Soundview Rehabilitation And Health Care Inc
Inspection history, citations, penalties and survey trends for this long-term care facility in Anacortes, Washington.
- Location
- 1105 27th Street, Anacortes, Washington 98221
- CMS Provider Number
- 505216
- Inspections on file
- 35
- Latest survey
- February 18, 2026
- Citations (last 12 mo.)
- 3
Citation history
Health deficiencies cited at Soundview Rehabilitation And Health Care Inc during CMS and state inspections, most recent first.
The facility failed to obtain and honor individual bathing and showering preferences for several residents, including those with stroke-related weakness, dementia, multiple sclerosis, and other conditions. Assessments and care plans documented that residents required extensive or maximal assistance with bathing and that it was very important for them to choose the type of bath (shower, tub, bed bath, or sponge bath), yet shower records showed infrequent showers over extended periods. The DON reported that residents were bathed according to a fixed twice-weekly schedule based on room assignment, with missed or refused showers expected to be offered the next day, rather than based on individualized resident choices.
The facility failed to establish a bed rail policy and did not comprehensively assess, document, or monitor bed rail use for three residents. One resident with heart failure, a prior fall, and moderate cognitive impairment had conflicting documentation about the type of rail used, and was repeatedly observed with both upper rails raised despite being unable to explain or demonstrate their use, while staff reported the resident required two-person assistance in bed. Another resident with muscle weakness and post-stroke weakness had orders and a care plan for bilateral bedrails that did not specify upper or lower rails, and the resident was consistently observed with both upper rails raised. A third resident with dementia and total dependence for bed mobility had care plan and assessment discrepancies regarding quarter versus half rails, with only verbal consent and undocumented risk/benefit discussions, and was also repeatedly observed with both upper rails raised. Across all three cases, Enabler Assessments referenced explaining risks and benefits without detailing them or specifying rail configuration, and there was no evidence of ongoing reassessment or maintenance.
Surveyors found that the facility failed to complete required hospital transfer documentation and provide written bed-hold and appeal-rights notices for two residents sent to the ER. For both residents, Nursing Home Transfer or Discharge Notices were incomplete, lacking representative information, the receiving facility’s address, and a brief explanation for the transfer. In one case, progress notes and bed-hold forms reflected only verbal consent to hold the bed, with no evidence that written transfer/bed-hold notices were given at either hospitalization. In the other case, staff documented an unsuccessful attempt to reach a family member and the resident’s later readmission, but there was no bed-hold notification in the chart and no documentation that written transfer or bed-hold information was provided. Staff interviews indicated that both floor nurses and social services were responsible for ensuring these notices were completed and given to residents or their representatives as soon as possible.
The facility did not have a qualified dietary manager in place, and the individual temporarily filling the role lacked the necessary credentials. This left the food and nutrition services without proper oversight by a staff member with the required competencies.
Surveyors found that perishable foods, including dressings and cheese, were not properly refrigerated, and multiple food items such as bread and cookies were kept past their expiration dates in storage and pantry areas. Staff confirmed these items were expired or improperly stored and needed to be discarded.
Surveyors observed that garbage was not properly disposed of, with both dumpsters repeatedly left open and surrounded by bags of trash, debris, and various discarded items such as mattresses and mini refrigerators. Staff were seen placing garbage in the dumpsters without closing the lids, and the area was noted to attract pests, including flies and seagulls. The administrator confirmed ongoing issues with rodents and acknowledged the need for improved cleanliness.
Surveyors identified failures in professional standards, including improper IV site and tubing management for a resident receiving IV antibiotics, administration of insulin and pain medication outside of physician-ordered parameters for multiple residents, and lack of adherence to orders for pressure-relieving devices and blood pressure medication parameters. Staff interviews and record reviews confirmed these deficiencies, with documentation and practice not aligning with physician orders or facility policy.
Surveyors observed multiple failures in infection prevention, including staff not removing contaminated gloves or performing hand hygiene during perineal care, improper use of PPE such as N95 respirators and gowns when caring for residents on transmission-based and enhanced barrier precautions, and uncovered transport of clean linens. Staff interviews revealed gaps in understanding and adherence to infection control protocols.
Two residents were allowed to self-administer respiratory inhalers without documented assessments of their cognitive and physical ability, as required by facility policy. Both residents kept inhalers at their bedside or on their person and self-administered them, but there was no evidence of completed assessments or care plan updates. Staff confirmed that assessments and secure storage were expected but not performed in these cases.
Two severely cognitively impaired residents were repeatedly observed in bed without call lights within reach, with one resident's call light found hanging on a curtain and another resident yelling during observations. Staff confirmed that call lights should always be accessible, but admitted to forgetting to provide them.
Annual performance evaluations were not completed for three staff members, and two staff members did not fulfill the required 12 hours of annual education. These deficiencies were confirmed through record reviews and administrator interviews.
Surveyors observed two instances where medications were administered late by an LPN, including an IV antibiotic and Levothyroxine, resulting in a medication error rate of 8 percent. The DON confirmed facility policy requires medications to be given within one hour of the scheduled time, but was unaware of the late administration events.
Surveyors observed that opened vials of aplisol used for TB testing were not dated or discarded as required, and temperature logs for the medication refrigerator were incomplete. An LPN confirmed the vials were not dated, and the interim DON stated that daily temperature checks were facility practice, but logs showed missed entries.
The facility failed to maintain complete and accurate medical records for two residents. One resident did not have required documentation of monitoring for medication side effects and targeted behaviors on multiple occasions, while another resident received a dose of pain medication that was not supported by an active physician order or documented in the MAR, with the only record being in the narcotic book. Staff interviews confirmed lapses in expected documentation practices.
The facility did not designate a qualified Infection Preventionist (IP) to oversee the infection prevention and control program, as required by their policy. For over two months, no individual was assigned as the on-site IP, even during a recent Influenza outbreak. Interviews revealed confusion among staff about who the IP was, and the Director of Nursing, despite having an IP certificate, confirmed that they had not assumed the role, nor had any other staff member.
The facility failed to obtain and document weights for two residents as per physician orders, leading to missed notifications of significant weight changes. One resident had missing weight records and care plans initiated posthumously, while another had undocumented weekly weights. Staff interviews revealed inconsistencies in weight documentation practices, and the facility lacked a weight policy.
The facility failed to conduct thorough investigations into abuse allegations involving three residents. A resident with a femur fracture reported rough handling and non-compliance with hip precautions by a nursing assistant. Another resident alleged abuse and neglect, but the investigation lacked comprehensive staff interviews. A third resident reported rough care and privacy violations, but the investigation was incomplete, and the wrong staff member may have been identified.
A resident reported abuse and neglect by a NAR, but the facility delayed in suspending the accused staff and initiating an investigation. The resident, who was cognitively intact, reported the incident to a NAC, who informed an LPN and the previous DNS. The accused staff continued to work the following night, and the facility administration was not notified until the next day, leading to the termination of the previous DNS for policy violations.
A resident reported an incident of alleged abuse and neglect involving a staff member, which was not reported to the state hotline within the required 24-hour period. The resident, who was cognitively intact, experienced rudeness and startling behavior from a staff member. Despite being informed, the facility staff delayed reporting the incident, violating the facility's policy and state guidelines.
A facility failed to ensure a NAR completed the required NAC certification within four months of hire. The staff member continued to work beyond the eligibility period without certification. The administrator was unaware of the completion status, leading to the staff's removal from the schedule.
The facility failed to ensure that the Director of Food and Nutrition Services had the proper qualifications. The designated staff member was not a certified Dietary Manager and was not enrolled in a certification program, placing all residents at risk of receiving dietary services from unqualified staff.
The facility failed to ensure staff compliance with Infection Prevention and Control Guidelines, affecting 14 residents requiring Enhanced Barrier Precautions (EBP). Staff lacked training and awareness of EBP, and no residents were observed on EBP. The facility also failed to establish an infection surveillance plan during a COVID-19 outbreak affecting 29 residents and did not implement a respiratory protection plan for 28 staff members. Additionally, the facility lacked a water management plan for Legionella and other pathogens.
The facility failed to ensure that the designated Infection Preventionist (IP) met the necessary qualifications for experience, education, and training or certification. The IP role was managed by multiple staff members without proper credentials, leading to incomplete data analysis and management of infections.
The facility failed to treat residents with dignity and respect, as evidenced by multiple incidents where residents' requests and needs were ignored or delayed, leading to feelings of humiliation and neglect. These incidents were not documented in the facility's logs.
The facility failed to report a COVID-19 outbreak affecting 29 residents and an unexpected death of a resident with acute pulmonary edema, COPD, and CHF. Staff were unaware of the reporting requirements, and the incidents were not logged in the state reporting log. This is a repeat citation from a previous survey.
The facility failed to meet professional standards for bowel management, PEG tube care, and resident positioning. Two residents did not receive necessary bowel medications as per physician orders, PEG tube supplies were not properly labeled or stored, and a hospice resident was not repositioned as required. Staff interviews revealed a lack of adherence to care plans and protocols.
A resident with severe cognitive impairment and a history of falls experienced nine unwitnessed falls over 90 days due to inadequate supervision and failure to update the care plan. Despite being on an anti-psychotic medication that increased fall risk, the facility did not effectively implement or update fall prevention interventions, leading to multiple injuries.
The facility failed to ensure that LNs and NACs had the appropriate competencies, skill sets, and proficiencies to provide nursing and related services for each resident. Six staff members were found to lack documented competency assessments in their training records, placing residents at risk for unmet care needs and a diminished quality of life. The Chief Operating Officer acknowledged that competencies had not been completed for any staff and that they were in the process of completing them.
The facility failed to properly store and label medications, including undated vaccines and a non-affixed lock box containing controlled substances. Staff were unaware of key management and storage requirements, leading to a repeat citation.
The facility failed to provide proper written notice and appeal rights information to four residents and their families before discharge. The facility used an incorrect form, leading to confusion and lack of proper documentation.
The facility failed to provide sufficient qualified staff, resulting in unmet care needs and diminished quality of life for several residents. Multiple residents reported significant delays in receiving care, particularly during evening and night shifts. Staff interviews revealed that the facility often operated with insufficient staff, and management was aware of the staffing shortages but did not provide adequate support.
The facility failed to provide accurate liability notices for three residents, using expired SNF/ABN forms with missing information. The Chief Operating Officer acknowledged the issue, noting that the responsible social service staff were on vacation.
The facility failed to provide a written bed-hold notice to a resident during multiple hospital transfers, despite having a policy and checklists in place. Staff interviews and resident confirmation indicated that the required documentation was not completed.
The facility failed to complete required Level II PASRR screenings for two residents, one of whom remained in the facility beyond the exempted hospital discharge period without a Level II evaluation, and another who was admitted with a serious mental illness but lacked the necessary Level II documentation in their medical record.
The facility failed to review and revise care plans for two residents, leading to potential health risks. One resident's care plan did not address significant constipation issues, while another's lacked specific instructions for dialysis care and central line management. Staff interviews revealed a lack of policy and inconsistencies in care plan management.
A resident with multiple unstageable pressure ulcers was not consistently provided with physician-ordered off-loading boots, despite care plan directives. Observations and staff interviews revealed that the resident's feet were not elevated, and the boots were not in use while the resident was in bed, increasing the risk of worsening and new pressure ulcers.
The facility failed to provide appropriate catheter care for two residents, leading to potential risks of urinary tract infections. Observations revealed improper handling of catheter bags and a lack of adherence to infection control practices.
The facility failed to provide consistent respiratory care for a resident with COPD, resulting in varying O2 flow rates and undated O2 tubing. Staff interviews revealed confusion about the prescribed O2 flow rate and a lack of facility policy for O2 management, leading to unmet care needs and a diminished quality of life.
The facility failed to ensure consistent communication and collaboration with the dialysis center for a resident requiring dialysis. The care plan lacked specific interventions, leading to missed medications and incomplete assessments. Staff were unaware of necessary dialysis assessments, and the facility lacked a policy to delineate responsibilities, resulting in ongoing issues with documentation and communication.
