South Creek Post Acute
Inspection history, citations, penalties and survey trends for this long-term care facility in Centralia, Washington.
- Location
- 917 South Scheuber Road, Centralia, Washington 98531
- CMS Provider Number
- 505373
- Inspections on file
- 42
- Latest survey
- February 20, 2026
- Citations (last 12 mo.)
- 21
Citation history
Health deficiencies cited at South Creek Post Acute during CMS and state inspections, most recent first.
The facility failed to follow its abuse/neglect reporting policy when an allegation involving a resident with COPD and opioid dependence was not promptly reported to the State Survey Agency. The Administrator received a report that the resident had wrist marks related to restraints and had been found unresponsive due to possible overmedication, but did not notify the state hotline as required, believing similar concerns had been previously investigated. The DON was not informed of the allegation during this period, did not initiate an investigation, and had no related documentation. The allegation and investigation were not documented and reported to the state hotline until weeks later, in violation of the facility’s requirement to report such allegations within two hours and applicable state regulations.
A resident with COPD and opioid dependence was the subject of an allegation involving wrist marks related to restraints and an episode of unresponsiveness due to possible overmedication. The Administrator received this allegation but did not initiate a new investigation, believing similar concerns had been addressed previously, and did not inform the DON. As a result, the DON was unaware of the allegation, did not start an investigation, and found no related documentation until much later, when the investigation was finally initiated and documented outside the required timeframe.
A resident did not receive physician-ordered CBC and BMP labs after an initial unsuccessful blood draw, and no further attempts or timely physician notifications were documented. The missed labs led to the resident's condition worsening, requiring hospital admission for profound anemia, hyponatremia, and acute renal failure.
A resident admitted with a wound infection did not receive the prescribed antibiotic Meropenem as ordered by an infectious disease provider. Due to a breakdown in the medication order entry and review process, the order was scanned into the electronic medical record but not entered or activated, resulting in the resident receiving a different antibiotic instead. Staff were unaware of the error until it was brought to their attention by the infectious disease provider.
A resident who required supervision while smoking was left unattended by a NAC, resulting in a fall and head injury. The facility's investigation inaccurately documented the fall as witnessed, despite statements confirming the resident was alone. The DON acknowledged discrepancies in the investigation documentation.
A resident was admitted and given an antihypertensive medication without documented vital signs, including blood pressure or pulse, in the electronic medical record. Staff interviews confirmed that vital signs should have been obtained and recorded both at admission and prior to medication administration, but no such documentation was found.
Two nurse technicians with expired credentials administered scheduled opioid and IV medications, including controlled substances, despite state regulations prohibiting such actions. Staff interviews revealed a lack of education and understanding about the nurse technician scope of practice, with both nursing and administrative staff unaware of the restrictions on medication administration for nurse technicians.
The facility did not ensure that the Dietary Manager had the necessary certification to oversee food and nutrition services, with oversight at times provided by an HR Director also lacking certification. The dietician was only present part-time, resulting in the kitchen being managed by staff without the required qualifications.
The facility did not obtain or maintain proper documentation of Advance Directives for two residents—one with severe cognitive impairment and another who declined an AD but required quarterly review—resulting in missing records and lack of evidence that AD information was provided or reviewed as required.
Two residents were found using bed rails without documented assessment, consent, or physician order, as required by facility policy. Staff confirmed that these steps were necessary, but review of the EHR and care plans showed they were missing for both a severely and a moderately cognitively impaired resident.
The facility did not coordinate required PASARR Level II evaluations for two residents who exhibited mental health symptoms and were prescribed psychotropic medications. Despite Level I screenings indicating the need for further assessment, no Level II referrals were made or documented, and staff interviews confirmed the absence of necessary evaluations in the records.
A resident admitted with schizoaffective disorder and moderate cognitive impairment did not have an accurate PASARR Level I assessment completed, as the screening failed to indicate a serious mental illness and left required sections incomplete. Facility staff later acknowledged the error and the lack of a referral for a Level II PASARR evaluation.
A resident with severe cognitive impairment did not have a documented activities care plan addressing her preferences, goals, or interventions. Despite staff awareness of her enjoyment of singing, morning exercises, and watching TV, the resident was repeatedly observed lying in bed and expressed a desire to participate in activities. Staff confirmed the absence of a care plan and noted limited activity participation.
A resident with dysphagia and moderate cognitive impairment did not receive enteral nutrition and water flushes according to physician orders, as the pump was set incorrectly. Additionally, multiple prescribed medications were not documented as administered in the MAR. Staff confirmed expectations for verifying orders and documentation were not met.
A resident with severe cognitive impairment and dependence on staff for personal hygiene was repeatedly observed with thick facial hair and expressed embarrassment and a desire for more frequent shaving. Staff interviews revealed inconsistent practices regarding the frequency of shaving, and records showed no documentation of care refusals, indicating a failure to provide consistent assistance with this activity of daily living.
A resident with severe cognitive impairment did not have a care plan addressing activity preferences, despite staff knowledge of her interests in singing, morning exercises, and watching TV. Observations showed the resident spent most of her time in bed without engagement in activities, and staff interviews confirmed limited participation due to lack of support in getting out of bed. The resident expressed interest in doing more activities.
The facility did not follow its bowel management protocol for several residents, resulting in extended periods without bowel movements and no documented interventions. Staff interviews and record reviews confirmed that licensed nurses did not initiate the required bowel protocol, despite clear policy expectations and documentation of missed bowel movements. Both cognitively impaired and alert residents were affected by this lapse in care.
A resident with severe cognitive impairment and a PRN oxygen order was repeatedly observed receiving continuous supplemental oxygen without corresponding documentation of oxygen flow rate or assessment of need in the MAR/TAR. Staff interviews revealed uncertainty about monitoring and documenting the resident's oxygen requirements, and records showed no evidence of SpO2 monitoring on room air as required by the order.
Surveyors found that an LPN stored multiple unlabeled medications in plastic cups marked only with room numbers in a medication cart, contrary to facility policy. The DON confirmed that medications should not be pre-poured or stored in this manner, resulting in a deficiency for improper medication storage and labeling.
Staff did not disinfect shared medical equipment, including Hoyer lifts and vital sign machines, between use with different residents. Disinfecting wipes were not available in key locations, and several staff members confirmed they had not cleaned equipment as required, despite facility expectations.
A resident with severe cognitive impairment was found with a loose, padded bed rail that moved several inches and was not securely attached to the bed frame. Multiple staff, including an LPN, DON, and Maintenance Director, confirmed the bed rail's looseness and lack of routine safety checks, resulting in a deficiency for not ensuring bed rails were properly secured.
A resident with moderate cognitive impairment and at risk for skin breakdown developed a lesion on the genitalia, which was not included in the care plan despite being assessed and communicated to the provider. Staff interviews confirmed the expectation for care plans to be updated with any change in condition, highlighting a deficiency in the facility's care planning process.
A facility failed to readmit a resident after hospitalization due to insurance issues and concerns about potential drug-related substances in his belongings. The resident, who underwent a leg amputation, was not provided with a discharge plan or a written explanation for the denial of readmission. The facility's policy required readmission regardless of payer source, but staff cited a change in ownership affecting insurance agreements as a reason for the denial.
A resident experienced an unwitnessed fall and was not assessed by the nurse on duty, despite being informed by a CNA. The resident had visible bruises, and neurological checks were only initiated the following day. The facility's protocol for falls, requiring immediate assessment and documentation, was not followed.
The facility failed to maintain cleanliness and food safety in its dry storage room and juice dispensing area. Observations revealed liquid and a black substance under a cart, condensation on the ceiling, and a wet, sticky juice dispensing area. Staff acknowledged the poor conditions, which posed a risk for foodborne illness.
The facility failed to maintain a safe and sanitary kitchen environment due to broken linoleum tiles exposing bare concrete near dishwashing and handwashing stations. The Maintenance Director placed mats over the exposed areas, and the Administrator acknowledged the issue, noting it was inherited from a previous owner and would be fixed soon.
The facility failed to maintain cleanliness and proper labeling in its kitchen and storage areas, posing a risk for foodborne illness. Surveyors observed dark residue on the ice machine, unlabeled and undated food items in storage, and lint on kitchen vents. The Dietary Manager and Assistant Director of Nursing acknowledged these lapses, indicating a failure to adhere to food safety protocols.
A facility failed to obtain necessary documentation and approvals for the use of padded quarter bed rails on a severely cognitively impaired resident. Despite the facility's policy requiring an evaluation, consent, physician's order, and care plan for such devices, these were not completed. Staff interviews confirmed the absence of required documentation, placing the resident at risk for injury and unmet needs.
