Spokane Falls Care
Inspection history, citations, penalties and survey trends for this long-term care facility in Spokane, Washington.
- Location
- 6021 North Lidgerwood, Spokane, Washington 99207
- CMS Provider Number
- 505024
- Inspections on file
- 46
- Latest survey
- March 4, 2026
- Citations (last 12 mo.)
- 4
Citation history
Health deficiencies cited at Spokane Falls Care during CMS and state inspections, most recent first.
A resident with cellulitis on both lower legs and a skin tear on the left lower leg did not receive consistent assessment and documentation of these non-pressure skin conditions as required by facility policy and the care plan. Initial Skin Grid and Total Body forms identified extensive cellulitis and a 3 cm open skin tear, but no subsequent Skin Grid or Total Body forms were found, and a later nursing note described a left lower leg wound without clarifying whether it was the cellulitis or the skin tear. Interviews with the RCM, an LPN, and the DNS confirmed that weekly wound assessments with measurements and documentation were expected for such conditions, yet the resident’s record lacked ongoing, clearly identified weekly monitoring.
Surveyors found that two residents did not receive medications as ordered by their providers. One resident with DM received short-acting insulin doses even when BG readings were below the ordered hold parameter, as documented on consecutive MARs and confirmed by the RCM and Administrator. Another resident with kidney disease and DM, treated for eye symptoms with ordered antibiotic eye drops, missed multiple documented doses both when the drops were ordered for one eye and after the order was changed to both eyes four times daily.
A resident with a history of stroke, encephalopathy, and significant cognitive decline was not properly identified as an elopement risk, despite multiple episodes of confusion, wandering, and leaving the facility unattended. The care plan and elopement risk assessments were not updated in a timely manner, and interventions such as wander guard devices were not effectively implemented, resulting in repeated unsupervised departures.
The facility did not perform required N-95 mask fit testing for all employees, with the last building-wide fit testing occurring in the spring of 2024. The Administrator confirmed the facility was out of compliance, and the Infection Preventionist was unable to provide documentation of completed fit tests, as none had been conducted since the previous round.
Two residents admitted with severe pain following recent surgery did not receive timely pain management, with delays of several hours before prescribed medications were administered. Both residents reported pain at the highest level and were not offered alternative interventions while waiting. Staff interviews confirmed that pain medication should have been provided promptly and that procedures were in place to access needed medications.
The facility did not identify or report multiple allegations of potential abuse and neglect to the State Survey Agency as required. A resident reported a roommate was left in soiled conditions overnight, another reported being left on a bedpan for extended periods, and a third described long delays in call light response and pain medication administration. These grievances were not logged or reported according to regulatory requirements.
Several dependent residents did not receive the required number of baths or showers, with some going up to two weeks or more without proper hygiene care. Additionally, multiple residents, including those with diabetes and physical limitations, did not receive necessary nail care, resulting in long, untrimmed, or jagged toenails. Staff interviews confirmed that inadequate staffing and scheduling issues contributed to missed showers and grooming, and documentation showed a lack of podiatry referrals for residents needing specialized foot care.
A resident with a history of stroke reported being yelled at and argued with by a staff member, an incident witnessed by a CNA who felt it amounted to verbal abuse and reported it to the DON. However, there was no documentation or evidence that the facility investigated the allegation, and the administrator was unaware of the details of the incident.
The facility did not consistently assess, monitor, or document non-pressure related skin conditions for two residents with multiple wounds, including surgical sites, ulcers, and moisture-associated skin damage. Despite policies requiring weekly monitoring and detailed documentation, records lacked wound descriptions, measurements, and evidence of ongoing assessment, and staff interviews confirmed inconsistent practices.
The facility did not consistently obtain timely and accurate weights or implement appropriate monitoring for two residents at nutritional risk, including one with significant weight loss and another on enteral nutrition. Required weekly weights, re-weighs for discrepancies, and proper documentation were not completed as per facility policy, placing residents at risk for unmet nutritional needs.