The facility failed to provide pharmaceutical services for a resident with end-stage renal disease, leading to missed doses of a prescribed Lidocaine patch. The resident experienced increased sedation from relying on pain pills due to the facility running out of the patches. Staff did not document the shortage or inform the DON, and the COO was unaware of the issue.
The facility failed to ensure that two residents were free from unnecessary psychotropic medications. One resident with severe cognitive impairment was prescribed quetiapine fumarate without attempts at gradual dose reduction or proper monitoring. Another resident was prescribed escitalopram without behavior monitoring, despite a pharmacist's directive. The facility did not follow its policy on antipsychotic and psychotropic medication use, leading to a repeat citation.
The facility failed to ensure that nurse aides received the required 12 hours of in-service training per year, as evidenced by the lack of documentation for two Nursing Assistants. The Chief Operating Officer admitted that the training had not been conducted recently, placing residents at risk for potential unmet care needs.
The facility failed to develop, implement, and document a person-centered discharge planning process for three residents discharged AMA. The discharges lacked proper documentation of discussions about AMA risks, physician notification, and follow-up care arrangements.
A resident with an inoperable hip fracture, anxiety, depression, and chronic pain experienced verbal and physical abuse from a Certified Nursing Assistant (CNA). The resident reported feeling scared, humiliated, and neglected due to the CNA's forceful and disrespectful care. The resident's family member also observed the rough handling. Concerns about the CNA's behavior were acknowledged by multiple staff members, including the Director of Nursing Services (DNS) and other Registered Nurses (RNs), who noted the CNA's rough and rude treatment towards residents. Despite initial reluctance, the resident eventually agreed to report the abusive conduct to facility management.
The facility failed to promote resident respect and dignity for three residents, who reported that a CNA was rough, rude, and unkind. Despite these concerns, there was no documentation or monitoring for psychosocial harm, and no care plan revisions were made.
The facility failed to investigate and document abuse allegations for three residents, who reported mistreatment by a CNA. No further investigations were conducted, and necessary documentation and notifications were not completed, placing the residents at risk for harm.
The facility failed to thoroughly investigate an allegation of possible abuse involving a resident. Key witness statements were not obtained, compromising the facility's ability to make an informed decision about the abuse allegation.
The facility failed to ensure a resident received treatment and care according to professional standards. The resident, diagnosed with a UTI and pneumonia, experienced a lack of documentation and monitoring, including symptoms leading to orders for a chest x-ray and urinalysis. Abnormal bleeding and clots were observed but not consistently documented or assessed. The resident's condition deteriorated, leading to hospitalization with acute UTI, hematuria, and severe sepsis.
Failure to Obtain and Honor Resident Bathing Preferences
Penalty
Summary
The deficiency involves the facility’s failure to obtain and honor residents’ bathing and showering preferences, including type, frequency, and time of day, for multiple residents. For one resident with a stroke and right-sided weakness, the admission MDS showed no cognitive impairment and no showers received during the assessment period, and the baseline care plan lacked documentation of daily bathing/showering preferences. The resident’s care plan indicated extensive assistance was needed, yet documentation showed only four showers provided over 26 days. Another resident with dementia and moderately impaired cognition had an MDS indicating it was very important to choose between a shower, tub bath, or bed bath, and the care plan documented a need for maximal assistance. Documentation showed this resident received three showers over 32 days, with one documented refusal. A third resident with multiple sclerosis had a care plan stating they were to be showered twice weekly and as necessary, but documentation over two separate date ranges showed only one shower in 14 days and no showers during an earlier period. A fourth resident with weakness and high blood pressure was dependent for bathing per the admission MDS and required extensive assistance per the Kardex, yet documentation showed only four showers over 22 days. A fifth resident with a stroke and right-sided residual paralysis had an admission MDS indicating it was very important to choose among tub bath, shower, bed bath, or sponge bath, and a care plan documenting extensive assistance with bathing needs, but documentation showed only four showers over 39 days. In an interview, the RN/DON stated residents were showered twice weekly according to a fixed room-based schedule, and that if a shower was refused or not offered, the expectation was that it would be offered the following day, indicating reliance on a set schedule rather than individualized resident bathing preferences.
Failure to Assess, Document, and Monitor Bed Rail Use for Multiple Residents
Penalty
Summary
The deficiency involves the facility’s failure to have a bed rail/side rail policy and to comprehensively assess, document, and monitor the use of bed rails for three residents. The facility did not develop a side rail/bed rail policy, and the DON was unable to state where risks and benefits were documented or how often side rails were reassessed. Enabler Device Assessments for the residents noted that risks and benefits of side rail use were explained, but the medical records lacked documentation of what specific risks and benefits were discussed, and there was no evidence of ongoing monitoring or maintenance of the bed rails. For one resident with heart failure, a fall with weakness, and moderate cognitive impairment, the Enabler Device Assessment indicated use of a half side rail to maximize independence and stated that risks and benefits were explained, but did not specify the number or location of rails or detail the risks and benefits. The ADL care plan documented use of a quarter side rail to assist with bed mobility. Multiple observations showed this resident in bed with both upper side rails raised while eating meals and resting. During interviews, the resident was unable to state whether they could use the side rails for turning or even place their hand on the rail, while an agency NAC reported that the resident required two-person assistance for bed mobility and stated the resident was able to use the side rails. Another resident with muscle weakness and a stroke with left-sided weakness, and no cognitive impairment, had a physician order and care plan indicating use of bilateral bedrails to maximize independence with turning and repositioning, but the order did not specify whether upper or lower rails were used. The Enabler Device Assessment again stated that risks and benefits were explained without documenting what they were or specifying the rail configuration. Observations repeatedly showed this resident in bed with both upper side rails raised while eating meals. A third resident with high blood pressure and dementia, dependent on staff for bed mobility and transfers, had a care plan allowing bilateral quarter side rails to assist with bed mobility, and an Enabler Assessment documenting use of a half rail, ability to remove it independently, and that risks and benefits were discussed with a family member who gave verbal consent. However, the record did not specify the number or location of rails or the content of the risk/benefit discussion, and observations showed both upper side rails raised when the resident was in bed or when the bed was unoccupied.
Incomplete Hospital Transfer Documentation and Missing Bed-Hold Notices
Penalty
Summary
The deficiency involves the facility’s failure to complete required hospital transfer documentation and provide proper written notices regarding transfer, appeal rights, and bed-hold policies for residents sent to the hospital. Facility policy on Admission, Transfer & Discharge – Bed Hold Policy required written information to residents or representatives specifying the duration of the state bed-hold policy, with two notices: one in advance of transfer and a second at the time of transfer or within 24 hours for emergencies, and documentation of attempts to reach the representative if contact was not made. A separate Bed Hold Policy Notification required the resident or representative to return a signed notification to the business office within 24 hours of transfer or discharge if they chose to retain the bed, and specified the amount to be charged for retaining the bed. For one resident, the Nursing Home Transfer or Discharge Notices for two separate hospitalizations were incomplete. The notices, dated for each transfer, stated that the transfer was necessary for the resident’s welfare and that their needs could not be met at the facility, but did not include the resident representative’s information, the address of the receiving facility, or a brief explanation of why the resident was sent to the ER. Progress notes showed that social services staff left a voicemail regarding bed hold and later documented that a family member verbally consented to hold the bed, and Bed Hold Policy Notification forms reflected verbal consent to hold the bed for each hospitalization. However, there was no documentation in the medical record that a written discharge/transfer notice and bed-hold information were actually provided to the resident or representative at the time of either hospital transfer. For another resident, a progress note documented that the resident was sent to the hospital via stretcher, and a later Nursing Home Transfer or Discharge Notice again stated that the transfer was necessary for the resident’s welfare and that their needs could not be met at the facility. This notice was also incomplete, lacking the resident representative’s information, the address of the receiving facility, and a brief explanation of the reason for ER transfer. Progress notes showed that social services attempted to contact the resident’s family member but were unable to leave a voicemail, and later documented the resident’s readmission. There was no documentation that a written discharge/transfer notice or bed-hold information was provided to the resident or representative at the time of transfer, and no Bed Hold Policy Notification was found in the chart for this hospitalization. Staff interviews confirmed that both floor nurses and social services were responsible for completing and providing transfer/discharge and bed-hold notices, and that these were expected to be given to residents and/or representatives as soon as possible, including after weekend transfers.
Lack of Qualified Dietary Manager
Penalty
Summary
The facility failed to designate a qualified individual to serve as the director of food and nutrition services. Review of the key personnel list during the entrance conference revealed that no staff member was listed as the dietary manager. Interviews with dietary staff and the administrator confirmed that the facility did not currently have a dietary manager, and the person temporarily filling the role lacked the necessary dietary credentials. This resulted in the absence of a staff member with the required competencies and skills to oversee food and nutrition services, as required by regulation.
Improper Food Storage and Expired Items in Food Service Areas
Penalty
Summary
Surveyors observed that the facility failed to properly store, distribute, and serve food in accordance with professional standards for food service safety. In the dry food storage room, individual containers of honey mustard dressing labeled 'keep refrigerated' were found stored in a cardboard box on a shelf at room temperature. Staff from dietary services confirmed that these dressings should have been refrigerated and would need to be disposed of due to improper storage. Further inspection of the pantry area in the resident dining room revealed additional issues. A plastic container of shredded cheese with an expiration date that had already passed was found in the refrigerator. On the counter, a bin of individual honey mustard dressings, also labeled 'keep refrigerated,' was left unrefrigerated. A half loaf of bread and individual packages of chocolate chip cookies were also found with expiration dates that had already passed. Staff members acknowledged that these items were expired or improperly stored and needed to be discarded.
Improper Garbage Disposal and Unsanitary Dumpster Area
Penalty
Summary
The facility failed to properly dispose of garbage and maintain cleanliness in the dumpster area, as observed on multiple occasions. Both dumpsters outside the facility were repeatedly found with their lids open, and staff were seen placing garbage inside without closing the lids. The area surrounding the dumpsters contained plastic bags of garbage, a protein drink carton with a straw, scattered debris, and two 5-gallon buckets filled with a thick sludge material topped with water. Additionally, there was a knee-high pile of yard waste, three mattresses, a cloth recliner chair, and four mini refrigerators next to the dumpsters. Flies were observed in the area, and a seagull was seen inside one of the dumpsters, removing garbage. During an interview and observation with the facility administrator, the same unsanitary conditions were noted, including the presence of used gloves and random papers behind the dumpsters. The administrator acknowledged ongoing issues with squirrels and mice around the dumpsters and was unaware of the contents of the sludge-filled buckets. The administrator confirmed that the dumpster lids should be kept closed and that the area required cleaning. These findings were cited as a failure to comply with proper garbage disposal and environmental cleanliness requirements.
Failure to Meet Professional Standards in IV Care, Medication Administration, and Pressure Ulcer Prevention
Penalty
Summary
The facility failed to ensure that services provided met professional standards of quality in several areas, as evidenced by direct observations, interviews, and record reviews. For one resident receiving intravenous (IV) medication, the facility did not follow its own policies regarding IV site and tubing management. The resident had a peripheral IV device with undated and frayed dressings, and the IV tubing was not labeled with the date, time, or nurse initials. The IV site dressing was discolored, peeling, and not changed as required, and the resident reported having to hold the IV in place due to leakage. Additionally, there was confusion among staff regarding the type of IV device in place, with physician orders incorrectly indicating a PICC line when only a peripheral IV was present. Infection control practices were not followed, as the IV tubing end was not capped when not in use. The facility also failed to ensure medications were administered according to physician orders and established parameters for multiple residents. One resident received insulin injections outside of the specified blood sugar parameters on numerous occasions, and staff did not notify the provider when medication was held or administered outside of these parameters. Another resident was given oxycodone for pain ratings below the ordered threshold, with multiple documented instances of administration for pain scores less than 7, contrary to the physician's order. Staff interviews confirmed a lack of awareness and adherence to these medication administration parameters. In addition, the facility did not ensure the use of pressure-relieving devices as ordered. One resident with an order for an alternating pressure mattress (APM) was observed to have a standard mattress in place during multiple observations, despite staff documentation indicating the APM was checked and functioning. Staff confirmed the APM had been removed, but documentation continued to reflect its presence and use. Another resident received blood pressure medication outside of the ordered parameters for pulse and systolic blood pressure, with several doses administered when vital signs were below the specified thresholds.
