routine activities such as repositioning and peri-care. Observations showed the resident attempting to reposition themselves, vocalizing pain, and reporting high pain scores, yet staff did not consistently assess or respond to these complaints as required. Interviews with staff revealed that pain assessments were only being conducted weekly rather than before and after medication administration, contrary to facility policy. The medical provider was not informed of the resident's increased pain, and pain assessments were not documented following administration of scheduled pain medication. Physical observations later revealed red areas and an open wound on the resident's buttocks, indicating ongoing discomfort and lack of effective pain management. Staff acknowledged that complaints of pain were not always followed by appropriate assessment or notification to the provider.
Failure to Complete and Document Annual Staff Performance Reviews
Penalty
Summary
The facility failed to complete annual staff performance reviews as required and did not provide education based on the outcomes of these reviews for one of five sampled staff members. Specifically, a nursing assistant certified (NAC) hired in December 2022 had an annual performance evaluation that was not dated or signed by either the evaluator or the staff member, and only one page of a two-page evaluation was available. No additional documentation was provided for this staff member's performance evaluation. During an interview, the administrator confirmed that evaluations had only recently been updated and were now being conducted on staff anniversary dates, but no further information was provided.
Duplicate Medication Orders and Administration Error
Penalty
Summary
The facility failed to ensure accurate pharmaceutical services for a resident with osteoporosis by allowing duplicate orders for Alendronate 70mg to be entered and administered. The resident had an original physician's order for Alendronate 70mg once weekly on Mondays at 5:00 AM, but a second, duplicate order was later entered for the same medication and dose to be given on Sundays at 7:00 AM. Medication Administration Records showed that both doses were signed as given on multiple consecutive weeks. Staff responsible for resident care were unaware of the duplicate order until it was brought to their attention, and there was an expectation that the system or pharmacy would catch such duplications. Additionally, the facility's medication error report did not thoroughly investigate whether the pharmacy supplied extra tablets or reconcile discrepancies in staff statements regarding the administration of the duplicate medication.
Failure to Prevent Duplicate Medication Orders and Ensure Accurate Pharmaceutical Review
Penalty
Summary
The facility failed to ensure that pharmaceutical services were provided in accordance with established procedures to guarantee accurate order entry, dispensing, and administration of medications for a resident with osteoporosis. Specifically, a duplicate order for Alendronate 70mg was entered, resulting in the resident receiving the medication twice weekly instead of once, as intended. Medication Administration Records confirmed that both doses were administered on consecutive Sundays and Mondays. This duplication error was not identified or addressed by the facility's medication management system or during the monthly consultant pharmacist review. Additionally, the resident had an active order for Enoxaparin, an injectable blood thinner, with no documented stop date or clarification of the treatment course. The consultant pharmacist's review did not address the duplicate Alendronate order or clarify the ongoing use of Enoxaparin, despite reviewing the resident's regimen monthly. Interviews with facility staff and the consultant pharmacist revealed an overreliance on the system to flag duplications and a lack of proactive review to identify and resolve medication order issues.
Failure to Ensure Required Training for Nursing Assistant Certified Staff
Penalty
Summary
The facility failed to ensure that one of five nursing assistant certified (NAC) staff received the required training in dementia care, abuse and neglect, communication, quality assurance performance improvement (QAPI), and the mandated 12-hour annual training. Review of the staff member's training record showed only a few completed documents related to abuse/neglect and care of the cognitively impaired, with no evidence of other required trainings. Interviews with facility staff revealed that there was no system in place to track the 12-hour education requirement for agency NACs, and responsibilities for tracking and providing training were unclear among staff. This deficiency was previously cited in a prior statement of deficiencies.
Failure to Ensure Nursing Assistant Maintained Active Certification
Penalty
Summary
The facility failed to ensure that a staff member working as a Nursing Assistant Certified (NAC) maintained an active professional certification. Review of the staff member's employment and certification records showed that their NAC certification had expired, yet they continued to work on multiple dates without a valid certification. The staff roster and timecard confirmed the staff member was scheduled and worked as an NAC during the period their certification was expired. The Business Office Manager acknowledged that although the staff member was hired with an active certification, there was a failure to follow up and verify the renewal of the certification, and the monthly license audit process had not been completed prior to discovering the lapse. The Interim Director of Nursing Services stated that all NACs are expected to have current certification.