A facility failed to develop a comprehensive care plan for a cognitively impaired resident using padded quarter bed rails, as required by their policy. Despite observations confirming the use of bed rails, staff interviews revealed the absence of documentation, evaluation, or consent for the device, highlighting a lapse in policy adherence.
The facility failed to provide preventative measures for contractures and consistent restorative services for two residents. One resident with a history of CVA and contractures did not receive adequate preventative measures, such as a splint. Another resident, who was supposed to be on a restorative program, received services on only a few occasions due to staff being reassigned, with no follow-up on days the resident refused services.
The facility failed to provide follow-up education for the PCV13 vaccine for a resident who had previously declined it. The resident's electronic health record lacked additional information about the vaccine, and staff were unsure if the resident's desire to receive the vaccine with her granddaughter was followed up. Staff indicated that the vaccine should be reviewed quarterly and offered annually if declined.
A resident with moderate cognitive impairment was sent to the ER and diagnosed with a narcotic overdose after receiving Morphine Sulfate ER. Despite the serious nature of the incident, the LTC facility failed to initiate a formal investigation. Staff interviews revealed that no investigation was documented, and a medication review conducted by a Residential Care Manager was informal and undocumented.
Failure to Timely Report Allegation of Abuse/Neglect to State Agency
Penalty
Summary
The facility failed to timely report an allegation of abuse and/or neglect to the State Survey Agency as required by its policy and state regulations. The facility’s abuse, neglect, exploitation, and misappropriation policy, dated September 2022, required that suspected abuse, neglect, exploitation, misappropriation, or injury of unknown source be reported immediately to the administrator and to other officials according to state law, defining “immediately” as within two hours for allegations involving abuse or resulting in serious bodily injury. Resident 1, admitted with diagnoses including COPD and opioid dependence, was the subject of an allegation received by the Administrator (Staff A) on 01/27/2026 at 2:10 PM. The allegation involved reported marks on the resident’s wrists related to restraints and that the resident had been found unresponsive due to being overmedicated. Despite receiving this allegation, Staff A did not report it to the state hotline at the time it was received, stating she believed a prior investigation had addressed similar concerns. The DON (Staff B) reported on 02/13/2026 at 2:00 PM that she had not been informed of the allegation between 01/27/2026 and 02/13/2026, had not initiated an investigation related to the reported restraint-related marks and unresponsiveness, and could not locate documentation of any such investigation. Facility documentation showed the allegation was not reported to the state hotline until 02/13/2026, and the facility investigation document was also dated 02/13/2026. The surveyors concluded that the facility failed to report the allegation within required timeframes, as referenced in WAC 388-97-0640(5)(b).
Failure to Timely Initiate and Document Abuse/Neglect Investigation
Penalty
Summary
The facility failed to initiate and complete a thorough investigation of an allegation of abuse and/or neglect within required timeframes, as required by its policy and WAC 388-97-0640(6). The facility’s abuse, neglect, exploitation, or misappropriation policy dated September 2022 stated that all allegations are to be thoroughly investigated, and that the administrator is responsible for initiating investigations upon receipt of an allegation and ensuring they are documented. Resident 1, admitted with diagnoses including COPD and opioid dependence, was the subject of an allegation reported to the Administrator (Staff A) on 01/27/2026 at 2:10 PM. The allegation involved reported marks on the resident’s wrists related to restraints and that the resident had been found unresponsive due to being overmedicated. Despite receiving this allegation on 01/27/2026, Staff A did not initiate a new investigation at that time, stating she believed a prior investigation had addressed similar concerns. The DON (Staff B) reported on 02/13/2026 at 2:00 PM that she had not been informed of the allegation between 01/27/2026 and 02/13/2026, had not initiated an investigation, and could not locate any documentation of an investigation specific to the reported restraint-related marks and unresponsiveness. Facility documentation showed the investigation was not initiated and documented until 02/13/2026. On 02/20/2026 at 1:10 PM, Staff B confirmed the facility did not initiate or complete the investigation within five working days of the allegation being received on 01/27/2026 because she was not aware of it.
Failure to Obtain Ordered Laboratory Services Resulting in Resident Harm
Penalty
Summary
The facility failed to obtain physician-ordered laboratory services for one resident, resulting in harm. The resident was admitted with orders for a CBC and BMP to be completed due to ongoing nausea. Documentation showed that the weekend RN supervisor attempted to draw the labs once but was unsuccessful, and there was no evidence of further attempts or that the physician was notified of the failed draw. The Medication Administration Record did not show that the labs were collected or completed, and the care plan required labs to be completed per physician orders with results reported to the physician. Interviews with staff confirmed that after the initial unsuccessful attempt, no additional efforts were made to obtain the labs, and the physician was not informed in a timely manner. As a result of the missed laboratory tests, the resident's condition deteriorated, leading to an emergency hospital admission. Hospital records documented that the resident was found to have profound anemia, hyponatremia, acute renal failure, and sepsis, requiring transfer to the intensive care unit. The resident reported feeling neglected and stated that the facility did not perform the necessary blood tests as ordered by the physician. Staff interviews confirmed that the labs were not obtained on the days following the initial order, and the physician was not kept informed of the ongoing failure to complete the ordered tests.
Failure to Administer Prescribed Antibiotic Due to Medication Order Entry Error
Penalty
Summary
The facility failed to ensure that a resident's prescribed medication, Meropenem, was administered as ordered by the infectious disease provider. The resident, who was admitted with a wound infection and was cognitively intact, had a care plan and provider orders specifying a four-week course of Meropenem 1g IV every 8 hours. However, a review of the resident's physician orders and medication administration records showed that Meropenem was never ordered or administered. Instead, the resident received a different antibiotic, Zosyn, during their stay. Interviews with facility staff revealed that the process for entering admission medication orders involved the medical records department inputting orders into the electronic medical record system (PCC), followed by review and activation by two nurses. The infectious disease clinic's orders for Meropenem were faxed and scanned into the resident's record before admission, but were not entered into the system for review and activation. This communication error resulted in the omission of the Meropenem order, and staff were unaware of the issue until notified by the infectious disease provider.
Failure to Thoroughly Investigate Unsupervised Fall During Smoking
Penalty
Summary
The facility failed to thoroughly investigate a fall involving a resident who was cognitively intact and required supervision while smoking. The resident's care plan and smoking assessment both indicated that staff supervision was necessary during smoking due to cognitive impairment and inability to safely smoke or access the smoking area independently. On the day of the incident, a nursing assistant (NAC) assisted the resident outside to smoke but left the resident unattended to use the restroom. During this time, the resident dropped a lit cigarette, leaned forward from the wheelchair to retrieve it, and subsequently fell, hitting her head on the concrete. The facility's fall investigation inaccurately documented the incident as a witnessed fall, despite statements from the resident and staff indicating the resident was left alone at the time. Interviews with the resident, a collateral contact, and staff confirmed the resident was unsupervised when the fall occurred. The Director of Nursing acknowledged discrepancies in the investigation documentation and agreed that the witness statement could have been more detailed. The failure to accurately investigate and document the circumstances of the fall resulted in a deficiency under WAC 388-97-0640 (6)(a)(b).
Failure to Document Vital Signs on Admission and Before Antihypertensive Administration
Penalty
Summary
The facility failed to obtain and document vital signs upon admission and prior to administering a blood pressure medication for one resident. According to the facility's policy, vital signs should be recorded in the resident's medical record upon admission. The resident, who was cognitively intact, was admitted and subsequently discharged on the same day. Physician orders required blood pressure monitoring prior to administering antihypertensive medication, specifically Metoprolol, and directed staff to notify the physician if systolic blood pressure was less than 100. However, review of the electronic medical record and medication administration record showed that the resident received Metoprolol without any documentation of vital signs, including blood pressure or pulse, at admission or before medication administration. Interviews with nursing staff, including a registered nurse, an LPN, a residential care manager, and the DON, confirmed that the facility's practice is to obtain and document vital signs for new admissions and before administering blood pressure medications. Staff described a process where vital signs are initially recorded on a sheet and then entered into the electronic medical record. Despite this, all interviewed staff were unable to locate any documentation of the resident's vital signs in the electronic medical record for the relevant period, confirming the deficiency.