Infection Control Deficiencies: Hand Hygiene, PPE, and Linen Management
Penalty
Summary
Multiple deficiencies in infection prevention and control were observed throughout the facility, including failures in hand hygiene, use of personal protective equipment (PPE), and linen management. During incontinent care for a resident, staff members failed to remove contaminated gloves and perform hand hygiene between tasks, instead touching clean briefs, drawers, and applying skin barrier with soiled gloves. Staff interviews confirmed a lack of adherence to proper glove removal and hand hygiene protocols during perineal care. Staff did not consistently follow transmission-based precautions for residents who tested positive for COVID-19. Several staff members entered rooms of COVID-19 positive residents without the required N95 respirators, gowns, gloves, or eye protection, despite clear signage indicating these requirements. In some cases, staff wore only surgical masks or failed to change PPE between resident rooms, and one staff member entered a room without any N95 masks available. Staff interviews revealed gaps in understanding and compliance with PPE protocols, including the need for N95 respirators and eye protection. Enhanced Barrier Precautions (EBP) were not properly implemented for residents with wounds or indwelling devices. Staff provided direct care, such as wound care and IV antibiotic administration, without donning gowns as required by EBP protocols. Additionally, clean linens were transported into the facility uncovered and handled with bare hands, contrary to facility policy. Interviews with staff and leadership indicated incomplete education on EBP and infection control procedures, contributing to the observed non-compliance.
Failure to Assess Residents for Safe Self-Administration of Medications
Penalty
Summary
The facility failed to ensure that residents were properly evaluated and assessed for the safe self-administration of medications, as required by facility policy. Specifically, two residents were observed to have respiratory inhalers at their bedside or on their person, and both reported self-administering these medications. Review of the medical records and staff interviews confirmed that neither resident had undergone a documented assessment for their cognitive and physical ability to safely self-administer medications, nor was there documentation in the medical record or care plan updates reflecting such an assessment. Facility policy requires that residents be assessed for cognition and physical ability before being permitted to self-administer medications, with documentation and care plan updates to follow if deemed appropriate. Observations showed that one resident, with a history of depression, muscle weakness, and cognitive communication deficit but assessed as cognitively intact, kept an inhaler at the bedside and self-administered it. Another resident, alert and oriented, kept an inhaler in their shirt pocket and also self-administered it. Staff interviews confirmed that the expectation was for assessments and secure storage, but these steps were not completed for the residents involved.
Failure to Ensure Call Lights Within Reach for Cognitively Impaired Residents
Penalty
Summary
The facility failed to ensure that call lights were within reach for two residents who were both severely cognitively impaired, as documented in their quarterly MDS assessments. Multiple observations over several days showed that one resident was repeatedly found in bed without a call light within reach, with the device noted to be hanging on a curtain instead. Staff interviews confirmed that the expectation was for all residents to have call lights within reach, but staff admitted to forgetting to provide this for the resident. Another resident, also severely cognitively impaired, was observed in bed with the call light out of reach on multiple occasions. During these times, the resident was noted to be yelling. Staff, including the Interim Director of Nursing Services, acknowledged that all residents should have access to a call light, regardless of their ability to use it. These observations and staff statements demonstrate a failure to reasonably accommodate the needs and preferences of these residents.
Failure to Complete Annual Staff Evaluations and Required Education
Penalty
Summary
The facility failed to complete annual performance evaluations for three out of five sampled staff members, as required. Additionally, two staff members did not complete the mandated 12 hours of annual education, with one missing 2 hours and another missing 5 hours. These deficiencies were identified through document reviews and interviews, which confirmed the absence of annual evaluations in employee files and incomplete education hours for the affected staff. The findings were based on a review of facility records and direct statements from the facility administrator.
Medication Error Rate Exceeds Regulatory Threshold Due to Late Administration
Penalty
Summary
The facility failed to ensure that medication error rates remained below 5 percent, as required. During observation of 25 medication administration opportunities, 2 errors were identified, resulting in an 8 percent error rate. One resident, admitted with pneumonia and digestive system disease, had a physician order for Zosyn IV antibiotic to be administered every eight hours at specific times. Staff G was observed administering this IV antibiotic one and a half hours late, explaining that medications were given in the order of residents down the hallway rather than by scheduled time. The Director of Nursing Services stated that facility policy required medications to be given within one hour of the scheduled time and was unaware of the late administration. Another resident, who was not cognitively impaired, was prescribed Levothyroxine for thyroid issues, which should be administered on an empty stomach 30 to 60 minutes before breakfast for optimal absorption. Staff G, an agency LPN, administered the resident's 7:00 AM dose of Levothyroxine one and a half hours late. These late administrations were directly observed and documented by surveyors, contributing to the facility's medication error rate exceeding the regulatory threshold.
Failure to Label and Discard Opened Medications and Maintain Refrigerator Temperature Logs
Penalty
Summary
Surveyors found that the facility failed to properly label and discard opened vials of aplisol, a solution used for tuberculosis testing, in the medication room refrigerator. During observation, two open vials of aplisol were found without any date indicating when they had been opened, despite the product label stating it expired 30 days after opening. A Licensed Practical Nurse confirmed that the vials were not dated upon opening and acknowledged that they should have been discarded. Additionally, the facility did not consistently record the temperature of the medication refrigerator as required by facility policy. Review of the temperature logs revealed multiple dates where no temperature was recorded. The interim Director of Nursing stated that the practice was to check the refrigerator temperature daily, with the night shift staff responsible for this task, but the logs showed this was not consistently done.
Incomplete Medical Records and Medication Documentation
Penalty
Summary
The facility failed to ensure complete, accurate, and accessible medical records for two residents. For one resident with bipolar disorder, depression, and anxiety, there were multiple instances where required documentation was missing. Physician orders required monitoring and documentation of adverse side effects related to antipsychotic and antidepressant medications, as well as targeted behaviors associated with the resident's mental health conditions, to be completed three times daily. However, documentation was missing on several specific dates across three consecutive months. Interviews with staff revealed that the expectation was for licensed staff to complete documentation by the end of each shift, but the Director of Nursing Services was unaware that this was not being consistently done. For another resident reviewed for pain management, a dose of Hydromorphone was signed out in the narcotic book, but there was no active physician order for the medication at the time, nor was there documentation of administration in the Medication Administration Record (MAR) or progress notes. The order for the pain medication was not confirmed until later that day, after the medication had already been signed out. Staff confirmed that the only documentation of the dose was in the narcotic book, with no corresponding entry in the resident's clinical record.
Failure to Designate an On-Site Infection Preventionist
Penalty
Summary
The facility failed to designate a qualified individual as the Infection Preventionist (IP) responsible for the infection prevention and control program. This deficiency was identified through interviews and record reviews, revealing that the facility had not had an IP on-site for over two months. The facility's policy required the IP to be employed on-site at least part-time. During an interview, the Administrator admitted that no individual had been designated as the on-site IP during a recent Influenza outbreak. Additionally, a Registered Nurse was unsure about who the IP was, and the Director of Nursing, who held an IP certificate, confirmed that they had not worked as the IP in the facility, nor had any other staff member for months.
Failure to Obtain and Document Resident Weights
Penalty
Summary
The facility failed to ensure that two residents with physician orders for daily and weekly weights had their weights obtained as required. Resident 1, who had diagnoses including heart failure and hypertension, had a physician order for daily weights with instructions to notify the provider if there was a significant weight change. However, there were missing weight records for several days, and no documentation indicated that the provider was notified of the resident's weight fluctuations. Additionally, care plans for hypertension and respiratory issues were initiated after the resident had passed away, indicating a lapse in timely care planning. Resident 2, admitted with conditions such as chronic heart failure and post-surgery recovery, was supposed to have weekly weights recorded. However, there were multiple instances where the required weekly weights were not documented in the treatment administration record or the electronic medical record. Interviews with staff revealed inconsistencies in the process of obtaining and documenting weights, with some staff not providing the necessary lists or failing to document weights accurately. The facility was unable to provide a weight policy and procedure when requested, highlighting a lack of structured guidance for staff. Interviews with various staff members, including nursing assistants and registered nurses, revealed a lack of consistent communication and documentation practices regarding residents' weights. This deficiency in obtaining and documenting weights placed residents at risk of poor health outcomes, as significant weight changes were not communicated to healthcare providers as required.
Inadequate Investigation of Abuse Allegations
Penalty
Summary
The facility failed to conduct thorough investigations for allegations of abuse and neglect involving three residents. Resident 3, who was admitted with a right femur fracture and required specific hip precautions, alleged that a nursing assistant was rough during care and did not follow the necessary precautions. Despite the grievance being filed, the facility did not investigate the allegation of the staff failing to adhere to the hip precautions, and key staff members were unaware of the specific allegations. Resident 1, who was cognitively intact and had a history of major depressive disorder and muscle weakness, reported an incident of abuse and neglect by a nursing assistant. The facility's incident report lacked comprehensive interviews with other staff members to rule out further instances of abuse, and the investigation did not thoroughly address the allegations of rough handling during care. Resident 2, diagnosed with bipolar disorder and diabetes, reported that a nursing assistant was rough during care and did not respect their privacy. The investigation was incomplete, as it did not include follow-up interviews with staff from other shifts. Despite the suspension of the identified staff member, the resident reported that the same nursing assistant continued to provide care, indicating a possible misidentification of the staff involved.
Failure to Protect Resident from Abuse and Neglect
Penalty
Summary
The facility failed to protect a resident from abuse and neglect by staff, as evidenced by an incident involving a Nursing Assistant Registered (NAR) who was reported to have been rude and rough with a resident. The resident, who was cognitively intact and had diagnoses including major depressive disorder and muscle weakness, reported the incident to a Nursing Assistant Certified (NAC) on the morning following the alleged abuse. The NAC informed a Licensed Practical Nurse (LPN) and the previous Director of Nursing Services (DNS) about the allegation. However, the accused staff member was not suspended until the following day, and the resident was not interviewed until two days after the incident was reported. The facility's policy required immediate suspension of staff accused of abuse and prompt reporting to the Administrator or Director of Nursing Services. Despite this, the accused staff member continued to work the night following the report, and the facility administration was not informed until the day after the incident was reported. The previous DNS was terminated for failing to follow the facility's abuse and neglect policy, and there was no documentation of their termination in their employee file. The facility also failed to report the incident to the Department of Health as required.
Failure to Timely Report Alleged Abuse and Neglect
Penalty
Summary
The facility failed to immediately report an allegation of abuse and neglect involving a resident, which was brought to the attention of a staff member. The incident involved a resident who was cognitively intact and had diagnoses including major depressive disorder and muscle weakness. The resident reported to a Nursing Assistant Certified (NAC) that another staff member had been rude, initially refused to assist with removing a blanket, and threw a package of wipes near the resident's head, startling them. This incident occurred on July 14, 2024, but was not reported to the state hotline until July 16, 2024, exceeding the 24-hour reporting requirement. Interviews with staff revealed that the NAC informed the nurse on duty and the prior Director of Nursing Services (DNS) about the incident, and a note was placed in the social services office. However, the mandated reporting to the state hotline was not done immediately as required by the facility's policy and state guidelines. The administrator acknowledged the delay in reporting, and the current DNS confirmed that such allegations should be reported to the state hotline promptly. This delay in reporting placed residents at risk for potential unidentified mistreatment.
Failure to Ensure Timely Certification of Nursing Assistant
Penalty
Summary
The facility failed to ensure that a staff member with a Nursing Assistant Registered (NAR) license completed the necessary training and certification to become a Nursing Assistant Certified (NAC) within four months of hire. Staff E was hired on April 24, 2024, as a NAR and was required to complete the NAC class and pass the state license exam by August 24, 2024. However, Staff E continued to work as a NAR beyond this date, specifically on the night shifts of August 27 and August 28, 2024, without having completed the required certification. During an interview, the facility's administrator, Staff A, acknowledged that Staff E was involved in a program to become an NAC but was unaware of their completion status. It was later confirmed via email that Staff E was no longer eligible to work as a NAR after August 24, 2024, and had been removed from the schedule.