Failure to Prevent Resident Elopement Due to Inadequate Supervision
Penalty
Summary
The facility failed to provide necessary supervision and services for a resident, resulting in an elopement incident. The resident, who had diagnoses including peripheral vascular disease, heart disease, and Alzheimer's disease, was found outside the facility by a neighbor. The facility's policy required residents to be assessed for wandering risk at admission, with specific interventions for those at increased risk. However, the resident's assessments initially determined they were not at risk for elopement, and their care plan for elopement risk was resolved without proper documentation or follow-up. Interviews with staff revealed a lack of awareness and communication regarding the resident's elopement risk and the facility's procedures. Staff members were unaware of the wander risk book and the resident's care plan updates. The Director of Nursing Services and the Clinical Regional Nurse did not ensure the resident had a wander guard, and there was confusion about the resident's risk status. This deficiency was a repeat issue from a previous survey, indicating ongoing problems with the facility's supervision and risk management processes.
Failure to Maintain Safe and Homelike Environment
Penalty
Summary
The facility failed to provide a safe, sanitary, and homelike environment in both resident units and the outdoor space. Observations revealed multiple issues including loose wallboard, broken ceiling tiles, mismatched paint, large dark stains on floors, and gouges in the drywall in various rooms. Additionally, the courtyard was overgrown with grass and weeds, and cluttered with gardening supplies, which was visible from resident rooms. Interviews with residents confirmed their dissatisfaction with the state of the courtyard, and the administrator acknowledged the absence of a maintenance person and a gardener, indicating ongoing issues with facility upkeep. Furthermore, the facility experienced problems with hot water availability, impacting residents' ability to receive showers. One resident reported not receiving a shower due to the lack of hot water, and a nursing assistant confirmed that showers were not being provided at the time. Water temperature measurements in the facility kitchen showed significantly low temperatures, ranging from 61.9 to 97 degrees Fahrenheit. The administrator admitted that the hot water issue was still being addressed. This deficiency was noted as a repeat citation from a previous survey.
Failure to Prevent Recurrent Falls and Injuries
Penalty
Summary
The facility failed to provide adequate supervision, implement interventions, and update the care plan to prevent accidents and falls for Resident 31. Despite being identified as a high fall risk due to multiple medical conditions including chronic respiratory failure, severe protein calorie malnutrition, muscle wasting, metabolic encephalopathy, cognitive communication deficit, and dementia, the resident experienced 11 falls between December 2023 and April 2024. The facility's fall care plan, initiated on 09/13/2023, included interventions such as ensuring the call light was within reach, offering toileting after G-tube feedings, and placing a sign in the room to remind the resident to use the call light. However, these interventions were not consistently updated or effectively implemented following each fall incident, leading to recurrent falls and injuries for the resident. The facility's investigations into each fall incident revealed that no new interventions were implemented after the falls on 01/04/2024, 01/07/2024, 01/09/2024, 01/16/2024, 02/14/2024, 02/18/2024, 03/06/2024, 04/04/2024, 04/22/2024, and 04/24/2024. The resident continued to self-transfer and not use the call light, which were identified as contributing factors to the falls. Despite the resident sustaining injuries such as skin tears, bruising, and bumps to the head, the facility did not implement additional or alternative interventions to prevent further falls. Observations made on multiple dates in May 2024 showed that the resident's environment did not consistently include all planned interventions, such as a sign to remind the resident to use the call light. Interviews with facility staff, including the Licensed Practical Nurse/Resident Care Manager, the Director of Nursing Services, and the Corporate Nurse, confirmed that fall interventions were supposed to be added to the care plan and communicated during shift changes. However, the Director of Nursing Services admitted that no new interventions were initiated for any of the 11 falls because the resident chose to self-transfer. The Administrator also stated that the resident's multiple falls had not been reviewed during the facility's Quality Assurance and Performance Improvement (QAPI) meetings. This lack of consistent and effective intervention and care plan updates contributed to the resident's recurrent falls and injuries.