Nurse Technicians Administered Prohibited Medications Without Proper Credentials
Penalty
Summary
The facility failed to comply with state and local regulations by allowing two nurse technicians, Staff D and Staff E, to administer scheduled and intravenous (IV) medications, including controlled substances, to residents. According to the state's administrative code, nurse technicians are not authorized to administer chemotherapy, blood or blood products, IV medications, scheduled drugs, or perform procedures on central lines. Despite this, records showed that Staff D administered scheduled opioid medications 11 times and IV medications three times in one month, while Staff E administered scheduled opioid medications 20 times and IV medications once during the same period. Both staff members' nurse technician credentials had expired at the time of these actions. Interviews with staff revealed a lack of understanding and education regarding the scope of practice for nurse technicians. Staff D reported that she was still in nursing school and believed she could perform medication administration tasks as long as an RN was present, but had not received specific education on which medications or routes were permitted. Staff C, an LPN, confirmed that nurse technicians dispensed controlled medications and had not received education on their roles. The Director of Nursing also stated that nurse technicians administered narcotic and IV medications, indicating a systemic lack of awareness and training regarding regulatory limitations.
Dietary Manager Lacked Required Certification
Penalty
Summary
The facility failed to ensure that the Dietary Manager had the required qualifications or certification to perform their duties in the kitchen. According to interviews and record review, the Dietary Manager began working in the position without having obtained the necessary dietary management certification and was still waiting for a proctor to administer the final test. During the Dietary Manager's absence, oversight of the kitchen was provided by the Human Resources Director, who also did not yet have the required certification but was in the process of obtaining it. The facility's dietician was only present on a part-time basis. This resulted in the kitchen being managed by staff who did not possess the required competencies and skills as mandated by regulation.
Failure to Obtain and Maintain Advance Directives Documentation
Penalty
Summary
The facility failed to obtain and/or maintain Advance Directives (AD) for two of twenty sampled residents. For one resident who was severely cognitively impaired, there was no documentation in the care plan or electronic health record (EHR) regarding the existence of an AD, nor evidence that information or assistance was provided to develop one. The social history assessment also did not indicate the presence of a responsible party or legal guardian, and staff confirmed that no outreach was made to the resident's family regarding guardianship or ADs. For another resident who was alert and oriented, the care plan documented that the resident did not wish to execute an AD at the time and that AD information should be offered quarterly and as needed. However, there was no documentation in the EHR that AD information was reviewed or offered on a quarterly basis or as needed. Staff interviews confirmed the lack of documentation and acknowledged that the facility's expectation was to review and offer AD information upon admission and quarterly.
Failure to Obtain Assessment, Consent, and Physician Order for Bed Rail Use
Penalty
Summary
The facility failed to obtain required assessments, consents, and physician orders for the use of bed rails for two residents. One resident, who was severely cognitively impaired, was observed multiple times with a padded bed rail in use, but there was no documentation in the electronic health record (EHR) of an assessment, consent, or physician order for the bed rail. Staff interviews confirmed that facility policy requires these steps before bed rails are used, and staff were unable to locate the necessary documentation for this resident. Another resident, who was moderately cognitively impaired, was observed with quarter bed rails and the bed positioned against the wall on several occasions. There were no physician orders or care plan entries addressing the use of bed rails or the bed's placement against the wall in the EHR. Staff confirmed that an assessment, consent, physician order, and care plan should have been in place for these interventions, but none were found for this resident.
Failure to Coordinate PASARR Level II Evaluations for Residents with Mental Health Needs
Penalty
Summary
The facility failed to coordinate the Preadmission Screen and Resident Review (PASARR) Level II services for two residents who required further evaluation for mental health needs. For one resident with moderate cognitive impairment, the Level I PASARR indicated a Level II evaluation was required, but no assessment was ever requested or obtained. This resident later developed new delusions and hallucinations and was started on new psychotropic medications, yet the PASARR was not updated to reflect these changes or to initiate a Level II referral. Another resident, admitted with a diagnosis of Post-Traumatic Stress Disorder and exhibiting symptoms such as mood instability, agitation, and refusals of care, also had a Level I PASARR indicating the need for a Level II evaluation. However, the assessment was never requested or obtained, despite the resident being treated with multiple psychotropic medications. Interviews with facility staff confirmed that the required referrals and documentation for Level II PASARR evaluations were not found in the electronic health record for either resident.
Failure to Complete Accurate PASARR Assessment for Mental Health Diagnosis
Penalty
Summary
The facility failed to ensure that a Pre-Admission Screening and Resident Review (PASARR) assessment was accurately completed for a resident with a documented mental health diagnosis. The resident was admitted with schizoaffective disorder and was noted to be moderately cognitively impaired, receiving both antipsychotic and antidepressant medications. However, the Level I PASARR completed prior to admission did not indicate the presence of a serious mental illness, such as schizophrenia or a mood disorder, and the section regarding service needs and assessor data was left incomplete. Upon review, facility staff acknowledged that the PASARR was inaccurate and that the necessary sections were not filled out, which should have prompted a referral for a Level II PASARR evaluation. The deficiency was identified through interviews and record reviews, which confirmed that the required screening process was not properly followed according to facility policy and regulatory requirements.
Failure to Develop Person-Centered Activities Care Plan for Cognitively Impaired Resident
Penalty
Summary
The facility failed to develop a person-centered activities care plan for a resident who was severely cognitively impaired. The resident was admitted to the facility and, according to the Admission Medicare - 5 Day Minimum Data Set assessment, was documented as severely cognitively impaired. A review of the resident's electronic health record (EHR) revealed there was no care plan addressing activity preferences, goals, or interventions. Multiple observations over several days showed the resident lying in bed, either sleeping or awake, with no evidence of engagement in activities. Interviews with staff indicated that the resident enjoyed singing, morning exercises, and watching TV in her room, but there was no care plan in place to support these preferences. Staff members acknowledged the absence of an activities care plan and noted that the resident did not participate in many activities, often remaining in bed. The resident herself expressed a desire to participate in activities but stated she only got out of bed sometimes. Staff also indicated that the resident might participate if encouraged to get out of bed, but no structured plan was documented to facilitate this.
Failure to Follow Professional Standards in Enteral Nutrition and Medication Documentation
Penalty
Summary
The facility failed to ensure that services provided met professional standards of practice for a resident receiving enteral nutrition. Specifically, a review of the resident's electronic health record revealed a physician order for enteral feeding with Jevity 1.2 at 70ml/hr over 18 hours, with water to run concurrently at 60ml/hr and tube flushes of 50ml pre and post feeding. However, during observation, the tube feeding pump was set to deliver water flushes at 50ml/hr instead of the ordered 60ml/hr. Staff confirmed that the pump settings did not match the physician's order, indicating a failure to verify and implement the correct settings at the beginning of the shift. Additionally, the facility did not document the administration of several medications for the same resident, as evidenced by blank entries in the Medication Administration Record (MAR) for multiple prescribed medications, including Pro-Stat Liquid, Amoxicillin-Pot Clavulanate, Guaifenesin ER, and Gabapentin Oral Solution. Staff interviews confirmed that it was the expectation for nurses to review physician orders, verify pump settings, and document medication administration, but these actions were not completed as required.
Failure to Provide Consistent Shaving Assistance for Dependent Resident
Penalty
Summary
The facility failed to provide necessary assistance with shaving for a resident who was severely cognitively impaired and dependent on staff for personal hygiene. Over several days, the resident was repeatedly observed with thick facial hair on her upper lip and chin, measuring about one quarter inch long. The resident expressed discomfort and embarrassment about the facial hair and stated that she would like to be shaved more often. She reported that shaving was only offered on shower days and not in between, despite her desire for more frequent care. Review of the resident's personal hygiene records showed no documentation of refusal of care for shaving during the observed period. Interviews with staff revealed inconsistent practices regarding the frequency of shaving, with some staff indicating it was offered daily and others stating it was only provided during showers. The Director of Nursing confirmed that shaving should be offered daily or as needed, and refusals should be documented, but this was not reflected in the resident's records. These findings demonstrate a failure to ensure consistent and adequate assistance with activities of daily living for a dependent resident.
Failure to Provide Resident-Centered Activities Based on Preferences
Penalty
Summary
The facility failed to provide resident-centered activities that incorporated the preferences, goals, or interventions for a resident who was severely cognitively impaired. The resident's electronic health record did not contain a care plan addressing activity preferences, and repeated observations over several days showed the resident lying in bed, either sleeping or awake, with no evidence of engagement in activities. Interviews with staff revealed that although the resident enjoyed singing, morning exercises, and watching TV, there was no care plan in place to support these interests. Staff also noted that the resident did not participate in group activities and spent most of her time in bed, with participation limited by lack of encouragement or assistance to get out of bed. The resident herself expressed a desire to participate in activities but indicated she did not do so regularly.