The facility failed to implement Enhanced Barrier Precautions for two residents, with staff not wearing required protective equipment during care. Hand hygiene was not performed during medication administration, and the Water Management Plan was incomplete, lacking specific interventions to prevent waterborne illnesses.
The facility failed to inform residents and their representatives about rights and responsibilities, including Medicaid rights, upon admission. This deficiency affected 10 residents, with delays in signing admission agreements and lack of documentation of discussions. Staff interviews revealed inconsistencies in completing and reviewing admission paperwork, leading to residents being uninformed of their rights.
The facility failed to provide necessary information on advanced directives to residents or their legal representatives upon admission. This affected several residents, including one who wished to change their DPOA and another who left against medical advice. Staff interviews revealed inconsistencies in the process of reviewing and explaining admission paperwork.
The facility failed to implement an effective admission policy, resulting in incomplete and delayed admission paperwork for several residents. This included not reviewing or signing admission agreements with cognitively intact residents and having cognitively impaired residents sign agreements instead of their legal representatives. Staff interviews revealed confusion and inconsistency in the admission process, leading to residents not being fully informed of their rights and care needs.
The facility failed to provide written information on bed hold policies to residents or their representatives upon admission, affecting eight residents. Documentation and interviews revealed inconsistencies and confusion among staff regarding the responsibility for reviewing and completing admission paperwork, leading to residents being uninformed about their bed hold rights.
A facility failed to monitor a resident's blood values on Coumadin, did not implement a bowel protocol for another resident, and did not adhere to oxygen and blood pressure medication parameters for a third resident. These deficiencies involved not notifying providers of critical lab results, not following bowel movement protocols, and administering medications outside of prescribed parameters.
The facility failed to provide comprehensive dialysis care for four residents, leading to deficiencies in medication administration, fluid intake monitoring, and care plan details. Residents exceeded fluid restrictions, and there was confusion about medication administration at the dialysis center. Staff interviews revealed a lack of clarity and communication regarding care plans and dialysis care management.
The facility did not complete annual evaluations and competency checks for nursing staff, affecting 6 out of 10 sampled employees, including nursing assistants, an LPN, and an RN. Evaluations and skills fairs had not been conducted for about two years, and the HR department confirmed the absence of documentation. The facility was auditing and working to complete these evaluations.
The facility failed to administer significant medications as ordered for four residents undergoing dialysis, leading to missed doses of essential medications. Staff assumed medications would be dialyzed out and omitted doses without consulting providers, potentially impacting residents' health. The Resident Care Manager was unaware of these omissions, and staff failed to communicate issues, resulting in the deficiency.
The facility failed to maintain compliance with Federal regulations, impacting residents' rights and admission documentation. Due to staffing changes and gaps in the Medical Records department, admission agreements and advance directives were incomplete, placing residents at risk of not being informed of their rights and care needs.
A resident with a urinary catheter was observed with their urine collection bag visible from the doorway, as the dignity bag was not in use. The facility's policy lacked guidance on maintaining dignity for catheter use, and staff confirmed the expectation to use dignity bags, which was not followed.
The facility failed to obtain informed consents for psychotropic medications for two residents. One resident received Paroxetine for depression without documented consent, while another received quetiapine for major depression without consent for 23 days. Staff interviews confirmed that consents should have been obtained prior to medication administration, but errors in the process led to these oversights.
A facility failed to assess a resident's ability to safely self-administer medications or store them at the bedside, as required by policy. The resident, with mild cognitive impairment, was observed using an over-the-counter antacid without notifying staff and without a provider's order. Staff acknowledged that the necessary evaluations and care planning were not completed, and the medication should not have been left unattended.
The facility failed to maintain functional sink faucets for two residents, impacting their ability to perform ADLs. One resident had their sink water turned off for weeks due to a leak, while another had a loose faucet. Staff were unaware of these issues, and no maintenance tickets were found, indicating a lack of communication and action.
The facility failed to ensure consistent mail delivery for residents, particularly on weekends, due to staffing issues. This affected residents' rights to receive and send mail promptly, as outlined in the facility's Resident Rights policy. Interviews with residents and staff confirmed that mail was not distributed on weekends, impacting the quality of life for several residents.