Failure to Complete Annual Performance Evaluations for CNAs
Penalty
Summary
The facility failed to complete required annual performance evaluations for three Certified Nursing Assistants (CNAs) who had been employed at the facility for more than one year. Specifically, Staff E, hired on 01/04/2013, Staff F, hired on 06/09/2020, and Staff G, hired on 12/06/2021, did not have annual performance reviews for the prior year in their employee files. This deficiency was confirmed during an interview with the Administrator on 05/14/2024, who acknowledged that the annual performance evaluations were not conducted. This failure to ensure staff members met yearly performance and competency requirements placed residents at risk for diminished quality of care.
Deficiencies in Food Storage, Preparation, and Hand Hygiene
Penalty
Summary
The facility failed to ensure food was stored, prepared, and served under sanitary conditions in the kitchen. The kitchen handwashing sink did not have hot water, with temperatures recorded as low as 60.1°F and fluctuating up to 97.4°F over several days. Staff Q, the Dietary Manager, acknowledged the issue and stated that repairmen were working on it. Additionally, there was no established process for cooling foods to be reused at a later meal, and foods were cooled at room temperature before being placed in the refrigerator without temperature checks to ensure safe cooling times. This lack of procedure was confirmed by Staff Q during an interview. Furthermore, Staff R, a Dietary Aide, was observed not performing hand hygiene when transitioning between the dirty and clean sides of the dishwashing process, and Staff S, another Dietary Aide, did not wash their hands after cleaning counters before plating food. Staff Q had to remind Staff S to wash their hands, highlighting a lapse in hand hygiene practices. These deficiencies in food storage, preparation, and hand hygiene practices placed residents at risk for foodborne illnesses. The observations and interviews revealed that the facility did not adhere to professional standards for food safety, as evidenced by the improper cooling of foods, inadequate handwashing facilities, and failure to perform hand hygiene during critical points in food handling. The ongoing issue with the hot water supply in the kitchen further exacerbated the risk, as it hindered proper sanitation practices. Staff interviews confirmed the lack of proper procedures and awareness regarding food safety protocols, contributing to the overall deficiency in maintaining sanitary conditions in the kitchen.
Deficiency in CNA Training and Education
Penalty
Summary
The facility failed to ensure that three of five Certified Nursing Assistants (CNAs) reviewed for training had the required 12 hours per year of in-service education and the required annual dementia training. Staff E, hired on 01/04/2013, did not have the required 12 hours of in-service education for the prior year. Staff F, hired on 06/09/2020, did not have the required 12 hours of in-service education or the required dementia training for the prior year. Staff G, hired on 12/06/2021, also did not have the required 12 hours of in-service education or the required dementia training for the prior year. The facility's administrator acknowledged challenges in retrieving older training records and admitted that dementia training had not been conducted for a while, and there was no tracking of the 12 hours of in-service education for all requested staff.
Failure to Honor Resident's Bathing Preferences
Penalty
Summary
The facility failed to honor a resident's choice regarding bathing frequency, specifically for Resident 21. Despite the resident's preference to bathe twice a week, documentation showed that the resident had only bathed three times in the last 30 days and had refused once. There was no documentation explaining the refusal or indicating that staff had re-approached the resident about the refusal, as required by the facility's policy. Interviews with the resident and staff confirmed that the resident was not being bathed as often as desired and that there was a lack of follow-up when the resident refused a bath. Additionally, the resident reported not receiving a shower on a specific day due to the unavailability of hot water. Staff interviews corroborated that the protocol for re-approaching residents who refuse a bath was not consistently followed. This failure to accommodate the resident's bathing preferences and to document and address refusals as per policy placed the resident at risk for unmet bathing needs and diminished quality of life.