Failure to Initiate Bowel Management Protocol for Multiple Residents
Penalty
Summary
The facility failed to initiate bowel management interventions as outlined in its bowel protocol for six of seven sampled residents. According to the facility's policy, licensed nurses are required to identify residents who have not had a bowel movement for three days, review their medication administration records, and initiate a stepwise bowel protocol involving medications and assessments. However, documentation revealed that multiple residents went between five and seven days without a bowel movement, and there was no evidence that the bowel protocol was initiated as required. Certified Nurse Assistants were responsible for charting bowel movements every shift, but the lack of follow-through by licensed nurses resulted in prolonged periods without intervention. Interviews with staff confirmed that the expected protocol was not followed. An LPN was unable to provide documentation that interventions were started for several residents, and a Resident Care Manager acknowledged that the protocol was not initiated for at least two residents after reviewing their records. The Director of Nursing Services also stated that it was the expectation for nurses to assess and initiate the protocol, but this did not occur. The residents affected included those who were moderately cognitively impaired as well as those who were alert and oriented, and the failure to provide timely bowel management interventions was confirmed through both record review and staff interviews.
Failure to Document and Assess Supplemental Oxygen Use
Penalty
Summary
The facility failed to ensure continuous supplemental oxygen was provided as needed for a resident with a physician's order for oxygen at 1-5 liters per minute via nasal cannula, to be administered when oxygen saturation (SpO2) was less than 88%. Review of the resident's medical record showed no documentation of oxygen flow rate in the Medication Administration Record (MAR) or Treatment Administration Record (TAR), despite multiple observations of the resident using 4L of oxygen via nasal cannula on several occasions. The resident's SpO2 levels for the month were consistently within normal range (92% to 98%), and daily skilled charting summaries documented normal breath sounds and respiratory rates with no respiratory distress. Interviews with facility staff revealed a lack of clarity regarding the assessment and documentation of the resident's need for continuous versus PRN oxygen. The Resident Care Manager and LPN acknowledged that nurses should monitor the resident's SpO2 on room air to determine the need for supplemental oxygen, but there was no evidence this was being done or documented. The Director of Nursing Services stated that nurses were expected to assess and document the need for continuous oxygen and record PRN oxygen use in the MAR/TAR, which was not observed in the records reviewed.
Improper Storage and Labeling of Medications in Medication Cart
Penalty
Summary
Surveyors observed that medications in the Middle South medication cart were not properly stored or labeled according to facility policy and professional standards. Specifically, the top drawer of the cart contained six or seven loose plastic medication cups, each with multiple unlabeled medications. The only identifying information on the cups was a room number written on them. When questioned, the LPN present quickly disposed of the cups before the surveyor could count or further inspect the medications. The LPN explained that the medications were for residents scheduled to go out to appointments and that one resident had refused their medications. The Director of Nursing (DON) later confirmed that it was her expectation that medications should not be pre-poured and that there should not be cups with unlabeled medications for multiple residents stored in the medication cart. The facility's policy requires medications to be stored in an orderly manner, with each resident's medications assigned to an individual area to prevent mixing. The observed practice did not comply with these requirements, resulting in a deficiency related to medication storage and labeling.
Failure to Disinfect Shared Medical Equipment Between Resident Use
Penalty
Summary
Staff failed to clean and disinfect shared medical equipment, such as Hoyer lifts and vital sign machines, between resident use on both North and South hallways. On multiple occasions, staff were observed moving a Hoyer lift from one resident's room to the hallway and then to another room without disinfecting it. Similarly, a nurse assistant used a vital sign machine on one resident and then used the same machine on another resident without cleaning it in between. Disinfecting wipes were not available in isolation carts or in certain rooms, and staff were unable to locate or had not used disinfecting wipes on shared equipment during their shifts. Interviews with staff, including a LPN, CNAs, and the Infection Prevention Nurse, confirmed that the expectation was to disinfect shared equipment between uses, but this was not being followed. The lack of adherence to infection prevention and control guidelines was observed and confirmed through staff interviews and record review, resulting in noncompliance with regulatory requirements.
Failure to Maintain Secure Bed Rail Attachment
Penalty
Summary
A deficiency was identified when a resident with severe cognitive impairment was found to have a bed rail that was not securely fastened to the bed frame. The bed rail, located on the upper right side of the bed and covered with padding, was observed to be loose, with approximately six to seven inches of movement back and forth and leaning away from the mattress by the same distance. The bracket attaching the bed rail to the bed frame was also observed to be loose during multiple observations on consecutive days. Staff interviews revealed that there was no routine schedule for checking bed rails for safety, and maintenance was only notified when staff identified an issue. The Resident Care Manager and LPN were unsure if the bed rail should be tighter, and the DON confirmed that the bed rail was too loose. The Maintenance Director also confirmed the need for tightening after inspecting the bed rail. These observations and interviews demonstrated a failure to ensure that bed rails were securely fastened and free of gaps, as required.
Failure to Update Care Plan After Change in Condition
Penalty
Summary
The facility failed to update the care plan of Resident 1 after a change in condition, specifically the development of a lesion on the resident's genitalia. Resident 1, who was moderately cognitively impaired and at risk for skin breakdown due to various health conditions, was admitted to the facility and had a skin care plan in place. However, this care plan did not include the newly identified lesion on the resident's genitalia, which was first noted on 01/31/2025. Despite the lesion being assessed by staff and communicated to the provider, the care plan was not updated to reflect this change in condition. Staff interviews revealed that the facility's protocol required care plans to be updated with any change in a resident's condition. Staff D, an RN, and Staff C, the Residential Care Manager and LPN, both acknowledged the absence of an updated care plan for the penile lesion. Staff B, the Director of Nursing Services, also confirmed the expectation for care plans to be revised with any change in condition. The failure to update the care plan placed residents at risk for unmet care needs and a decreased quality of life.
Failure to Readmit Resident After Hospitalization
Penalty
Summary
The facility failed to ensure the readmission of a resident after a planned hospitalization, which was a violation of their own policy on bed-holds and returns. The policy required that residents be permitted to return to the facility following hospitalization or therapeutic leave, regardless of payer source. However, after the resident underwent surgery for a leg amputation, the facility did not readmit him, citing issues with his insurance coverage due to a change in ownership affecting agreements with insurers. The resident reported that nothing was discussed with him regarding his discharge plan, and the facility staff confirmed that no discharge plan was implemented. Additionally, the Admission Director expressed concerns about potential drug-related substances found in the resident's belongings, which influenced the decision not to readmit him. The Administrator was unaware of the reasons for the resident's non-return and stated that insurance status should not have been a factor. Furthermore, the facility did not provide the resident with a written explanation for the denial of readmission or information on his appeal rights, as confirmed by the Administrator. The Director of Nursing Services also confirmed the absence of a discharge plan in the resident's electronic medical record.
Failure to Assess Resident After Unwitnessed Fall
Penalty
Summary
The facility failed to ensure a resident was properly assessed after an unwitnessed fall, which was a deficiency in providing quality care related to falls. The incident involved a resident who was cognitively intact and required some assistance with Activities of Daily Living. The resident experienced a fall on New Year's Eve, which was not documented in the progress notes, and the initial neurological evaluations were only conducted the following day. The resident had visible bruises on the right side of her forehead and around her right eye, indicating a lack of immediate assessment and care. The facility's investigation revealed that the nurse on duty, Staff D, was informed of the fall by a CNA, Staff E, but did not assess the resident. Staff E reported the fall to Staff D, who allegedly did not take action to assess the resident despite being informed twice. The resident's roommate also confirmed that no nurse came to assess the resident after the fall, and the resident herself did not recall the fall or being assessed until the morning when neurological checks began. Interviews with facility staff, including the Director of Nursing Services and the Infection Preventionist, highlighted that the facility's protocol for falls was not followed. The protocol required immediate nursing assessment, neurological checks, and documentation, none of which were completed in a timely manner. The facility's expectation was for nurses to investigate falls promptly, consider potential abuse or neglect, and implement interventions to prevent further incidents, which did not occur in this case.
Deficiency in Food Storage and Cleanliness
Penalty
Summary
The facility failed to maintain cleanliness and food safety standards in its dry storage room and juice dispensing area. During an inspection, a pink wheeled cart in the dry storage room was found with clear and brown liquid underneath, and a black, spotted substance was observed on the floor and baseboards. Additionally, there was liquid dripping from a ceiling vent, and condensation patches were forming on the ceiling above shelving that held dry foods. Staff C, the Dietary Manager, acknowledged the poor condition of the storeroom, noting it was the worst she had encountered in four years. Staff D, the Maintenance Director, confirmed the water dripping from the ceiling vent was not normal, and Staff E, the Infection Preventionist, found the black substance's appearance unacceptable. In the juice dispensing area, the floor and compressor were wet, sticky, and had a black, spotted substance. Staff C stated that the area was cleaned by a contractor responsible for refilling the juices, but admitted the cleanliness was below her standards. Staff A, the Administrator, confirmed the juice dispensing area was dirty and acknowledged the need for management oversight in cleaning. The facility's failure to maintain these areas in a clean and sanitary manner placed residents at risk for foodborne illness and cross-contamination.