The facility failed to conduct timely PASRR evaluations and referrals for three residents with newly evident mental conditions. Two residents diagnosed with depression and started on psychotropic medication did not receive the necessary PASRR level I screening and level II referral. Another resident with a PASRR level II recommendation for behavioral health services experienced a delay in receiving these services. Staff misunderstandings and lack of timely action contributed to these deficiencies.
The facility failed to conduct required PASRR Level II evaluations for two residents with mental health histories prior to admission. One resident with major depressive disorder and another with depression were admitted without the necessary evaluations, as their PASRR Level I screenings did not identify serious mental illness. This oversight risked unmet behavioral health needs.
The facility failed to develop timely baseline care plans for two residents dependent on dialysis, as required within 48 hours of admission. One resident's care plan was delayed by nearly a month, while another had no documented dialysis care interventions during their stay. Staff interviews indicated a multi-step care plan process, but initial plans did not address immediate dialysis needs.
A facility failed to document a discharge summary and AMA form for a resident who left against medical advice due to dissatisfaction with their room. The resident's medical records lacked necessary documentation, including progress notes and notifications to relevant parties. Staff interviews confirmed the absence of required documentation and the failure to notify Adult Protective Services.
The facility failed to properly assess and monitor residents for substance use disorder, safe smoking abilities, and post-fall evaluations. A resident with alcohol abuse was not assessed for SUD risks, another resident with hemiplegia struggled to re-enter the facility after smoking, and a hospice resident did not receive required post-fall assessments. These deficiencies highlight lapses in policy enforcement and resident safety evaluations.
A resident with symptoms of a UTI experienced delays in receiving timely interventions due to the facility's inadequate lab procedures. The resident, who was occasionally incontinent and had a history of amputation, reported urinary frequency and urgency. Despite these symptoms, the care plan lacked relevant interventions, and the urine sample was delayed due to the lab's weekend schedule. The Medical Director expressed concerns about the facility's diagnostic criteria, and the DON acknowledged the delay in processing the sample.
A facility failed to discontinue previous tube feeding orders for a resident with a feeding tube, leading to conflicting documentation in the MAR. The resident, who received more than 51% of their nutrition through the tube, had new orders for Glucerna and water flushes, but the previous orders for Osmolite and water flushes were not discontinued. Staff believed the resident did not receive both formulas due to correct pump programming, but documentation showed both sets of orders were administered.
A facility failed to identify and address trauma in a resident, leading to a deficiency in trauma-informed care. The resident, with a history of hemiplegia and depression, was admitted without a comprehensive trauma assessment, and their care plan lacked interventions for social concerns. Staff interviews revealed a lack of understanding and implementation of trauma-informed practices, putting the resident at risk for re-traumatization.
A resident with a stimulant-induced psychotic disorder did not receive timely behavioral health services as required by their PASRR Level II evaluation. Critical sections of the Social Services Admission Evaluation were left blank, and a behavioral health referral was delayed until several months after admission. The resident expressed concerns about the lack of trauma-informed care, and staff interviews revealed a lack of understanding of the PASRR process.
The facility failed to complete timely medication regimen reviews for three residents, leading to potential risks of unnecessary medication use. A resident with coronary artery disease experienced a delay in discontinuing Clopidogrel, while another resident with diabetes continued receiving insulin without timely physician evaluation. Additionally, a resident with mental health diagnoses had missing MRR documentation for several months. Staff interviews revealed gaps in the MRR process due to management changes.
Expired medications were found in the South Hall medication room and cart, and emergency kits were improperly sealed. An LPN failed to count lorazepam during narcotic reconciliation, and the DON was unaware of expired medications. In the North Hall, liquid Ativan was not logged into the narcotic book, leading to inadequate tracking. The facility's policy for controlled drugs was not followed, resulting in deficiencies.
The facility failed to ensure the Dietary Manager had the necessary certification, despite the part-time status of the Regional Registered Dietician. The Dietary Manager, in their role for nearly three years, lacked the required certification, possessing only a food handler card. The Administrator confirmed the need for certification due to the dietician's part-time presence.