Failure to Follow PASRR Process for Two Residents
Penalty
Summary
The facility failed to ensure the Preadmission Screening and Resident Review (PASRR) process was followed for two residents, leading to deficiencies in their care. Resident 37, who was admitted with bipolar disorder and schizoaffective disorder, had a Level II PASRR evaluation completed, but the full report was not incorporated into the resident's medical record or plan of care. This oversight was confirmed by the Social Services Director, who acknowledged that the PASRR Level II report had not been scanned into the record or its recommendations implemented. Similarly, Resident 8, admitted with major depressive disorder, anxiety disorder, and hypertension, was identified with Serious Mental Illness (SMI) indicators on admission. Although the Level I PASRR was forwarded for a Level II evaluation, there was no documentation in the resident's Electronic Medical Record (EMR) to show that the Level II PASRR had been completed. Staff members indicated that turnover in the social services department led to the completed Level II PASRR being sent to an invalid email, and an audit was being conducted to identify other residents with similar documentation issues.
Incomplete Baseline Care Plans for Three Residents
Penalty
Summary
The facility failed to fully develop a baseline care plan and provide a written summary of the baseline care plan information for three residents. Resident 15, who was admitted with diagnoses including a left femur fracture, Alzheimer's, diabetes, and hypertension, had an incomplete baseline care plan lacking information on pain, skin conditions, fall risk, bladder incontinence, nutrition, Alzheimer's/cognition, diabetes, and hypertension. Additionally, there was no documentation that a written summary of the baseline care plan was given to Resident 15 or their representative. Similarly, Resident 191, admitted with multiple fractures, Alzheimer's, dementia with agitation, aphasia, hypertension, and constipation, also had an incomplete baseline care plan missing details on pain, fall risk, skin conditions, nutrition, incontinence, constipation, Alzheimer's, communication, care refusals, behaviors, hypertension, and anti-depressant use. There was no documentation that a written summary of the baseline care plan was provided to Resident 191 or their representative. Resident 37, admitted with bipolar disorder and schizoaffective disorder, had a Level II PASRR evaluation pending, but the baseline care plan did not address this pending evaluation. The facility was using a checklist for baseline care plans, which included a social services section and PASRR information, but this had not been completed for Resident 37. Staff K, a Registered Nurse/Corporate Nurse, confirmed the use of the checklist but did not provide additional information for the residents in question. This failure placed the residents at risk of not being informed of their medications, dietary instructions, services, and treatments to be administered, or goals of care, potentially leading to unmet care needs.
Failure to Implement Comprehensive Care Plan for Resident
Penalty
Summary
The facility failed to develop and implement a comprehensive care plan for Resident 18, who was reviewed for nutrition. Resident 18 was admitted to the facility with an order for daily weights as per the hospital discharge summary dated 04/03/2024. However, from the date of admission to 05/15/2024, staff documented only one weight on the day of admission. Staff C, an LPN/Resident Care Manager, admitted in an interview that they do not always receive or review discharge summaries and assumed another nurse would handle it. Additionally, Staff C mentioned that Resident 18 had been refusing to be weighed but failed to notify the resident's physician of these refusals. This issue was a repeat citation from previous surveys dated 02/17/2023 and 06/21/2023, indicating a persistent problem in the facility's care planning process.
Failure to Maintain Clean Respiratory Equipment
Penalty
Summary
The facility failed to ensure the cleanliness of respiratory care tubing equipment for three residents, leading to the use of potentially soiled equipment. Resident 31, who had chronic respiratory failure and COPD, was observed multiple times using oxygen and nebulizer equipment that lacked documentation of regular cleaning or replacement. Staff interviews confirmed that there were no specific orders for changing or cleaning the equipment, and the tubing was not dated to indicate when it was last replaced. Similarly, Resident 33, with diagnoses including hypertensive heart disease and congestive heart failure, and Resident 141, with CHF, COPD, and respiratory failure, were also found to be using undated and potentially unclean respiratory equipment. Staff acknowledged the lack of orders and documentation for the maintenance of this equipment. The Director of Nursing admitted that the facility did not have a policy for the maintenance of oxygen and nebulizer equipment, further contributing to the deficiency.