Deficiency in Kitchen Floor Maintenance
Penalty
Summary
The facility failed to maintain a safe and sanitary environment in the kitchen area, as observed by surveyors. The kitchen floor had broken linoleum tiles near the dishwashing and handwashing stations, exposing approximately 5 square feet of bare concrete at the dishwashing station and 2 square feet at the handwashing station. This condition was acknowledged by the Maintenance Director, who had placed mats over the exposed areas as a temporary measure. The Administrator was also aware of the issue, noting that the building was acquired in this condition from a previous corporation and that the broken tiles were slated for repair as soon as possible.
Food Safety and Cleanliness Deficiencies
Penalty
Summary
The facility failed to maintain cleanliness and proper labeling in its kitchen and storage areas, which posed a risk for foodborne illness among residents. During an initial tour, surveyors observed a dark residue on the ice machine dispenser snout, indicating a lack of cleanliness. Additionally, an opened Ben & Jerry's ice cream container in the walk-in freezer and an opened container of egg shade food coloring in dry storage were not labeled or dated, violating food safety standards. Lint was also observed hanging from overhead vents in the kitchen prep area and tray line side, further indicating inadequate maintenance of cleanliness. During a follow-up visit, the issues persisted, with seven items found opened and unlabeled in the dry storage room. The ice machine still had dark residue, which the Dietary Manager identified as black dirt. Lint continued to hang from vent covers over the hot-hold food service/prep area and behind the tray line. In the north nourishment refrigerator/freezer, several opened items, including a milk jug, rainbow sherbet ice cream, and a box of Kentucky Fried Chicken, were not labeled or dated. The Assistant Director of Nursing confirmed that staff were responsible for labeling items with the date opened, highlighting a lapse in adherence to food safety protocols.
Failure to Obtain Required Documentation for Bed Rails
Penalty
Summary
The facility failed to obtain necessary documentation and approvals for the use of physical restraints on a resident, specifically padded quarter bed rails. The facility's policy requires a Bed Rail/Bed Enabler/Device Evaluation to be completed prior to the use of such devices, along with obtaining consent from the resident or their representative, a physician's order, and incorporating the device into the resident's care plan. However, for Resident 17, who was severely cognitively impaired, these steps were not followed. Observations on multiple occasions confirmed the presence of bed rails, yet the resident's electronic health record lacked any evaluation assessment, consent, or physician's order related to the bed rails. Interviews with facility staff, including registered nurses and resident care managers, revealed a lack of compliance with the facility's policy. Staff members acknowledged the absence of the required documentation and care planning for Resident 17's bed rails. The Assistant Director of Nursing also confirmed that it was expected for residents to have assessments, consents, orders, and care plans for such devices, indicating a lapse in adherence to established procedures. This oversight placed the resident at risk for injury, unmet needs, and a diminished quality of life.
Failure to Document Care Plan for Bed Rails
Penalty
Summary
The facility failed to develop a comprehensive care plan for a resident who was severely cognitively impaired and required the use of padded quarter bed rails on both sides of the bed. Despite the facility's policy requiring that the use of such devices be included in the care plan with the goal of using the least restrictive measures, the care plan for this resident did not document the use of the bed rails. This oversight was identified during a review of the resident's electronic health record and was confirmed through multiple observations of the resident in bed with the padded quarter bed rails in place. Interviews with facility staff, including a Registered Nurse, a Resident Care Manager, and the Assistant Director of Nursing, revealed that it was the facility's expectation to have care plans for residents using bed rails or mobility bars. However, staff were unable to locate any evaluation, consent, order, or care plan for the resident's use of the quarter bed rails. The lack of documentation and care planning for the bed rails was acknowledged by the staff, indicating a lapse in following the facility's policy and procedures.
Failure to Provide Preventative Measures and Consistent Restorative Services
Penalty
Summary
The facility failed to ensure preventative measures for contractures and consistent restorative services for two residents, leading to a deficiency in maintaining activities of daily living (ADLs). Resident 30, who was moderately cognitively impaired and had a history of a cerebral vascular accident (CVA) with contractures to the left hand, reported being unable to open her left hand. Despite this, staff did not provide adequate preventative measures, such as a splint, to address the contractures. Staff F, a Resident Care Manager and LPN, did not believe the resident's nails were causing harm, and Staff C, an Assistant Director of Nursing and RN, suggested offering a splint only after the issue was raised. Resident 17, who was severely cognitively impaired, was supposed to be on a restorative program as per their care plan. However, the Restorative Task form indicated that the resident received services on only a few occasions, with over 85% of the month lacking services. The form noted that the resident refused services on some days, and on other days, services were not available because restorative aids were pulled to the floor. There was no documentation of follow-up for the days the resident refused services, and Staff C confirmed that the lack of documentation was due to the restorative aids being reassigned.
Failure to Provide Follow-Up Education on Pneumococcal Vaccine
Penalty
Summary
The facility failed to provide follow-up education for the Pneumococcal Conjugate Vaccine (PCV13) for one of the five sampled residents reviewed for immunizations. Resident 45 had previously declined the PCV13, as documented in a consent form dated August 11, 2020, without any reason provided for the declination. No additional information about the pneumococcal vaccine was found in the resident's electronic health record. On May 23, 2024, Staff J, an Infection Preventionist and LPN, stated that the PCV13 should be reviewed quarterly at care conferences, but was unsure if this was followed up for Resident 45, who had expressed a desire to receive the vaccine with her granddaughter. Staff C, the Assistant Director of Nursing and RN, mentioned that if the pneumococcal vaccine was declined, it should be offered to long-term care residents every year.
Failure to Investigate Narcotic Overdose Incident
Penalty
Summary
The facility failed to initiate an investigation after a resident was sent to the emergency room and later admitted with a diagnosis of narcotic overdose. The resident, who was moderately cognitively impaired, had a physician order for Morphine Sulfate ER to be administered twice daily for pain. On a particular day, a licensed nurse noted a sudden change in the resident's mental status, including unresponsiveness and inability to follow directions, prompting a transfer to the emergency room. The emergency department documented signs of opioid withdrawal and administered Narcan multiple times, leading to a diagnosis of narcotic overdose and hypoxia. Despite these events, the facility's accident and incident investigation log did not reflect any investigation into the medication overdose. Interviews with facility staff revealed that no formal investigation was conducted. The Director of Nursing Services acknowledged the lack of an investigation, and the Administrator admitted uncertainty about whether an investigation had been initiated. The Residential Care Manager conducted a medication review but found no evidence of an overdose and did not document the review, indicating a failure to formally investigate the incident.
Latest citations in Washington
A resident with cerebral palsy and a court-appointed guardian experienced multiple episodes of nausea, vomiting, loose stools, abdominal discomfort, fatigue, and later refusal of meals and medications, leading to changes in the care plan including close monitoring, lab testing, and IV fluid administration. Despite a facility policy recognizing court-appointed guardians as resident representatives with decision-making authority, staff did not document any notification to the guardian during these changes in condition or treatment decisions. The guardian reported not being contacted when the resident stopped eating or developed stomach issues and felt the facility did not respect the guardianship, while the DON acknowledged there were multiple missed opportunities to notify the guardian of the resident’s change from baseline.
A resident with depression, anxiety, moderate cognitive impairment, and urinary incontinence, care-planned for q2h checks and assistance with toileting, was found by a visitor to be soaking wet, unusually agitated, and reporting they had been told to wait to be changed and referred to with a derogatory remark. The visitor filed a written grievance alleging abuse/neglect related to delayed incontinence care and removal of the resident’s tablet as a consequence. Although an incident report noted that the matter was reported to the state and that the resident was not soaking wet, a CNA who actually changed the resident later reported the resident’s brief, pants, wheelchair, and socks were soaked and that the resident was acting timid and repeatedly saying they had to sit for five minutes, but this CNA was never interviewed. The DON acknowledged not investigating the resident’s behavior or interviewing this CNA, and the grievance official acknowledged the facility did not fully investigate or communicate findings and resolution to the complainant, resulting in a failure to follow the facility’s grievance policy.
A resident with dementia, respiratory failure, and heart failure developed new shortness of breath with an O2 sat of 90%, and a physician ordered transfer to the ED for tx and eval. An RN completed an SBAR, notified the MD and family, and reported to the oncoming nurse that the resident needed ED transfer and that paramedics should be contacted, then left the facility. Instead of calling 911 for this emergent respiratory distress, staff arranged non-emergent transport through a contracted ambulance service, resulting in the resident remaining at the facility for several hours without pickup until the dispatcher later instructed staff to call 911. The DON stated that 911 is expected to be used for emergent conditions and the contracted service only for non-emergent transport.