The facility failed to provide two residents with their preferred beverage, coffee, upon request, leading to unmet care needs. One resident, with malnutrition, waited hours for coffee, while another expressed dissatisfaction with its unavailability. Staff interviews revealed inconsistencies in coffee availability, with some indicating it should be available 24/7, but operational limitations and cost concerns led to shortages.
A facility failed to maintain accurate medical records for a resident, who was inaccurately documented as having allergies to Acetaminophen, Baclofen, and Morphine. Despite these documented allergies, the resident was regularly administered Morphine and Tylenol as prescribed. Staff interviews revealed awareness of the inaccuracies, yet corrections were not made, placing the resident at risk of unmet care needs.
A facility failed to explain an arbitration agreement to a resident in their preferred language, Mandarin, despite the resident's severe cognitive impairment and need for an interpreter. The agreement was signed by the resident in English, without involvement from their legal representative. Staff interviews revealed inconsistencies in the process of reviewing arbitration agreements, with uncertainty about the availability of agreements in other languages and the use of interpreter services.
A facility failed to coordinate care with a hospice provider for a resident with cancer, dementia, and heart failure. The facility did not designate a staff member to coordinate hospice care, leading to confusion and assumptions about hospice aides' responsibilities. The resident reported infrequent hospice visits, and there was a lack of documentation regarding bathing services. Interviews revealed staff uncertainty about hospice aides' schedules, and the hospice provider confirmed that bath aide services had not been utilized until recently.
The facility failed to investigate allegations of abuse and neglect for two residents, leading to unaddressed grievances. A resident reported inappropriate sexual comments from a roommate, while another experienced neglect in care, including missed showers and untreated wounds. Despite grievances, no investigations were conducted, and care conferences were inadequately attended.
The facility did not maintain the required RN coverage of at least eight hours a day, seven days a week. Staffing records showed no RN coverage for multiple days in October and November. The Staffing Coordinator and Administrator confirmed the deficiency, noting reliance on agency staff who often sent LPNs instead of RNs.
A resident with chronic pain and depression was subjected to ongoing sexually inappropriate comments from another resident, despite filing a grievance and requesting a room change. The facility failed to investigate or separate the residents in a timely manner, leaving the resident feeling scared and uncomfortable. Another resident also reported similar inappropriate behavior from the same individual.
A resident with heart disease was prescribed Carvedilol twice daily, but the order was changed to once daily without authorization. This error went unnoticed until a cardiology appointment revealed the resident had been on a lower dose for several months. The system flagged the change, but it was not addressed, and the responsible LPN no longer worked at the facility.
A facility failed to maintain sanitary conditions for food storage, with a persistent leak causing water accumulation in the walk-in refrigerator and dry storage room. Staff reported the issue to administration, but it remained unresolved for about a month, leading to water pooling on canned goods and saturated cardboard boxes. The Maintenance Director and Dietary Manager confirmed the ongoing problem, and the Infection Preventionist highlighted concerns about the unsanitary conditions.
The facility failed to maintain a homelike environment during construction in all hallways, causing significant noise disturbances and discomfort for residents. Construction activities involved loud equipment and left tools obstructing hallways, leading to complaints from residents and staff about noise, fatigue, and headaches.
The facility failed to maintain proper medication storage temperatures in both the North and South medication rooms. Thermometers indicated temperatures exceeding 80 degrees Fahrenheit, and staff did not consistently log these temperatures or notify the DON. Temporary solutions like propping doors open were used, but no formal policy was in place. The administrator was unaware of the thermometer's limitations.
The facility experienced a malfunction in the call light system affecting 10 resident rooms due to ongoing construction, leading to unmet care needs. Residents reported long wait times and ineffective alternative measures like bells. Staff confirmed the system's age and construction issues contributed to the problem, with the call light board at the nurses' station showing discrepancies in room alerts.
The facility failed to maintain and monitor IV access devices for two residents, leading to overdue dressing changes and delayed initiation of saline flushes. One resident's PICC line dressing was not changed for 15 days, and another resident's dressing was undated with no documentation of changes. Orders for saline flushes were delayed by seven days. Limited RN availability contributed to these deficiencies.