Unqualified Director of Food and Nutrition Services
Penalty
Summary
The facility failed to ensure that the person designated as the Director of Food and Nutrition Services, Staff J, had the proper qualifications. Staff J, who had been employed at the facility since December 7, 2021, was not a certified Dietary Manager (DM) and was not enrolled in a program to obtain the necessary certification. This was confirmed during an interview on May 23, 2024, when Staff J stated they were not a certified DM and had been in the position for a short time. Additionally, the Chief Operating Officer, Staff A, acknowledged that Staff J was not yet enrolled in a certification program. This deficiency placed all residents at risk of receiving dietary services from staff without the required competencies and skills to carry out food and nutrition services.
Infection Control Deficiencies in Facility
Penalty
Summary
The facility failed to ensure staff compliance with Infection Prevention and Control Guidelines and national standards of practice across two hallways, affecting 14 residents who required Enhanced Barrier Precautions (EBP). Observations revealed that staff were not using appropriate personal protective equipment (PPE) such as gowns and gloves during high-contact activities for residents with wounds or indwelling medical devices. Interviews with staff indicated a lack of training and awareness regarding EBP, and no residents were observed to be on EBP during multiple walking rounds. Additionally, the facility's infection preventionist and other staff members were not clear on the implementation and requirements of EBP. The facility also failed to establish an infection surveillance plan during a COVID-19 outbreak, which affected 29 residents. The infection control log did not include an analysis, surveillance monitoring, or employee data related to the outbreak. Interviews with staff revealed that the outbreak was overwhelming, and many staff members were out sick. The Director of Nursing Services admitted that no summary or root cause analysis was completed for the outbreak, and the Chief Operating Officer was unaware of the lack of investigation and infection risk assessment. Furthermore, the facility did not implement a respiratory protection plan (RPP) for 28 of 59 employed staff, including NACs, licensed nurses, therapy staff, kitchen staff, housekeepers, and administrative staff. The facility also failed to establish a water management plan to monitor and control Legionella and other waterborne pathogens. Despite multiple requests, no water management plan was provided. Interviews with staff confirmed the absence of compliance with national infection control standards and the lack of a designated program administrator for the RPP since the previous infection preventionist left in December 2023.
Failure to Ensure Qualified Infection Preventionist
Penalty
Summary
The facility failed to ensure that the designated Infection Preventionist (IP) met the necessary qualifications for experience, education, and training or certification to assume responsibility for the Infection Prevention Control Program (IPCP). The facility's policy required the IP to be qualified through special training certification, education, and experience, and to oversee various duties including surveillance, antibiotic stewardship, data analysis, outbreak management, and employee health and safety. However, the facility's IP, a Registered Nurse/Director of Nursing Services, only had a certificate of participation from another facility, which did not list any staff name or specific certification. Additionally, the staff roster did not reflect an IP on the facility's staff, and the facility was in a transition period for the IP role with a Licensed Practical Nurse (LPN) expected to take over the role in the future. Interviews with various staff members revealed that there had been turnover in the IP role, and there was uncertainty about the completion of infection control program tasks related to antibiotic stewardship, analysis, and assessment of infections. The facility had not had a designated IP since December 2023, and infection control practices were being managed by multiple staff members without proper qualifications. The documents provided by the facility showed incomplete data analysis and management of infections, and the staff responsible for infection control practices did not have the necessary credentials or certification. The facility's Chief Operating Officer acknowledged that the provided certification did not have a staff employee name and was unaware of any other documentation to support the qualifications of the staff in the IP role.
Failure to Treat Residents with Dignity and Respect
Penalty
Summary
The facility failed to ensure that each resident was treated with respect, dignity, and failed to promote and protect the rights of each resident. Resident 12, who had no cognitive impairment, reported feeling humiliated when staff refused to move a chair by the window for them to see the northern lights, citing fall risk as the reason. This incident was not logged in the facility's incident or grievance logs. Resident 19, who also had no cognitive impairment, experienced prolonged discomfort and pain due to delayed assistance after returning from dialysis. The resident felt neglected and believed they were labeled as a difficult patient, which affected the staff's attitude towards them. This issue was also not recorded in the incident or grievance logs. Resident 27, with multiple orthopedic conditions and no cognitive impairment, reported feeling humiliated due to having to wait for extended periods to be changed after a bowel movement. The resident attributed this to understaffing, and this incident was not documented in the facility's logs either. Resident 23, with multiple cardiac diagnoses and no cognitive impairment, expressed frustration at being told to go to bed by staff, which made them feel like a child. The resident preferred to stay up and walk to alleviate leg cramps. This issue was similarly not recorded in the facility's logs. The Chief Operating Officer acknowledged that residents should have a dignified existence and be treated with respect and dignity, and noted that these could be considered abuse allegations.
Failure to Report Communicable Disease Outbreak and Unexpected Death
Penalty
Summary
The facility failed to develop and implement policies and procedures for reporting a communicable disease outbreak and an unexpected death to the state reporting agency. Specifically, the facility did not report a COVID-19 outbreak that affected 29 residents between February and March 2024, nor did they log this outbreak on the state reporting log. Staff B, the Director of Nursing Services, and Staff A, the Chief Operating Officer, were unaware of the requirement to report and log communicable disease outbreaks. Additionally, the facility's infection log did not reflect staff affected by the outbreak, and there was no report filed with the Complaint Resolution Unit (CRU) for the COVID-19 outbreak during this period. The facility also failed to report and log the unexpected death of Resident 32, who had diagnoses including acute pulmonary edema, COPD, and CHF. Resident 32 was found unresponsive in their bed and passed away on May 5, 2024. There was no communication between the facility and the coroner regarding this unexpected death, and it was not logged in the state reporting log. Staff B admitted to being unaware that some unexpected deaths should be logged, reported, and investigated. Additionally, there was no Advance Directive or POLST form found in Resident 32's medical records, and Staff E stated that an unsigned POLST form would have been discarded. This is a repeat citation from a previous survey dated March 13, 2023.
Failure to Meet Professional Standards in Bowel Management, PEG Tube Care, and Resident Positioning
Penalty
Summary
The facility failed to ensure professional standards were met for several residents in various aspects of care. For two residents reviewed for bowel management, the facility did not administer necessary bowel medications as per physician orders, leading to prolonged periods without bowel movements. Resident 18 experienced significant constipation and pain due to irregular administration of Miralax and other bowel medications, while Resident 235 did not receive as-needed medications despite documented issues with bowel movements. Both residents' care plans lacked a focus on constipation, and staff interviews revealed a lack of awareness and adherence to bowel protocols. For residents with PEG tubes, the facility did not follow proper procedures for storing and labeling tube feeding supplies. Resident 30 and Resident 9 had tube feeding supplies that were not marked with dates or names, and there were no physician orders or care plan directions for the maintenance and replacement of these supplies. Observations showed that the supplies were not labeled, and unused formula was not stored according to manufacturer guidelines. Staff interviews confirmed the absence of a policy for PEG tube care and maintenance. The facility also failed to follow a toileting plan for a resident and did not ensure proper positioning and comfort for a hospice resident. Resident 8 was not offered toileting every two hours as per their care plan, leading to extended periods without being checked or toileted. Resident 6, who required repositioning every two hours and the use of heel protection boots, was observed in the same position for extended periods and without the necessary boots. Staff interviews indicated a lack of adherence to the care plan and confusion about the management of the resident's ROHO cushion for comfort and pressure relief.
Failure to Prevent Falls and Ensure Adequate Supervision
Penalty
Summary
The facility failed to ensure adequate supervision to prevent accidents for a resident with severe cognitive impairment and a history of falls. The resident, who was on an anti-psychotic medication that could cause sedation and unstable gait, experienced nine unwitnessed falls over a 90-day period. Despite being identified as a high fall risk, the resident's care plan interventions were not consistently updated or followed, and several falls resulted in injuries, including a head laceration that required hospital treatment and staples. The facility's fall assessment and management policy required a resident-centered fall prevention plan based on relevant assessment information, including medication reviews and identification of specific risks. However, the facility did not adequately review or update the resident's care plan after each fall. Interventions such as reminding the resident to use the call light and not leaving the resident unattended were either duplicated or not effectively implemented. Staff interviews revealed a lack of awareness and oversight regarding the resident's sun-downing behaviors and the potential impact of the anti-psychotic medication on fall risk. The facility's interdisciplinary team (IDT) did not conduct thorough root cause analyses or consider all contributing factors to the resident's falls. The Director of Nursing Services (DNS) and other staff members acknowledged the need for better oversight and completion of fall investigations. The Chief Operating Officer confirmed that the IDT should review the resident's health record, assessments, and conduct a root cause analysis to prevent further falls, but this process was not adequately followed for the resident in question.
Failure to Ensure Staff Competency
Penalty
Summary
The facility failed to ensure that Licensed Nurses (LNs) and Nursing Assistants Certified (NACs) had the appropriate competencies, skill sets, and proficiencies to provide nursing and related services for each resident in accordance with the facility assessment. Specifically, six staff members (Staff C, D, H, P, S, and BB) were found to lack documented competency assessments in their training records. This deficiency was identified through interviews and record reviews, revealing that the facility did not complete the required competency assessments for these staff members, which placed residents at risk for unmet care needs and a diminished quality of life. The facility's assessment, updated on 11/22/2023, indicated that nurse aides and licensed nurses would participate in annual skill fairs and be assessed annually for care competencies by qualified nurses and consultant educators. However, the training records for the six staff members did not include documentation of these assessments. During an interview on 05/24/2024, the Chief Operating Officer acknowledged that competencies had not been completed for any staff and that they were in the process of completing them. This lack of documented competency assessments was a direct violation of the facility's own policies and regulatory requirements.
Improper Storage and Labeling of Medications
Penalty
Summary
The facility failed to ensure that drugs and biologicals were stored in accordance with state and federal laws in the medication storage room. During an observation and interview, it was found that the medication refrigerator contained a can of beer with no name or date, two opened and undated bottles of Afluria (influenza vaccine), one opened and undated bottle of Apisol (used for TB skin tests), and a locked black box that was not permanently affixed to the refrigerator. Staff present during the observation were unaware of the key's location for the lock box and the requirement for the box to be permanently affixed. Further investigation revealed that the key for the black lock box was hanging on a wall near the door, accessible to unauthorized personnel. The lock box contained four unopened vials of Lorazepam (Schedule IV injectable anti-anxiety medication) and one unopened liquid bottle of Lorazepam. Staff members, including the Chief Operating Officer, were unaware of the improper storage and key management practices. This deficiency was a repeat citation from a previous survey dated 03/13/2023.
Failure to Provide Proper Discharge Notices and Appeal Rights
Penalty
Summary
The facility failed to provide written notice to four residents (Residents 18, 240, 241, and 242) and their family members regarding the facility's intention and justification for discharging the residents. Additionally, the facility did not inform the residents and their family members about their right to appeal the discharge decision, including contact information for advocacy groups. This deficiency was identified through interviews and record reviews, which revealed that the facility used an incorrect form (NOA) that did not provide the necessary information about appeal rights and advocacy contacts. Resident 18 was transferred to the hospital multiple times without receiving or signing any paperwork regarding the discharge notice. The facility's progress notes and interviews with staff confirmed that the correct transfer discharge notice was not provided. Similarly, Resident 240 was discharged against medical advice (AMA) without proper documentation of a Notice of Transfer/Discharge. The resident's family member signed a document at the time of discharge but did not know what it was and did not receive a copy. Residents 241 and 242 also left the facility AMA without proper documentation of a Notice of Transfer/Discharge. Interviews with staff and reviews of the residents' electronic medical records confirmed the absence of the required notices. The facility's Chief Operating Officer acknowledged the confusion with the NOA form and admitted that the social worker should have been providing the accurate transfer discharge notice but failed to do so.