A resident with anoxic brain injury, dysarthria, and documented lack of decisional capacity alleged physical abuse and expressed fear of their identified representative, yet social services only reported the allegation to the state and did not complete an incident report, revise the care plan, or implement protective interventions. The same representative continued to be treated as the resident’s decision-maker and visited frequently, with staff noting suspicious odors of foreign substances and concerns about possible illicit substance use. Psychiatry later documented concern that the representative was providing illicit substances, and the resident was subsequently hospitalized for altered mental status and overdose, after which the representative was banned. Key staff, including the DON, unit manager, and administrator/abuse coordinator, were unaware of the initial abuse allegation, and social services did not timely explore or clarify legal decision-making authority or alternative representation for the resident.
A resident with severe cognitive impairment, osteoarthritis, and spinal spondylosis, care planned for 2-person Hoyer transfers, was being moved by two CNAs using a mechanical lift when one corner loop of the sling became disengaged, causing the resident to fall about four feet, strike the floor and the lift, and sustain head abrasion, multiple rib fractures, and lumbar vertebral fractures. Facility policy required staff to verify secure sling attachment, examine hooks, clips, fasteners, and strap stability, and ensure the sling bar was sound before lifting, but during this transfer the sling loop detached despite staff believing it was properly fastened and hearing it click into place; post-incident assessment showed the loop had come loose, the sling appeared in good condition, and a CNA later reported thinking one of the round metal disks on the lift might have been slightly loose, while maintenance logs documented no prior concerns with the lifts or slings.
The facility failed to revise and individualize care plans to reflect current needs and preferences for multiple residents, including one cognitively intact resident with hemiplegia, hemiparesis, and mononeuropathy who had bilateral shoulder surgery and could not tolerate BP measurements on the upper arms but preferred forearm readings. Despite repeatedly informing staff, this preference was not documented in the care plan or Kardex, and direct care staff and the RN/UM were unaware of it. Another cognitively intact resident with hemiplegia, contractures, and weakness reported they were supposed to get out of bed for two hours daily, but some NACs did not know this, even though the MAR/TAR contained an order to document times up and back to bed. The surveyors concluded that care plans were not accurately revised for several residents, placing them at risk for unidentified and unmet care needs and diminished quality of life.
Surveyors found that two residents with hemiplegia, hemiparesis, weakness, and contractures did not receive restorative nursing services, including ROM exercises and splint/brace or orthotic assistance, after therapy discharge. Although PT and OT discharge summaries documented established restorative ROM and transfer programs, recommended PROM to affected extremities, and recommended splint/brace use and assistance with orthotic wear, these recommendations were not entered as restorative referrals in the EHR. As a result, the residents’ care plans and records showed no restorative programs, and both residents reported that therapy and restorative exercises had stopped, while the DON, rehab director, and MDS coordinator confirmed they were unaware of and had not implemented the recommended restorative services.
A resident with cancer, cognitive impairment, and declining strength experienced multiple unwitnessed falls, most occurring while attempting to toilet or move toward the bathroom, culminating in a fractured ankle requiring ED treatment. Although assessments identified fall and incontinence risks and the facility’s policy required individualized interventions, the comprehensive care plan lacked a toileting plan and did not include several interventions that were discussed in incident investigations, such as consistent wheelchair placement and frequent rounding for bathroom assistance. Staff reported relying on verbal reminders and education to use the call light, despite acknowledging the resident’s impulsivity and failure to call for help, and the resident’s bed remained furthest from the bathroom while repeated bathroom-related falls occurred without the trend being recognized or addressed in the care plan.
A resident with a history of acute urinary retention and acute kidney injury had a Foley catheter deemed permanent by the hospital, with instructions that it not be removed in the SNF. At a later urology visit, the catheter was removed, and the resident returned with no new orders documented. Facility staff did not document bladder assessments, post-void residuals, or urine output, and CNA documentation showed the resident did not void that evening. Over the next day, the resident had vomiting, poor intake, altered level of consciousness, tachycardia, hypotension, and no documented wet briefs. A bladder scan eventually showed more than 2000–2500 mL of retained urine, and a new catheter drained a large volume. The resident and a roommate reported moaning, crying out in pain, and repeatedly alerting staff that the resident was not urinating and that the catheter was not draining, while nurses documented catheter care when no catheter was in place and later had to flush and replace the catheter due to continued complaints.
Surveyors found that nurses and nurse aides did not consistently administer medications according to professional standards and facility policy. Multiple residents reported that agency nurses were slow with medications, did not fully follow instructions, and often gave routine meds late. Observations showed an LPN administering expired Humalog/Lispro insulin well past the scheduled time, an LPN giving several scheduled meds (including Tizanidine) late and all at once, and an RN attempting to give sliding-scale insulin nearly two hours late, which a resident refused after already eating. Another resident received Methocarbamol two hours late after questioning the RN, and a resident on scheduled Tramadol had doses given without timely documentation, with a discrepancy between the narcotic count and pills remaining. These events demonstrated failures in timely administration, use of non-expired medications, and immediate, accurate MAR and narcotic documentation.
Failure to Notify Court-Appointed Guardian of Resident’s Clinical Changes
Penalty
Summary
The deficiency involves the facility’s failure to notify a resident’s court-appointed guardian of significant clinical changes and care decisions, contrary to its own policy and state requirements. The facility’s policy on Resident Representatives, revised 02/2021, states that a resident representative includes a court-appointed guardian or conservator and that the facility treats the representative’s decisions as those of the resident to the extent delegated or required by the court. Resident 1, admitted with cerebral palsy, had a Superior Court guardianship letter dated 02/07/2025 indicating a guardian of person and conservator of the estate with full authority, identifying Collateral Contact 1 (CC1) as the guardian. Despite this, multiple clinical events and changes in condition were documented without any corresponding documentation that CC1 was notified. Progress notes and provider notes show that Resident 1 experienced an episode of nausea and vomiting, frequent loose stools, abdominal discomfort, bloating, worsening fatigue, generalized weakness, and later refusal of meals and medications over at least a 24-hour period, with observations that the resident appeared frailer, more fatigued, and had no energy or interest to talk. The provider developed care plans including close monitoring for deterioration, sending stool to the lab, and later initiating IV fluids for rehydration, with a plan to call family/POA for discussion. However, there was no documentation that the guardian was notified at any of these points, including when IV fluids were started. CC1 reported that they were not contacted when the resident stopped eating or developed stomach issues, and expressed that the facility did not respect their guardianship and that involvement in care planning took too long. The DON confirmed on record review that there were many opportunities to notify the guardian when the resident’s condition changed from baseline and that there was no evidence staff did so.
Failure to Thoroughly Investigate and Resolve Resident Grievance Regarding Incontinence Care and Staff Conduct
Penalty
Summary
The deficiency involves the facility’s failure to thoroughly investigate and resolve a grievance alleging neglect and disrespect toward a resident, as required by its grievance policy. The resident had depression, anxiety, moderate cognitive impairment, occasional urinary incontinence, and required moderate assistance with toileting, with a care plan directing staff to check the resident every two hours, ask about toileting needs, and ensure they were clean and dry. A collateral contact reported arriving to visit the resident and finding them soaking wet and agitated, with behavior that was not typical for the resident. The collateral contact documented in a written grievance that the resident’s tablet was off, the resident appeared upset, and the resident reported being told they had to wait five minutes to be changed and that staff would change their “nasty *ss” in five minutes, leading the collateral contact to believe the resident had been given a consequence of no tablet and sitting in wet clothes, which they characterized as abuse/neglect and requested immediate removal of the responsible staff and a report filed. The facility documented receipt of the grievance and created an incident report indicating the matter was reported to the state agency, and that the unit manager interviewed the collateral contact and the resident, with the resident described as confused and denying being soaking wet. The incident report stated that a different nursing assistant was assigned to assist with the brief change and that the unit manager believed the resident was not soaking wet, and that the resident and collateral contact were satisfied when they left the room. However, a CNA who actually changed the resident reported that the resident’s brief was soaked through their pants onto the wheelchair and their socks were soaked, and that the resident was timid, repeatedly saying they had to sit for five minutes, and not acting like themselves; this CNA stated they were never interviewed or asked about the grievance or the resident’s condition. The DON acknowledged not interviewing this CNA or investigating the resident’s behavior and why they were upset, and the unit manager did not recall whether the collateral contact was present during follow-up and did not believe they followed up with the collateral contact regarding the grievance. The administrator, identified as the Grievance Official, stated the facility should have thoroughly investigated the grievance and discussed findings and resolution with the collateral contact, indicating the grievance process was not fully carried out in accordance with policy and WAC 388-97-0460.