Failure to Ensure Proper Consents and Gradual Dose Reductions for Psychotropic Medications
Penalty
Summary
The facility failed to ensure that Resident 8 was free from unnecessary psychotropic medications. Resident 8, who was readmitted with diagnoses including major depressive disorder, unspecified dementia with psychotic disturbance, anxiety disorder, and hypertension, was prescribed bupropion, quetiapine, and diazepam. However, the facility did not obtain consent for the use of the antianxiety medication and did not conduct gradual dose reductions (GDR) for the antipsychotic and antidepressant medications as required. The care plan indicated that a GDR was declined by the provider, but there was no documented history of GDR attempts or evidence of hallucinations in the resident's progress notes, despite the increase in quetiapine dosage at the request of the resident's representative to treat hallucinations. Interviews with staff revealed that there had been turnover in the social services department, leading to audits being initiated to review residents on psychotropic medications. The audit was reviewed in an interdisciplinary meeting to discuss potential GDRs, and monthly IDT meetings were planned to continue these reviews. Staff also indicated that the process for obtaining consents involved providing a consent form with medication risks to the resident or their representative, and the medication would not be administered until consent was obtained. Despite these processes, the facility failed to ensure proper consents and GDRs for Resident 8, resulting in a repeat citation from a previous survey.
Failure to Store Medications Safely
Penalty
Summary
The facility failed to store medications in a safe place for one resident, identified as Resident 18, who had medications stored in their room. During an observation and interview on May 9, 2024, it was noted that Lantus and Humalog insulin pens were being stored in a basin on Resident 18's windowsill. Resident 18 stated that the insulins had been there since the previous Friday. Later that day, the Director of Nursing Services was observed removing the insulins from the resident's room but was unable to provide any information on why the medications were being stored there. This failure placed residents at risk for receiving compromised or ineffective medications and for having unintended access to drugs that should have been securely stored.
Incomplete and Inaccurate Clinical Records for Resident with Skin Conditions
Penalty
Summary
The facility failed to ensure clinical records were complete and accurate for Resident 21, who was reviewed for skin conditions. Resident 21, who was cognitively intact and had a diagnosis of atrial fibrillation requiring a blood thinner medication, was observed on 05/09/2024 to have scattered bruising on their feet and lower legs in various stages of healing. However, the weekly skin assessments dated 05/04/2024 and 05/11/2024 did not document any bruising. Additionally, the Treatment Administration Record from 05/01/2024 through 05/14/2024 showed that staff were supposed to monitor for bruising three times a day and document negative (-) for no bruising and positive (+) for bruising, but the licensed staff had only documented check marks instead of the required symbols. In interviews conducted on 05/14/2024 and 05/15/2024, Resident 21 stated they did not recall how they got the bruises, and Staff C, a Licensed Practical Nurse/Resident Care Manager, acknowledged that the bruises should have been documented and monitored. Staff P, a Registered Nurse, was unable to provide further information regarding the use of check marks instead of the required symbols for monitoring adverse effects of the blood thinner medication. This failure to ensure complete and accurate clinical records placed residents at risk for unmet needs.
Inadequate Infection Control Practices During Resident Care
Penalty
Summary
The facility failed to use adequate infection control practices for Resident 18 during wound and incontinent care. Staff N, a Nursing Assistant Certified (NAC), was observed wiping the resident's groin and then, without changing gloves, wiping the resident's abdominal folds which had a rash. This action resulted in contamination of the resident's bedding, clothing, and the light pull cord. Additionally, during a wound dressing change, Staff N did not change gloves after cleaning the resident's groin and subsequently touched the resident's clean brief, gown, bedding, and call light pull cord with the same contaminated gloves. In an interview, Staff J, the RN/Infection Prevention and Control Nurse, confirmed that the staff did not follow proper procedures. Staff J mentioned that a recent inservice on pericare had been conducted, but acknowledged that more auditing, inservicing, and education were needed. This incident is a repeat citation from previous surveys conducted on 02/17/2023 and 12/13/2023.
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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