Insufficient Staffing Leading to Unmet Resident Care Needs
Penalty
Summary
The facility failed to provide sufficient qualified staff to meet the needs of residents, resulting in unmet care needs and diminished quality of life for several residents. The facility's assessment indicated an average daily census of 31 residents, with staffing ratios determined by the Director of Nursing Services (DNS) based on resident acuity and staff skills. However, the facility did not maintain 24-hour Registered Nurse (RN) coverage for 24 out of the last 30 days, and the Chief Operating Officer (COO) acknowledged the staffing issues and the inability to apply for an RN staffing waiver. Multiple residents reported significant delays in receiving care, particularly during evening and night shifts. Resident 19 experienced prolonged discomfort and pain due to delayed assistance after returning from dialysis, while Resident 185 had to wait over 30 minutes for help and ended up self-transferring due to frustration. Resident 85 corroborated these issues, noting that their roommate, Resident 19, was left in their wheelchair for an extended period after dialysis. Resident 27 described feeling humiliated due to long waits for assistance with bowel movements, and Resident 18 reported wait times exceeding half an hour when aides were busy. Staff interviews revealed that the facility often operated with insufficient staff, particularly on evening shifts. Nursing assistants (NACs) reported being unable to complete all required tasks, such as feeding assistance, oral care, and turning residents every two hours, due to the lack of personnel. The facility's staffing sheets were found to be inaccurate, and management was aware of the staffing shortages but did not provide adequate support. The resident council minutes consistently highlighted concerns about call light response times and the need for more aides and nursing staff, further emphasizing the ongoing staffing issues at the facility.
Failure to Provide Accurate Liability Notices
Penalty
Summary
The facility failed to ensure the provided liability notice was completed accurately for three residents reviewed for liability notices. Resident 135's Skilled Nursing Facility Advanced Beneficiary Notice (SNF/ABN) form was found to be expired, lacked the resident's name, and had blank spaces where information should have been filled in to indicate the resident's choice. Resident 136's SNF/ABN form was also expired and had blank spaces where the resident's choice should have been indicated. Similarly, Resident 137's SNF/ABN form was expired and had blank spaces where the resident's choice should have been indicated. In an interview, the Chief Operating Officer acknowledged that the ABN forms provided were expired and not correctly completed. The social service staff responsible for filling out these documents were on vacation at the time. The Chief Operating Officer confirmed that the correct forms are now available but admitted that the provided ABN forms were incomplete and contained missing information.
Failure to Provide Bed-Hold Notice
Penalty
Summary
The facility failed to provide a written bed-hold notice to Resident 18 at the time of transfer or within 24 hours of transfer to the hospital. Resident 18, who was admitted to the facility on 06/07/2023 and had no cognitive impairment according to the Admission Minimum Data Set assessment dated 05/03/2024, was transferred to the hospital multiple times without receiving the required bed-hold notice. Progress notes from 11/02/2023, 03/02/2024, 04/09/2024, and 05/15/2024 all lacked documentation of a bed-hold offer. Additionally, social service notes from 11/03/2023 also did not mention a bed-hold offer. Interviews with staff revealed that the facility had a policy to offer bed holds, but this was not consistently followed. Staff A, the Chief Operating Officer, confirmed that there was no bed-hold documentation for Resident 18 and acknowledged that bed holds were not being completed. Staff M, an LPN, stated that bed holds were supposed to be completed if the resident was able, but this did not occur. Resident 18 also confirmed that they did not receive or sign any paperwork during their last four hospital transfers. Staff A later admitted that bed holds were not being done, despite having checklists in place for staff to follow.
Failure to Complete Required PASRR Screenings
Penalty
Summary
The facility failed to ensure a Level II Preadmission Screening and Resident Review (PASRR) screening for residents with serious mental illness (SMI), intellectual disability (ID), or a related condition was completed if the scheduled discharge did not occur. Resident 19 was admitted to the facility and had a Level I PASRR form indicating no Level II evaluation was needed due to an exempted hospital discharge. However, after the resident remained in the facility for more than 30 days, no Level II PASRR was completed as required. This oversight was identified through a review of Resident 19's medical record, which showed no evidence of a Level II PASRR being conducted after the 30-day period had elapsed. Additionally, the facility failed to ensure a resident with a Level I PASRR screening form was complete prior to admission. Resident 240, who was admitted with a diagnosis of schizophrenia, had a Level I PASRR form indicating the need for a Level II evaluation. Although the Level I was completed at the hospital and the resident was referred for a Level II evaluation, the facility's medical records did not contain the completed Level II evaluation. Interviews with the Social Services Director and Health Information Manager confirmed the absence of the Level II evaluation in Resident 240's medical record, highlighting a lapse in ensuring the necessary documentation was included and completed upon admission.
Failure to Review and Revise Care Plans
Penalty
Summary
The facility failed to review and revise care plans for two residents, leading to potential risks for their health and well-being. Resident 18, who was admitted with respiratory failure, kidney failure, and polyneuropathy, experienced multiple instances of constipation that were not addressed in the care plan. Despite the Admission Care Area Assessment (CAA) indicating that constipation should be included in the care plan due to decreased bed mobility, the care plan initiated on 06/14/2023 did not reflect this issue. This oversight occurred despite the resident having significant periods without bowel movements, as documented in the bowel monitors from 02/15/2024 to 05/06/2024. Resident 19, admitted with end-stage renal disease and dependent on dialysis, had a care plan that lacked specific instructions and necessary details. The care plan did not specify which arm to avoid for blood draws and blood pressure measurements, nor did it include care instructions for a right chest central line added on 04/17/2024. Additionally, the care plan did not delineate tasks between the kidney center and the facility, leaving staff unclear about their responsibilities. Interviews with staff revealed a lack of policy for care planning and dialysis care, and inconsistencies in how care plans were revised and managed.
Failure to Implement Physician-Ordered Pressure Relief Interventions
Penalty
Summary
The facility failed to ensure that a resident was provided with physician-ordered pressure relief interventions. Specifically, the resident, who was admitted with multiple unstageable pressure ulcers, was not consistently using off-loading boots as recommended by the wound care team. Observations showed that the resident's feet were not elevated, and the off-loading boot was not in use while the resident was in bed, despite the care plan and medication administration record indicating that the boots should always be used to prevent further pressure ulcer development. Interviews with staff revealed that there was an expectation for the resident to wear the off-loading boots at all times while in bed, and staff were supposed to check on the resident at least once per shift to ensure proper positioning of the boots. However, these interventions were not consistently implemented, as evidenced by the resident being observed without the boots on multiple occasions. This failure to follow the prescribed interventions placed the resident at risk for worsening of existing pressure ulcers and development of new ones.
Failure to Provide Appropriate Catheter Care
Penalty
Summary
The facility failed to ensure that two residents, who were reviewed for the use and care of a catheter, received appropriate care and services to minimize the risk of urinary tract infections. Resident 13, who was admitted with diagnoses including injury of the urethra and urinary tract infection, was observed having their catheter bag emptied by a Nursing Assistant Certified (NAC) without the use of antiseptic to clean the drain tube before or after draining. This action was contrary to the facility's policy on catheter care, which mandates the use of aseptic techniques to prevent infections. Resident 235, admitted with diagnoses including hip replacement and chronic obstructive pulmonary disease, had a catheter bag that was observed to be uncovered, hooked to their walker, and completely full of urine. The resident's catheter bag was not emptied in a timely manner, and staff did not follow proper infection control practices, such as cleaning the drain tube with an alcohol wipe. Additionally, Resident 235's follow-up appointment with a urologist was scheduled later than recommended. Interviews with staff revealed inconsistencies in the understanding and implementation of catheter care protocols, further contributing to the deficiency.
Failure to Provide Consistent Respiratory Care
Penalty
Summary
The facility failed to provide safe and appropriate respiratory care for Resident 237, who was admitted with diagnoses including Chronic Obstructive Pulmonary Disease (COPD), anxiety disorder, and cachexia. The resident's Medication Administration Record (MAR) indicated a physician's order to check oxygen (O2) saturations every shift and adjust the O2 flow to maintain saturations above 89 percent. However, there were no instructions on changing the O2 tubing, and the resident's care plan lacked interventions for changing the O2 tubing and did not specify the O2 flow rate. Observations over several days showed inconsistent O2 flow rates and undated O2 tubing, with the resident reporting difficulty in breathing and infrequent changes of the O2 tubing since admission. Interviews with staff revealed a lack of clarity on the prescribed O2 flow rate and an absence of a facility policy or procedure for O2 management. This deficiency was a repeat citation from a previous survey dated 03/13/2023. On multiple occasions, Resident 237 was observed with varying O2 flow rates, none of which were consistently maintained as per the physician's order. The resident expressed difficulty in breathing and noted that the O2 tubing had only been changed once since their admission. Staff interviews indicated confusion regarding the correct O2 flow rate and the protocol for changing O2 tubing. Additionally, the facility lacked a policy or procedure for managing O2 therapy, contributing to the inconsistency in care. This failure to adhere to professional standards of practice placed the resident at risk for unmet care needs and a diminished quality of life.
Failure to Ensure Consistent Communication and Care for Dialysis Resident
Penalty
Summary
The facility failed to ensure consistent and ongoing communication and collaboration with the dialysis facility for Resident 19, who required dialysis services. The care plan for Resident 19 lacked specific interventions and collaboration details between the nursing home and dialysis staff. It did not specify which arm to avoid for blood pressure measurements, the location of dialysis, contact information, or the nephrologist's details. Additionally, the care plan did not include instructions for the care of the access site, monitoring for complications, or medication administration before, during, or after dialysis. This lack of detailed planning and communication led to missed medications and incomplete assessments for Resident 19. Resident 19, who had been on dialysis since 2008, reported not receiving their phosphorus binders and having high potassium levels. The facility's records showed that necessary labs were not drawn since admission, and there were no clear orders for medication administration on dialysis days. Interviews with staff revealed that they were unaware of the need for dialysis assessments and the existence of a dialysis communication binder. The facility also lacked a policy to delineate responsibilities between the facility and the dialysis center, leading to confusion and missed documentation. The review of the Hemodialysis Communication forms showed incomplete assessment information on 20 out of 22 dialysis dates. Staff interviews indicated that the dialysis communication binder rarely made it back to the facility, and there was no clear understanding of which medications to send with the resident to dialysis. The facility's Chief Operating Officer acknowledged the lack of a dialysis policy and the ongoing issues with missed documentation and communication. This deficiency placed Resident 19 at risk for unmet care needs and inadequate quality of care.
Failure to Administer Pain Medication
Penalty
Summary
The facility failed to consistently provide pharmaceutical services to meet the needs of Resident 19, who was admitted with diagnoses including end-stage renal disease, depression, and gout. The resident was on a scheduled pain medication regimen, including a Lidocaine external patch for pain relief. However, the Medication Administration Record (MAR) showed multiple instances where the Lidocaine patch was not administered, with reasons coded as hospitalization or the resident being out of the facility, despite no documentation supporting these claims. Additionally, there were days when the medication was held without proper documentation in the progress notes. Interviews with Resident 19 and staff revealed that the facility ran out of Lidocaine patches for several days, forcing the resident to rely on pain pills, which led to increased sedation. Staff admitted to not documenting the shortage or informing the Director of Nursing Services. The Chief Operating Officer was unaware of the issue until the interview. This failure to ensure timely processing and administration of ordered medications placed Resident 19 at risk for discomfort and pain, anxiety, and unmet needs.
Failure to Ensure Residents Were Free from Unnecessary Psychotropic Medications
Penalty
Summary
The facility failed to ensure that two residents were free from unnecessary psychotropic medications. Resident 7, who had severe cognitive impairment and dementia, was prescribed quetiapine fumarate without any documented attempts at gradual dose reduction (GDR). The facility did not monitor or document the resident's non-pharmacological interventions or the effectiveness of these interventions. Interviews with staff revealed a lack of awareness regarding the necessity of monitoring and documenting behaviors and the appropriate use of antipsychotic medications for dementia-related behaviors. Additionally, the required Abnormal Involuntary Movement Scale (AIMS) assessment was not completed upon admission for Resident 7. Resident 27, who had no cognitive impairment but was diagnosed with depression and an anxiety disorder, was prescribed escitalopram. However, the resident's current diagnoses did not include anxiety or depression, and there was no behavior monitoring in place for the use of escitalopram. The pharmacist's medication review had directed staff to add behavior monitoring, but this was not implemented. This issue was a repeat citation from a previous survey. The facility's policy on antipsychotic and psychotropic medication use was not followed, as it required that such medications be prescribed at the lowest possible dosage for the shortest period and be subject to GDR and re-review. The facility's failure to implement person-centered behavioral interventions and appropriate monitoring placed the residents at risk for medication-related complications and unnecessary psychotropic medication use.