Failure to Obtain Timely Emergency Transport for Resident in Respiratory Distress
Penalty
Summary
The deficiency involves the facility’s failure to obtain timely emergency medical services for a resident experiencing new-onset respiratory distress. The resident had dementia, respiratory failure, and heart failure, with severe cognitive impairment and a need for substantial assistance with activities of daily living. On the day the resident was sent to the hospital, a collateral contact observed the resident having difficulty breathing, appearing unable to get enough air, and looking as if they were sleeping or unconscious, and reported this to staff with a request to contact the doctor. An SBAR Communication Form documented that the resident was experiencing shortness of breath that had not occurred before, with an oxygen saturation of 90%. The physician was notified and ordered the resident sent to the emergency department for treatment and evaluation, and the collateral contact was notified shortly thereafter. Progress notes later documented that, despite the order for emergency department transfer, the resident was still awaiting pickup by Olympic transportation several hours later, with no estimated time of arrival. At approximately 3:30 AM, the dispatcher informed the facility that they could not provide transportation and instructed that 911 be called; only then was 911 contacted and the resident transported to the hospital via ambulance for respiratory distress. The RN caring for the resident stated they completed the SBAR, notified the physician and family, and at the end of their shift reported to the oncoming nurse that the resident needed to be sent to the emergency department for respiratory distress and that paramedics should be contacted, then left assuming 911 would be called. The DON stated that staff are expected to contact 911 for emergent conditions such as shortness of breath or respiratory distress, and that Olympic Ambulance is used only for non-emergent transport.
Failure to Provide Social Service Advocacy After Abuse Allegation and Questionable Representative
Penalty
Summary
The deficiency involves the facility’s failure to provide appropriate medically-related social services and advocacy for a resident following an allegation of abuse and concerns about the resident’s representative. The resident had an anoxic brain injury, dysarthria, moderate cognitive impairment, and was dependent on staff for activities of daily living. A hospital palliative care note documented that the resident lacked decisional capacity, had no DPOA, that the legal next of kin (CC4) did not want to be part of care decisions, and that care decisions were being deferred to another contact (CC5). CC5 accompanied the resident on admission, signed admission forms, and was listed as the primary contact in the medical record profile. On a date in February, during communication therapy, the resident reported that CC5 had done something to them, pounded their hands on their chest, recalled being hit in the back of the head by an unknown person, and stated they were sometimes afraid of CC5. A social services staff member reported this allegation to the state agency but did not complete a facility incident report, did not initiate care plan changes or interventions, and took no further action. CC5 continued to be treated as the resident’s representative, and progress notes documented CC5 at the bedside on multiple dates, including an entry noting the room smelled like foreign substances and that CC5 was seen waking the resident and then asking the nurse to administer pain medications. A psychiatry note later documented concern that CC5 was providing the resident with illicit substances and stated it would be prudent for the resident to identify a POA. Subsequently, the resident was found unresponsive, transported to the hospital, and later readmitted after altered mental status and overdose, with a provider note stating that CC5 posed a significant danger to the resident and was banned from visiting. After readmission, staff attempted to contact CC4 for consent to treat but initially reached someone who stated they were not CC4. The social service director acknowledged that, beyond reporting the initial allegation, no additional interventions were implemented, that CC5 continued to be used as the resident’s representative after the allegation, and that they had not explored legal authority for decision making following the abuse allegation or concerns about substances. The social service assistant reported they did not speak with the resident about the hospital stay or CC5 and did not complete an incident report or care plan changes after the allegation. The unit manager and DON were unaware of the initial abuse allegation, and the administrator, who served as abuse coordinator, also stated they were unaware of the allegation and that an investigation should have been initiated and a representative for the resident investigated at a minimum.
Injury from Mechanical Lift Sling Detachment During Transfer
Penalty
Summary
The facility failed to ensure a safe mechanical lift transfer when a resident was being moved with a Hoyer lift and sling, resulting in a fall and injury. Facility policy for using a mechanical lifting machine required staff to securely attach sling straps to the sling bar according to manufacturer’s instructions, double-check the security of the sling attachment before lifting, examine all hooks, clips, or fasteners, check strap stability, and ensure the sling bar was securely attached and sound. Despite these requirements, during a transfer for dinner, two CNAs placed the sling under the resident, attached the loops at each corner of the sling to the lift, and raised the resident off the bed into the space between the bed and wheelchair when the bottom left corner of the sling became disengaged from the lift. The resident involved had multiple diagnoses including osteoarthritis, cervical and thoracic spondylosis, and Alzheimer’s disease, with the Minimum Data Set documenting severely impaired cognitive skills for daily decision-making. The resident’s care plan required the assistance of two staff during Hoyer lift transfers. During the transfer, the resident fell approximately four feet, landing on her buttocks, bouncing, and then falling backward and striking her head on the leg of the Hoyer lift. Hospital records documented that the resident sustained an abrasion to the back of the head, fractures of the 6th, 7th, 8th, and 10th ribs, and fractures of the 1st and 2nd lumbar vertebra. Staff interviews and observations showed that staff believed the sling loops had been securely fastened and reported hearing the loops click into place before lifting. One CNA stated that they had barely lifted the resident off the bed when the bottom left loop became disconnected and the resident fell. Another CNA reported being shocked and unable to figure out what had happened. A nurse who assessed the resident and then examined the equipment after the fall noted that one of the loops of the sling had become disengaged but stated the sling appeared to be in good condition. During a later demonstration, a CNA indicated she thought one of the round metal disks on the lift might have been a little loose. Maintenance logs for Hoyer slings and lifts for the preceding months documented no concerns with the slings or lifts, and the DON acknowledged expecting a citation due to the resident’s injury from the fall.
Failure to Revise Care Plans to Reflect Resident Needs and Preferences
Penalty
Summary
The deficiency involves the facility’s failure to revise and individualize comprehensive care plans to reflect residents’ current needs and preferences, as required by its own care planning policy. For one resident with hemiplegia, hemiparesis following cerebrovascular disease, and mononeuropathy of the upper limb, the admission MDS showed intact cognition and upper extremity impairment. This resident reported having bilateral shoulder surgery and an inability to tolerate blood pressure measurements on the upper arms due to pain, and stated a preference for BP measurements on the forearms. The resident reported having informed multiple nursing staff of this preference, but staff continued to place the cuff on the upper arms. Review of the resident’s care plan and Kardex showed no interventions or instructions regarding forearm BP cuff placement. A NAC confirmed they were unaware of the preference until the resident told them directly and that this instruction was not documented in the Kardex. The RN/Unit Manager, who stated they were responsible for revising and reviewing care plans when there were changes, also confirmed they were not aware of the resident’s preference and that it should have been updated in the care plan. Another resident, readmitted with hemiplegia and hemiparesis following a nontraumatic subarachnoid hemorrhage, contracture of the left hand, and weakness, was cognitively intact and required maximum assistance for bed mobility per a quarterly MDS. This resident stated they were supposed to get out of bed for two hours every day, but some NACs were not aware of this care requirement. Review of the resident’s March 2026 MAR/TAR showed an order to document the time the resident got up and the time they returned to bed daily. The report states that, overall, the facility failed to revise care plans accurately to reflect residents’ needs for three of four residents reviewed for care plan revision, placing them at risk for unidentified and unmet care needs and a diminished quality of life.