Failure to Ensure Required In-Service Training for Nurse Aides
Penalty
Summary
The facility failed to develop, implement, and maintain an in-service training program to ensure that nurse aides received the required 12 hours of training per year. Specifically, two Nursing Assistants (Staff H and BB) did not have documented evidence of completing the mandatory training hours. The facility's assessment, updated on 11/22/2023, outlined various training topics, including communication, resident rights, abuse prevention, infection control, and person-centered care. However, the facility did not document the duration or start time of the in-service training sessions, leading to a lack of evidence that the required training was completed. During an interview, the Chief Operating Officer (Staff A) acknowledged that the training schedule for 2024 was in place but admitted that the training had not been conducted recently. Staff A also mentioned that some staff had received training on some topics, but there was no comprehensive documentation to confirm the completion of the required 12 hours of in-service training for the nurse aides. This failure placed residents at risk for potential unmet care needs.
Failure to Implement Person-Centered Discharge Planning
Penalty
Summary
The facility failed to develop, implement, and document a person-centered discharge planning process for three residents who were discharged against medical advice (AMA). Resident 240, who had diagnoses including rhabdomyolysis, schizophrenia, and osteoarthritis, was discharged AMA after testing positive for COVID-19. There was no documentation of discussions with the resident about AMA risks, physician notification, or attempts to schedule follow-up care. Additionally, the resident's family member was unaware that the discharge was considered AMA and had to coordinate a medical appointment for more medications, resulting in the resident going without medication for a week. Resident 241, who had a left hip repair and shingles, left the facility AMA without proper documentation of discussions about AMA risks, physician notification, or attempts to schedule follow-up care. The resident's care plan indicated a plan to return home with family support, but the discharge was unplanned, and there was no evidence of appropriate discharge planning. Resident 242, who had a stroke and high blood pressure, also left the facility AMA. The resident's care plan included a plan to discharge home with their spouse and home health support, but there was no documentation of discussions about AMA risks, physician notification, or confirmation that home health services were secured. The facility's staff acknowledged that the process for AMA discharges was not fully followed, including the lack of concise documentation of medications sent with the residents.
Failure to Protect Resident from Verbal and Physical Abuse by CNA
Penalty
Summary
The facility failed to protect Resident 2 from verbal and physical abuse, leading to harm and psychological distress. Resident 2, admitted with diagnoses including an inoperable fracture around the prosthetic in their right hip, anxiety, depression, and chronic pain, experienced discomfort and humiliation due to forceful care provided by Staff B, a Certified Nursing Assistant (CNA). Resident 2 reported instances of Staff B being physically forceful, disrespectful, and rude during care activities, causing the resident to feel scared, humiliated, and neglected. The resident's family member also witnessed Staff B's rough handling of Resident 2 without showing any kindness or support for the resident's injuries. Multiple staff members, including Staff A, Registered Nurse/Director of Nursing Services (DNS), and Staff D, acknowledged concerns about Staff B's behavior, with reports of rough and rude treatment towards residents. Staff A expressed worry about residents who may not be able to report abuse if subjected to Staff B's behavior. Despite Resident 2's reluctance to file a grievance initially, they eventually agreed for Staff D to report Staff B's abusive conduct to the facility's management.
Failure to Promote Resident Respect and Dignity
Penalty
Summary
The facility failed to provide care in a manner that promoted resident respect and dignity for three residents. Resident 3, who was cognitively intact, reported that Staff B accused them of being racist and gave them mean looks. Despite the resident's request to not have Staff B care for them, there was no further documentation or monitoring for psychosocial impact, and no care plan revisions were made. Resident 3 expressed feeling shocked, insulted, and uncomfortable due to Staff B's behavior, which was corroborated by other staff members who noted complaints about Staff B's rough and rude care. Resident 4, who had moderate cognitive impairment and required maximum assistance with daily activities, reported that Staff B was grumpy, unkind, and handled them roughly during transfers. Despite these concerns, there was no documentation of assessment for signs of injury or psychosocial harm, and no care plan interventions were made. Resident 4 expressed fear of being pushed off the bed and stated they felt unsafe and worried about Staff B's care. Resident 5, who had moderate cognitive impairment and was on hospice services, reported that Staff B was rough and not gentle. The resident's spouse also noted that Staff B was short and did not have time for the resident. There was no documentation related to Resident 5's allegations or monitoring for psychosocial harm. Staff members, including the Director of Nursing Services, acknowledged that Staff B had a history of being rough and rude with residents, but no additional investigation or monitoring was conducted for the three residents who expressed concerns about Staff B.
Failure to Investigate and Document Abuse Allegations
Penalty
Summary
The facility failed to implement its policy regarding identifying and investigating potential allegations of abuse and neglect for three residents. Specifically, the facility did not identify potential abuse, timely report allegations, complete thorough investigations, assess and monitor residents for harm, notify responsible parties and providers, or document the allegations and revise care plans. This failure was evident in the cases of three residents who voiced concerns about the treatment and care provided by a Certified Nursing Assistant (CNA), referred to as Staff B. Despite these allegations, no further investigations were conducted, and the necessary documentation and notifications were not completed, placing the residents at risk for various forms of harm. Resident 3, who had a diagnosis of depression, reported that Staff B accused them of being racist and gave them mean looks. Resident 4, with diagnoses including stroke, depression, anxiety, and mood disorder, stated that Staff B was always grumpy and unkind. Resident 5, who had a fractured sacrum, alleged that Staff B was rough with them. In all three cases, there were no progress notes, investigations, or care plan revisions documented, and the residents' emergency contacts and providers were not informed of the allegations. The Director of Nursing Services (DNS) confirmed that no further actions were taken regarding these allegations, as they were mistakenly considered part of a single investigation.
Failure to Thoroughly Investigate Allegation of Abuse
Penalty
Summary
The facility failed to thoroughly investigate an allegation of possible abuse and/or neglect involving a resident. The investigation did not include obtaining witness statements from the alleged staff member, other key staff who regularly worked with the alleged staff member, or residents who might have reported similar treatment. This lack of thorough investigation compromised the facility's ability to make an informed decision about whether abuse was substantiated and to identify the extent and impact of the potential abuse. The facility's policy required all reports of abuse, neglect, exploitation, misappropriation, mistreatment, and injuries of unknown source to be thoroughly investigated. However, the investigation into the allegation against Staff B did not include specific interviews or statements from key individuals, including the staff member who reported the allegation and those who worked closely with Staff B. The Director of Nursing Services acknowledged the failure to obtain and document these statements, which hindered the facility's ability to determine the validity of the abuse allegations.
Failure to Monitor and Document Resident's Condition
Penalty
Summary
The facility failed to ensure that Resident 1 received treatment and care in accordance with professional standards of practice. Resident 1, who was admitted with an inoperable right ankle fracture and a heart attack, was diagnosed with a urinary tract infection (UTI) and pneumonia. Despite these diagnoses, there was a lack of documentation and monitoring of Resident 1's condition, including symptoms leading to the orders for a chest x-ray and urinalysis, and subsequent assessments for UTI, pneumonia, and antibiotic treatment. This resulted in inaccurate and missing information in Resident 1's clinical record, placing the resident at risk for unidentified complications. On multiple occasions, staff observed and reported abnormal bleeding and clots in Resident 1's brief, which appeared to be vaginal. However, there was no consistent documentation or assessment of these symptoms. Staff interviews revealed that the bleeding was reported to the Advanced Registered Nurse Practitioner (ARNP), but there was no clear documentation of the source of the bleeding or detailed monitoring of the resident's condition. The resident's condition deteriorated, leading to an emergency hospital admission where they were diagnosed with acute UTI, acute hematuria, and severe sepsis. Interviews with staff indicated that the facility's protocol for monitoring and documenting changes in a resident's condition was not followed. Staff were expected to place residents on alert monitoring for at least 72 hours when there were changes in condition or new orders, but this was not done for Resident 1. The lack of proper documentation and monitoring contributed to the resident's decline and subsequent hospitalization. The facility's failure to adhere to professional standards of practice and ensure accurate and timely documentation placed Resident 1 at significant risk for medical complications.
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A resident with cerebral palsy and a court-appointed guardian experienced multiple episodes of nausea, vomiting, loose stools, abdominal discomfort, fatigue, and later refusal of meals and medications, leading to changes in the care plan including close monitoring, lab testing, and IV fluid administration. Despite a facility policy recognizing court-appointed guardians as resident representatives with decision-making authority, staff did not document any notification to the guardian during these changes in condition or treatment decisions. The guardian reported not being contacted when the resident stopped eating or developed stomach issues and felt the facility did not respect the guardianship, while the DON acknowledged there were multiple missed opportunities to notify the guardian of the resident’s change from baseline.
A resident with depression, anxiety, moderate cognitive impairment, and urinary incontinence, care-planned for q2h checks and assistance with toileting, was found by a visitor to be soaking wet, unusually agitated, and reporting they had been told to wait to be changed and referred to with a derogatory remark. The visitor filed a written grievance alleging abuse/neglect related to delayed incontinence care and removal of the resident’s tablet as a consequence. Although an incident report noted that the matter was reported to the state and that the resident was not soaking wet, a CNA who actually changed the resident later reported the resident’s brief, pants, wheelchair, and socks were soaked and that the resident was acting timid and repeatedly saying they had to sit for five minutes, but this CNA was never interviewed. The DON acknowledged not investigating the resident’s behavior or interviewing this CNA, and the grievance official acknowledged the facility did not fully investigate or communicate findings and resolution to the complainant, resulting in a failure to follow the facility’s grievance policy.
A resident with dementia, respiratory failure, and heart failure developed new shortness of breath with an O2 sat of 90%, and a physician ordered transfer to the ED for tx and eval. An RN completed an SBAR, notified the MD and family, and reported to the oncoming nurse that the resident needed ED transfer and that paramedics should be contacted, then left the facility. Instead of calling 911 for this emergent respiratory distress, staff arranged non-emergent transport through a contracted ambulance service, resulting in the resident remaining at the facility for several hours without pickup until the dispatcher later instructed staff to call 911. The DON stated that 911 is expected to be used for emergent conditions and the contracted service only for non-emergent transport.
A resident with anoxic brain injury, dysarthria, and documented lack of decisional capacity alleged physical abuse and expressed fear of their identified representative, yet social services only reported the allegation to the state and did not complete an incident report, revise the care plan, or implement protective interventions. The same representative continued to be treated as the resident’s decision-maker and visited frequently, with staff noting suspicious odors of foreign substances and concerns about possible illicit substance use. Psychiatry later documented concern that the representative was providing illicit substances, and the resident was subsequently hospitalized for altered mental status and overdose, after which the representative was banned. Key staff, including the DON, unit manager, and administrator/abuse coordinator, were unaware of the initial abuse allegation, and social services did not timely explore or clarify legal decision-making authority or alternative representation for the resident.
A resident with severe cognitive impairment, osteoarthritis, and spinal spondylosis, care planned for 2-person Hoyer transfers, was being moved by two CNAs using a mechanical lift when one corner loop of the sling became disengaged, causing the resident to fall about four feet, strike the floor and the lift, and sustain head abrasion, multiple rib fractures, and lumbar vertebral fractures. Facility policy required staff to verify secure sling attachment, examine hooks, clips, fasteners, and strap stability, and ensure the sling bar was sound before lifting, but during this transfer the sling loop detached despite staff believing it was properly fastened and hearing it click into place; post-incident assessment showed the loop had come loose, the sling appeared in good condition, and a CNA later reported thinking one of the round metal disks on the lift might have been slightly loose, while maintenance logs documented no prior concerns with the lifts or slings.
The facility failed to revise and individualize care plans to reflect current needs and preferences for multiple residents, including one cognitively intact resident with hemiplegia, hemiparesis, and mononeuropathy who had bilateral shoulder surgery and could not tolerate BP measurements on the upper arms but preferred forearm readings. Despite repeatedly informing staff, this preference was not documented in the care plan or Kardex, and direct care staff and the RN/UM were unaware of it. Another cognitively intact resident with hemiplegia, contractures, and weakness reported they were supposed to get out of bed for two hours daily, but some NACs did not know this, even though the MAR/TAR contained an order to document times up and back to bed. The surveyors concluded that care plans were not accurately revised for several residents, placing them at risk for unidentified and unmet care needs and diminished quality of life.
Surveyors found that two residents with hemiplegia, hemiparesis, weakness, and contractures did not receive restorative nursing services, including ROM exercises and splint/brace or orthotic assistance, after therapy discharge. Although PT and OT discharge summaries documented established restorative ROM and transfer programs, recommended PROM to affected extremities, and recommended splint/brace use and assistance with orthotic wear, these recommendations were not entered as restorative referrals in the EHR. As a result, the residents’ care plans and records showed no restorative programs, and both residents reported that therapy and restorative exercises had stopped, while the DON, rehab director, and MDS coordinator confirmed they were unaware of and had not implemented the recommended restorative services.
A resident with cancer, cognitive impairment, and declining strength experienced multiple unwitnessed falls, most occurring while attempting to toilet or move toward the bathroom, culminating in a fractured ankle requiring ED treatment. Although assessments identified fall and incontinence risks and the facility’s policy required individualized interventions, the comprehensive care plan lacked a toileting plan and did not include several interventions that were discussed in incident investigations, such as consistent wheelchair placement and frequent rounding for bathroom assistance. Staff reported relying on verbal reminders and education to use the call light, despite acknowledging the resident’s impulsivity and failure to call for help, and the resident’s bed remained furthest from the bathroom while repeated bathroom-related falls occurred without the trend being recognized or addressed in the care plan.
A resident with a history of acute urinary retention and acute kidney injury had a Foley catheter deemed permanent by the hospital, with instructions that it not be removed in the SNF. At a later urology visit, the catheter was removed, and the resident returned with no new orders documented. Facility staff did not document bladder assessments, post-void residuals, or urine output, and CNA documentation showed the resident did not void that evening. Over the next day, the resident had vomiting, poor intake, altered level of consciousness, tachycardia, hypotension, and no documented wet briefs. A bladder scan eventually showed more than 2000–2500 mL of retained urine, and a new catheter drained a large volume. The resident and a roommate reported moaning, crying out in pain, and repeatedly alerting staff that the resident was not urinating and that the catheter was not draining, while nurses documented catheter care when no catheter was in place and later had to flush and replace the catheter due to continued complaints.
Surveyors found that nurses and nurse aides did not consistently administer medications according to professional standards and facility policy. Multiple residents reported that agency nurses were slow with medications, did not fully follow instructions, and often gave routine meds late. Observations showed an LPN administering expired Humalog/Lispro insulin well past the scheduled time, an LPN giving several scheduled meds (including Tizanidine) late and all at once, and an RN attempting to give sliding-scale insulin nearly two hours late, which a resident refused after already eating. Another resident received Methocarbamol two hours late after questioning the RN, and a resident on scheduled Tramadol had doses given without timely documentation, with a discrepancy between the narcotic count and pills remaining. These events demonstrated failures in timely administration, use of non-expired medications, and immediate, accurate MAR and narcotic documentation.
Failure to Notify Court-Appointed Guardian of Resident’s Clinical Changes
Penalty
Summary
The deficiency involves the facility’s failure to notify a resident’s court-appointed guardian of significant clinical changes and care decisions, contrary to its own policy and state requirements. The facility’s policy on Resident Representatives, revised 02/2021, states that a resident representative includes a court-appointed guardian or conservator and that the facility treats the representative’s decisions as those of the resident to the extent delegated or required by the court. Resident 1, admitted with cerebral palsy, had a Superior Court guardianship letter dated 02/07/2025 indicating a guardian of person and conservator of the estate with full authority, identifying Collateral Contact 1 (CC1) as the guardian. Despite this, multiple clinical events and changes in condition were documented without any corresponding documentation that CC1 was notified. Progress notes and provider notes show that Resident 1 experienced an episode of nausea and vomiting, frequent loose stools, abdominal discomfort, bloating, worsening fatigue, generalized weakness, and later refusal of meals and medications over at least a 24-hour period, with observations that the resident appeared frailer, more fatigued, and had no energy or interest to talk. The provider developed care plans including close monitoring for deterioration, sending stool to the lab, and later initiating IV fluids for rehydration, with a plan to call family/POA for discussion. However, there was no documentation that the guardian was notified at any of these points, including when IV fluids were started. CC1 reported that they were not contacted when the resident stopped eating or developed stomach issues, and expressed that the facility did not respect their guardianship and that involvement in care planning took too long. The DON confirmed on record review that there were many opportunities to notify the guardian when the resident’s condition changed from baseline and that there was no evidence staff did so.
Failure to Thoroughly Investigate and Resolve Resident Grievance Regarding Incontinence Care and Staff Conduct
Penalty
Summary
The deficiency involves the facility’s failure to thoroughly investigate and resolve a grievance alleging neglect and disrespect toward a resident, as required by its grievance policy. The resident had depression, anxiety, moderate cognitive impairment, occasional urinary incontinence, and required moderate assistance with toileting, with a care plan directing staff to check the resident every two hours, ask about toileting needs, and ensure they were clean and dry. A collateral contact reported arriving to visit the resident and finding them soaking wet and agitated, with behavior that was not typical for the resident. The collateral contact documented in a written grievance that the resident’s tablet was off, the resident appeared upset, and the resident reported being told they had to wait five minutes to be changed and that staff would change their “nasty *ss” in five minutes, leading the collateral contact to believe the resident had been given a consequence of no tablet and sitting in wet clothes, which they characterized as abuse/neglect and requested immediate removal of the responsible staff and a report filed. The facility documented receipt of the grievance and created an incident report indicating the matter was reported to the state agency, and that the unit manager interviewed the collateral contact and the resident, with the resident described as confused and denying being soaking wet. The incident report stated that a different nursing assistant was assigned to assist with the brief change and that the unit manager believed the resident was not soaking wet, and that the resident and collateral contact were satisfied when they left the room. However, a CNA who actually changed the resident reported that the resident’s brief was soaked through their pants onto the wheelchair and their socks were soaked, and that the resident was timid, repeatedly saying they had to sit for five minutes, and not acting like themselves; this CNA stated they were never interviewed or asked about the grievance or the resident’s condition. The DON acknowledged not interviewing this CNA or investigating the resident’s behavior and why they were upset, and the unit manager did not recall whether the collateral contact was present during follow-up and did not believe they followed up with the collateral contact regarding the grievance. The administrator, identified as the Grievance Official, stated the facility should have thoroughly investigated the grievance and discussed findings and resolution with the collateral contact, indicating the grievance process was not fully carried out in accordance with policy and WAC 388-97-0460.
Failure to Obtain Timely Emergency Transport for Resident in Respiratory Distress
Penalty
Summary
The deficiency involves the facility’s failure to obtain timely emergency medical services for a resident experiencing new-onset respiratory distress. The resident had dementia, respiratory failure, and heart failure, with severe cognitive impairment and a need for substantial assistance with activities of daily living. On the day the resident was sent to the hospital, a collateral contact observed the resident having difficulty breathing, appearing unable to get enough air, and looking as if they were sleeping or unconscious, and reported this to staff with a request to contact the doctor. An SBAR Communication Form documented that the resident was experiencing shortness of breath that had not occurred before, with an oxygen saturation of 90%. The physician was notified and ordered the resident sent to the emergency department for treatment and evaluation, and the collateral contact was notified shortly thereafter. Progress notes later documented that, despite the order for emergency department transfer, the resident was still awaiting pickup by Olympic transportation several hours later, with no estimated time of arrival. At approximately 3:30 AM, the dispatcher informed the facility that they could not provide transportation and instructed that 911 be called; only then was 911 contacted and the resident transported to the hospital via ambulance for respiratory distress. The RN caring for the resident stated they completed the SBAR, notified the physician and family, and at the end of their shift reported to the oncoming nurse that the resident needed to be sent to the emergency department for respiratory distress and that paramedics should be contacted, then left assuming 911 would be called. The DON stated that staff are expected to contact 911 for emergent conditions such as shortness of breath or respiratory distress, and that Olympic Ambulance is used only for non-emergent transport.
Failure to Provide Social Service Advocacy After Abuse Allegation and Questionable Representative
Penalty
Summary
The deficiency involves the facility’s failure to provide appropriate medically-related social services and advocacy for a resident following an allegation of abuse and concerns about the resident’s representative. The resident had an anoxic brain injury, dysarthria, moderate cognitive impairment, and was dependent on staff for activities of daily living. A hospital palliative care note documented that the resident lacked decisional capacity, had no DPOA, that the legal next of kin (CC4) did not want to be part of care decisions, and that care decisions were being deferred to another contact (CC5). CC5 accompanied the resident on admission, signed admission forms, and was listed as the primary contact in the medical record profile. On a date in February, during communication therapy, the resident reported that CC5 had done something to them, pounded their hands on their chest, recalled being hit in the back of the head by an unknown person, and stated they were sometimes afraid of CC5. A social services staff member reported this allegation to the state agency but did not complete a facility incident report, did not initiate care plan changes or interventions, and took no further action. CC5 continued to be treated as the resident’s representative, and progress notes documented CC5 at the bedside on multiple dates, including an entry noting the room smelled like foreign substances and that CC5 was seen waking the resident and then asking the nurse to administer pain medications. A psychiatry note later documented concern that CC5 was providing the resident with illicit substances and stated it would be prudent for the resident to identify a POA. Subsequently, the resident was found unresponsive, transported to the hospital, and later readmitted after altered mental status and overdose, with a provider note stating that CC5 posed a significant danger to the resident and was banned from visiting. After readmission, staff attempted to contact CC4 for consent to treat but initially reached someone who stated they were not CC4. The social service director acknowledged that, beyond reporting the initial allegation, no additional interventions were implemented, that CC5 continued to be used as the resident’s representative after the allegation, and that they had not explored legal authority for decision making following the abuse allegation or concerns about substances. The social service assistant reported they did not speak with the resident about the hospital stay or CC5 and did not complete an incident report or care plan changes after the allegation. The unit manager and DON were unaware of the initial abuse allegation, and the administrator, who served as abuse coordinator, also stated they were unaware of the allegation and that an investigation should have been initiated and a representative for the resident investigated at a minimum.
Injury from Mechanical Lift Sling Detachment During Transfer
Penalty
Summary
The facility failed to ensure a safe mechanical lift transfer when a resident was being moved with a Hoyer lift and sling, resulting in a fall and injury. Facility policy for using a mechanical lifting machine required staff to securely attach sling straps to the sling bar according to manufacturer’s instructions, double-check the security of the sling attachment before lifting, examine all hooks, clips, or fasteners, check strap stability, and ensure the sling bar was securely attached and sound. Despite these requirements, during a transfer for dinner, two CNAs placed the sling under the resident, attached the loops at each corner of the sling to the lift, and raised the resident off the bed into the space between the bed and wheelchair when the bottom left corner of the sling became disengaged from the lift. The resident involved had multiple diagnoses including osteoarthritis, cervical and thoracic spondylosis, and Alzheimer’s disease, with the Minimum Data Set documenting severely impaired cognitive skills for daily decision-making. The resident’s care plan required the assistance of two staff during Hoyer lift transfers. During the transfer, the resident fell approximately four feet, landing on her buttocks, bouncing, and then falling backward and striking her head on the leg of the Hoyer lift. Hospital records documented that the resident sustained an abrasion to the back of the head, fractures of the 6th, 7th, 8th, and 10th ribs, and fractures of the 1st and 2nd lumbar vertebra. Staff interviews and observations showed that staff believed the sling loops had been securely fastened and reported hearing the loops click into place before lifting. One CNA stated that they had barely lifted the resident off the bed when the bottom left loop became disconnected and the resident fell. Another CNA reported being shocked and unable to figure out what had happened. A nurse who assessed the resident and then examined the equipment after the fall noted that one of the loops of the sling had become disengaged but stated the sling appeared to be in good condition. During a later demonstration, a CNA indicated she thought one of the round metal disks on the lift might have been a little loose. Maintenance logs for Hoyer slings and lifts for the preceding months documented no concerns with the slings or lifts, and the DON acknowledged expecting a citation due to the resident’s injury from the fall.