Failure to Implement Restorative Nursing and Splint/Brace Programs After Therapy Discharge
Penalty
Summary
The deficiency involves the facility’s failure to provide restorative nursing services, including range of motion (ROM) exercises and splint/brace assistance, to maintain or prevent decline in mobility and contractures for two residents with significant motor impairments. The facility’s undated Restorative Nursing Services policy stated that residents would receive restorative care as needed to achieve and maintain optimal functioning and that residents may initiate a restorative program upon discharge from rehabilitative care. Despite this, surveyors found that residents with documented hemiplegia, hemiparesis, weakness, and contractures were not placed on restorative programs and had no restorative interventions documented in their electronic health records (EHRs). Resident 1 was admitted with hemiplegia and hemiparesis following cerebrovascular disease, a left lower leg fracture, and weakness, and the admission MDS showed intact cognition, moderate assistance needs for bed mobility and transfers, and one-sided upper and lower extremity impairment. During observation, the resident was seen lying in bed with a bent inward left forearm and hand and reported no longer receiving therapy or nursing-assisted exercises. The care plan initiated in January showed no restorative services, and the care plan history and EHR contained no restorative nursing interventions. However, the PT discharge summary from February documented that restorative ROM and transfer programs had been established and trained, including PROM to the left upper and lower extremities and stand-by assist with transfers, and the OT discharge summary recommended a splint/brace to prevent contracture. The OT stated that the splint/brace was not tried due to lack of time before insurance was discontinued, and both the Director of Rehab and the MDS coordinator confirmed there was no restorative referral in the EHR and they were unaware of the recommendations. Resident 2 was readmitted with hemiplegia and hemiparesis following a nontraumatic subarachnoid hemorrhage, a left-hand contracture, and weakness, and the quarterly MDS showed intact cognition, maximum assistance needs for bed mobility, total assistance for transfers, bilateral upper and lower extremity impairment, and no therapy or restorative programs. The resident reported that therapy had been discontinued months earlier and that no restorative staff were assisting with exercises. The care plan and EHR showed no restorative services. OT evaluation documented left upper extremity ROM impairment, a left-hand contracture, and prior use of a left orthotic to manage flexion tone, and the OT discharge summary recommended restorative care and assistance with donning/doffing the orthotic. The PT discharge summary recommended restorative programs if Medicaid Part B services did not continue. The Director of Rehab confirmed therapy was discontinued and that restorative nursing programs were recommended, but both the Director of Rehab and the MDS coordinator stated there were no restorative referrals in the EHR after readmission, and the MDS coordinator confirmed the resident had no restorative programs since readmission.
Failure to Implement Effective Fall and Toileting Interventions for High-Risk Resident
Penalty
Summary
The deficiency involves the facility’s failure to provide adequate supervision, identify fall trends, and implement progressive, resident-centered interventions for a resident with multiple falls and declining strength. The facility’s own Falls and Fall Risk Management policy required staff to identify interventions related to residents’ specific risks and causes to prevent falls and minimize complications. The resident’s Care Area Assessment identified cancer-related risks for pain, falls, and ADL decline, and stated that falls and urinary incontinence would be addressed in the care plan with an objective of improvement and risk minimization. However, the comprehensive care plan did not include a urinary or ADL care plan and contained no toileting plan, despite the resident’s identified risks and prior fall history. Over a series of falls, the resident repeatedly fell while attempting to toilet or move toward the bathroom, yet the facility did not recognize or address this pattern in its investigations or care planning. The resident had multiple unwitnessed falls: next to the bed while getting up to use the restroom, in the bathroom while standing to use the toilet, and near or in the bathroom on several occasions. Incident investigations and post-fall assessments documented environmental factors such as clutter, items on the floor, water on the floor, and issues with footwear, as well as the resident’s increasing weakness, impulsivity, poor safety awareness, and poor insight into limitations. Interventions documented in investigations and risk reviews included encouraging use of the front-wheeled walker, keeping the wheelchair and walker accessible, ensuring proper footwear and non-skid socks, and providing resident education on safe transfers, ambulation, and assistive device use. However, several of these planned interventions, including placement of the wheelchair and frequent rounding/toileting assistance, were not added to or reflected in the care plan as stated. Staff interviews further showed that the resident frequently fell while trying to go to the bathroom and that staff relied on verbal education and reminders to use the call light, even though the resident often did not use it. Staff acknowledged the resident’s impulsivity and tendency to get up independently despite instructions, and one staff member stated that nursing assistants were verbally instructed to offer bathroom assistance, but this intervention was not documented in the care plan. The resident’s bed remained the one furthest from the bathroom throughout the stay, and none of the facility’s investigations identified the trend of bathroom-related falls or addressed toileting options in the care plan. Ultimately, the resident sustained a left ankle fracture after another bathroom-related fall, requiring transfer to the emergency department for evaluation and treatment, and later records documented additional fractures and a decline in condition. The surveyors concluded that the facility’s failures placed residents at risk of repeated falls and injuries.
Failure to Monitor Urinary Retention After Foley Removal Leading to Prolonged Pain
Penalty
Summary
The deficiency involves the facility’s failure to adequately assess and monitor a resident for complications associated with an indwelling urinary catheter and urinary retention, particularly after catheter removal. The resident had a history of acute kidney injury due to urinary retention, which improved after Foley catheter placement in the hospital. Hospital discharge documentation indicated the catheter was placed for acute urinary retention, was deemed permanent, and included instructions that, given the resident’s significant retention and acute renal failure, staff at the skilled nursing facility should not attempt Foley removal. The facility’s catheter care plan directed staff to empty the catheter as needed and record output in milliliters, but review of the last 30 days of documentation showed continence was not rated due to the indwelling catheter and there was no documented urinary output in milliliters on the treatment administration records. The resident had a scheduled urology appointment at which the urinary catheter was discontinued. Upon return from this appointment, nursing documentation initially indicated no new orders, and an alert note later stated the catheter was discontinued and staff were monitoring for retention or pain. However, there was no documented bladder assessment or urinary output following catheter removal. Nursing assistant documentation showed that the resident did not void on the evening shift that same day. Despite the catheter having been removed, the treatment administration record showed staff continued to document provision of catheter care on subsequent shifts when no catheter was in place. Over the next day, the resident experienced vomiting, decreased oral intake, and an altered level of consciousness, with vital signs showing tachycardia and low blood pressure, and staff documented decreased urine output. A bladder scan performed later revealed more than 2000–2500 milliliters of urine in the bladder, and an indwelling catheter was reinserted, initially draining a large volume of urine. The provider note indicated the resident had not eaten since the prior night, was unable to hold down fluids, and staff were unsure whether the resident had urinated in incontinence briefs, with no wet briefs reported since the resident’s return from the hospital after catheter removal. The provider expressed concern that the documented early-morning wet brief might not be accurate given the large bladder volume on scan and stated this should require further investigation. Subsequent notes described the resident moaning and complaining of pain, with limited urine output in the catheter bag and staff flushing and then replacing the catheter due to continued complaints. Interviews with the resident, the roommate, and staff indicated the resident was crying out and moaning in pain, the roommate repeatedly alerted staff that the resident was not urinating and that the catheter was not draining, and staff had to seek assistance to replace the catheter. Facility leadership and clinical staff later acknowledged that typical practice after catheter removal would include contacting the provider, placing the resident on alert, performing post-void residuals with bladder scans, and documenting monitoring, which was not done in this case.
Medication Administration Delays, Documentation Errors, and Use of Expired Insulin
Penalty
Summary
The deficiency involves the facility’s failure to ensure sufficient nursing staff with appropriate competencies and skill sets to administer medications according to professional standards of practice, facility policy, and prescriber orders. The facility’s medication administration policy required medications to be given as prescribed, in accordance with manufacturers’ specifications and good nursing principles, with no expired medications used, and doses administered within 60 minutes of the scheduled time and documented immediately after administration. Multiple residents reported that agency nurses often gave medications late, did not read full instructions, or were slow in bringing medications, and that routinely scheduled medications were not consistently provided without residents having to ask. Surveyors observed several specific medication administration failures. For a resident with diabetes, an LPN drew up and administered Humalog/Lispro insulin from a multi-dose vial that had been opened and dated “02/16” with no year, making it expired per policy, and administered the dose nearly 1 hour and 45 minutes after it was due. Another resident with care plan instructions to receive medications as ordered had multiple scheduled medications (Gabapentin, Oxybutynin, Baclofen, and Tizanidine) that were ordered at specific times throughout the day; the LPN was observed administering all four together and acknowledged that at least one (Tizanidine) was late, while the resident reported that receiving them together at that time was typical and not at their request. For another diabetic resident, an RN checked blood sugar and prepared sliding scale Humalog/Lispro insulin almost two hours after the scheduled time; the resident refused the insulin, stating they had already finished lunch. Additional deficiencies were identified with other residents’ pain and scheduled medications. One resident with a pain care plan and an order for Methocarbamol four times daily at set times approached the cart requesting Methocarbamol and Tylenol; the RN initially stated the Methocarbamol had already been given, but then administered it two hours after it was due when the resident pointed out the scheduled timing. For another resident with a risk for pain care plan and Tramadol ordered three times daily at specific times, an LPN retrieved a PRN pain medication while the electronic record showed no 8:00 AM medications documented; the LPN stated they had given them but had not yet documented. Later, an RN prepared the 2:00 PM Tramadol dose, and review of the narcotic count showed a discrepancy between the number of pills documented and the number remaining in the card. The RN stated they had given the 8:00 AM Tramadol but had not signed it out, then signed out both the 8:00 AM and 2:00 PM doses at that time. Residents interviewed consistently reported that medications were sometimes or frequently late, that agency nurses did not always follow instructions, and that they often had to request medications that were routinely scheduled.
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