Failure to Revise Care Plans to Reflect Resident Needs and Preferences
Penalty
Summary
The deficiency involves the facility’s failure to revise and individualize comprehensive care plans to reflect residents’ current needs and preferences, as required by its own care planning policy. For one resident with hemiplegia, hemiparesis following cerebrovascular disease, and mononeuropathy of the upper limb, the admission MDS showed intact cognition and upper extremity impairment. This resident reported having bilateral shoulder surgery and an inability to tolerate blood pressure measurements on the upper arms due to pain, and stated a preference for BP measurements on the forearms. The resident reported having informed multiple nursing staff of this preference, but staff continued to place the cuff on the upper arms. Review of the resident’s care plan and Kardex showed no interventions or instructions regarding forearm BP cuff placement. A NAC confirmed they were unaware of the preference until the resident told them directly and that this instruction was not documented in the Kardex. The RN/Unit Manager, who stated they were responsible for revising and reviewing care plans when there were changes, also confirmed they were not aware of the resident’s preference and that it should have been updated in the care plan. Another resident, readmitted with hemiplegia and hemiparesis following a nontraumatic subarachnoid hemorrhage, contracture of the left hand, and weakness, was cognitively intact and required maximum assistance for bed mobility per a quarterly MDS. This resident stated they were supposed to get out of bed for two hours every day, but some NACs were not aware of this care requirement. Review of the resident’s March 2026 MAR/TAR showed an order to document the time the resident got up and the time they returned to bed daily. The report states that, overall, the facility failed to revise care plans accurately to reflect residents’ needs for three of four residents reviewed for care plan revision, placing them at risk for unidentified and unmet care needs and a diminished quality of life.
Failure to Implement Restorative Nursing and Splint/Brace Programs After Therapy Discharge
Penalty
Summary
The deficiency involves the facility’s failure to provide restorative nursing services, including range of motion (ROM) exercises and splint/brace assistance, to maintain or prevent decline in mobility and contractures for two residents with significant motor impairments. The facility’s undated Restorative Nursing Services policy stated that residents would receive restorative care as needed to achieve and maintain optimal functioning and that residents may initiate a restorative program upon discharge from rehabilitative care. Despite this, surveyors found that residents with documented hemiplegia, hemiparesis, weakness, and contractures were not placed on restorative programs and had no restorative interventions documented in their electronic health records (EHRs). Resident 1 was admitted with hemiplegia and hemiparesis following cerebrovascular disease, a left lower leg fracture, and weakness, and the admission MDS showed intact cognition, moderate assistance needs for bed mobility and transfers, and one-sided upper and lower extremity impairment. During observation, the resident was seen lying in bed with a bent inward left forearm and hand and reported no longer receiving therapy or nursing-assisted exercises. The care plan initiated in January showed no restorative services, and the care plan history and EHR contained no restorative nursing interventions. However, the PT discharge summary from February documented that restorative ROM and transfer programs had been established and trained, including PROM to the left upper and lower extremities and stand-by assist with transfers, and the OT discharge summary recommended a splint/brace to prevent contracture. The OT stated that the splint/brace was not tried due to lack of time before insurance was discontinued, and both the Director of Rehab and the MDS coordinator confirmed there was no restorative referral in the EHR and they were unaware of the recommendations. Resident 2 was readmitted with hemiplegia and hemiparesis following a nontraumatic subarachnoid hemorrhage, a left-hand contracture, and weakness, and the quarterly MDS showed intact cognition, maximum assistance needs for bed mobility, total assistance for transfers, bilateral upper and lower extremity impairment, and no therapy or restorative programs. The resident reported that therapy had been discontinued months earlier and that no restorative staff were assisting with exercises. The care plan and EHR showed no restorative services. OT evaluation documented left upper extremity ROM impairment, a left-hand contracture, and prior use of a left orthotic to manage flexion tone, and the OT discharge summary recommended restorative care and assistance with donning/doffing the orthotic. The PT discharge summary recommended restorative programs if Medicaid Part B services did not continue. The Director of Rehab confirmed therapy was discontinued and that restorative nursing programs were recommended, but both the Director of Rehab and the MDS coordinator stated there were no restorative referrals in the EHR after readmission, and the MDS coordinator confirmed the resident had no restorative programs since readmission.
Failure to Implement Effective Fall and Toileting Interventions for High-Risk Resident
Penalty
Summary
The deficiency involves the facility’s failure to provide adequate supervision, identify fall trends, and implement progressive, resident-centered interventions for a resident with multiple falls and declining strength. The facility’s own Falls and Fall Risk Management policy required staff to identify interventions related to residents’ specific risks and causes to prevent falls and minimize complications. The resident’s Care Area Assessment identified cancer-related risks for pain, falls, and ADL decline, and stated that falls and urinary incontinence would be addressed in the care plan with an objective of improvement and risk minimization. However, the comprehensive care plan did not include a urinary or ADL care plan and contained no toileting plan, despite the resident’s identified risks and prior fall history. Over a series of falls, the resident repeatedly fell while attempting to toilet or move toward the bathroom, yet the facility did not recognize or address this pattern in its investigations or care planning. The resident had multiple unwitnessed falls: next to the bed while getting up to use the restroom, in the bathroom while standing to use the toilet, and near or in the bathroom on several occasions. Incident investigations and post-fall assessments documented environmental factors such as clutter, items on the floor, water on the floor, and issues with footwear, as well as the resident’s increasing weakness, impulsivity, poor safety awareness, and poor insight into limitations. Interventions documented in investigations and risk reviews included encouraging use of the front-wheeled walker, keeping the wheelchair and walker accessible, ensuring proper footwear and non-skid socks, and providing resident education on safe transfers, ambulation, and assistive device use. However, several of these planned interventions, including placement of the wheelchair and frequent rounding/toileting assistance, were not added to or reflected in the care plan as stated. Staff interviews further showed that the resident frequently fell while trying to go to the bathroom and that staff relied on verbal education and reminders to use the call light, even though the resident often did not use it. Staff acknowledged the resident’s impulsivity and tendency to get up independently despite instructions, and one staff member stated that nursing assistants were verbally instructed to offer bathroom assistance, but this intervention was not documented in the care plan. The resident’s bed remained the one furthest from the bathroom throughout the stay, and none of the facility’s investigations identified the trend of bathroom-related falls or addressed toileting options in the care plan. Ultimately, the resident sustained a left ankle fracture after another bathroom-related fall, requiring transfer to the emergency department for evaluation and treatment, and later records documented additional fractures and a decline in condition. The surveyors concluded that the facility’s failures placed residents at risk of repeated falls and injuries.
Failure to Monitor Urinary Retention After Foley Removal Leading to Prolonged Pain
Penalty
Summary
The deficiency involves the facility’s failure to adequately assess and monitor a resident for complications associated with an indwelling urinary catheter and urinary retention, particularly after catheter removal. The resident had a history of acute kidney injury due to urinary retention, which improved after Foley catheter placement in the hospital. Hospital discharge documentation indicated the catheter was placed for acute urinary retention, was deemed permanent, and included instructions that, given the resident’s significant retention and acute renal failure, staff at the skilled nursing facility should not attempt Foley removal. The facility’s catheter care plan directed staff to empty the catheter as needed and record output in milliliters, but review of the last 30 days of documentation showed continence was not rated due to the indwelling catheter and there was no documented urinary output in milliliters on the treatment administration records. The resident had a scheduled urology appointment at which the urinary catheter was discontinued. Upon return from this appointment, nursing documentation initially indicated no new orders, and an alert note later stated the catheter was discontinued and staff were monitoring for retention or pain. However, there was no documented bladder assessment or urinary output following catheter removal. Nursing assistant documentation showed that the resident did not void on the evening shift that same day. Despite the catheter having been removed, the treatment administration record showed staff continued to document provision of catheter care on subsequent shifts when no catheter was in place. Over the next day, the resident experienced vomiting, decreased oral intake, and an altered level of consciousness, with vital signs showing tachycardia and low blood pressure, and staff documented decreased urine output. A bladder scan performed later revealed more than 2000–2500 milliliters of urine in the bladder, and an indwelling catheter was reinserted, initially draining a large volume of urine. The provider note indicated the resident had not eaten since the prior night, was unable to hold down fluids, and staff were unsure whether the resident had urinated in incontinence briefs, with no wet briefs reported since the resident’s return from the hospital after catheter removal. The provider expressed concern that the documented early-morning wet brief might not be accurate given the large bladder volume on scan and stated this should require further investigation. Subsequent notes described the resident moaning and complaining of pain, with limited urine output in the catheter bag and staff flushing and then replacing the catheter due to continued complaints. Interviews with the resident, the roommate, and staff indicated the resident was crying out and moaning in pain, the roommate repeatedly alerted staff that the resident was not urinating and that the catheter was not draining, and staff had to seek assistance to replace the catheter. Facility leadership and clinical staff later acknowledged that typical practice after catheter removal would include contacting the provider, placing the resident on alert, performing post-void residuals with bladder scans, and documenting monitoring, which was not done in this case.
Medication Administration Delays, Documentation Errors, and Use of Expired Insulin
Penalty
Summary
The deficiency involves the facility’s failure to ensure sufficient nursing staff with appropriate competencies and skill sets to administer medications according to professional standards of practice, facility policy, and prescriber orders. The facility’s medication administration policy required medications to be given as prescribed, in accordance with manufacturers’ specifications and good nursing principles, with no expired medications used, and doses administered within 60 minutes of the scheduled time and documented immediately after administration. Multiple residents reported that agency nurses often gave medications late, did not read full instructions, or were slow in bringing medications, and that routinely scheduled medications were not consistently provided without residents having to ask. Surveyors observed several specific medication administration failures. For a resident with diabetes, an LPN drew up and administered Humalog/Lispro insulin from a multi-dose vial that had been opened and dated “02/16” with no year, making it expired per policy, and administered the dose nearly 1 hour and 45 minutes after it was due. Another resident with care plan instructions to receive medications as ordered had multiple scheduled medications (Gabapentin, Oxybutynin, Baclofen, and Tizanidine) that were ordered at specific times throughout the day; the LPN was observed administering all four together and acknowledged that at least one (Tizanidine) was late, while the resident reported that receiving them together at that time was typical and not at their request. For another diabetic resident, an RN checked blood sugar and prepared sliding scale Humalog/Lispro insulin almost two hours after the scheduled time; the resident refused the insulin, stating they had already finished lunch. Additional deficiencies were identified with other residents’ pain and scheduled medications. One resident with a pain care plan and an order for Methocarbamol four times daily at set times approached the cart requesting Methocarbamol and Tylenol; the RN initially stated the Methocarbamol had already been given, but then administered it two hours after it was due when the resident pointed out the scheduled timing. For another resident with a risk for pain care plan and Tramadol ordered three times daily at specific times, an LPN retrieved a PRN pain medication while the electronic record showed no 8:00 AM medications documented; the LPN stated they had given them but had not yet documented. Later, an RN prepared the 2:00 PM Tramadol dose, and review of the narcotic count showed a discrepancy between the number of pills documented and the number remaining in the card. The RN stated they had given the 8:00 AM Tramadol but had not signed it out, then signed out both the 8:00 AM and 2:00 PM doses at that time. Residents interviewed consistently reported that medications were sometimes or frequently late, that agency nurses did not always follow instructions, and that they often had to request medications that were routinely scheduled.
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