Failure to Consistently Assess and Document Non-Pressure Skin Conditions
Penalty
Summary
The facility failed to assess, monitor, and document non-pressure skin conditions in accordance with its policy and the resident’s care plan for one resident with cellulitis and a skin tear. The facility’s wound policy required weekly monitoring and documentation in the electronic medical record for wounds such as diabetic ulcers, significant skin tears, and other skin conditions, including size, color, odor, healing progression, notifications, and other pertinent information. On admission, the Skin Grid form documented cellulitis on both of the resident’s lower legs, wrapping around the calf and measuring 1.5 feet long, but no subsequent Skin Grid forms were found in the record for ongoing cellulitis monitoring. The resident’s care plan documented cellulitis on both lower legs and directed weekly and as-needed assessment, including measurements and evaluation of the wound perimeter, wound bed, and healing progress, and was later updated to include a left lower calf skin tear with instructions for nursing to monitor and document location, size, and treatment. The Total Body form dated 12/16/2025 showed a 3 cm round open skin tear on the resident’s left lower leg, but there was no further documentation of additional assessments of this skin tear and no additional Total Body forms in the record. The admission assessment documented diagnoses including cellulitis and diabetes, and that the resident was able to make needs known. A nurse progress note dated 01/02/2026 described a wound on the left lower leg as red, without odor or drainage, painful, with scaly surrounding skin, but did not specify whether this referred to the cellulitis or the skin tear, despite both being located on the left lower leg. Interviews with the RCM, an LPN, and the DNS confirmed that facility practice and expectations were for weekly Total Body forms and Skin Grids, with assessment, measurement, and evaluation of non-pressure skin issues, including cellulitis, but the resident’s record lacked consistent weekly documentation and clear identification of the wounds being assessed.
Failure to Administer Insulin and Antibiotic Eye Drops as Ordered
Penalty
Summary
The deficiency involves the facility’s failure to administer medications as ordered by providers for two residents, specifically related to insulin and antibiotic eye drops. One resident with diabetes was admitted on 12/26/2025 and had orders dated 12/12/2025 for long-acting insulin twice daily and short-acting insulin three times daily with meals, plus a sliding scale. On 12/16/2025, the short-acting insulin order was changed from 20 units with meals to 10 units with meals plus sliding scale, with explicit parameters to hold the insulin if the blood sugar was less than 110 mg/dl. Despite this, the December 2025 MAR showed the short-acting insulin was administered nine times when the blood sugar was below 110 mg/dl, and the January 2026 MAR showed it was administered five times under the same condition. The RCM stated that for this resident, staff should have held the insulin when blood sugar readings were under 110 mg/dl, and the Administrator confirmed that insulin had not been held as ordered. Another resident with kidney disease and diabetes had an order for antibiotic eye drops after reporting blurry vision, redness, and tearing in the left eye. On 02/02/2026, the physician ordered antibiotic eye drops to the left eye twice daily for 10 days. The February 2026 MAR documented that the drops were started as ordered, but 3 of 6 possible doses were not administered. On 02/05/2026, after the resident’s left eye vision improved and the right eye developed yellow discharge, the order was changed to antibiotic eye drops in both eyes four times daily for 10 days. Documentation showed that 7 of 40 possible doses under this revised order were missed. The Administrator confirmed that doses of the antibiotic drops had not been given as ordered.
Failure to Supervise Cognitively Impaired Resident Leading to Unattended Departures
Penalty
Summary
A deficiency occurred when the facility failed to provide adequate supervision and ensure a safe environment for a resident with significant cognitive impairment and poor safety awareness. The resident, who had a history of stroke, heart disease, encephalopathy, and demonstrated moderate to severe cognitive decline, was not initially identified as an elopement risk upon admission. Despite multiple documented instances of confusion, disorientation, and wandering behavior, the resident's care plan was not updated to reflect their cognitive decline or risk for elopement. The resident left the facility unattended on more than one occasion, including one instance where they signed themselves out and did not return as expected, prompting staff to contact the family and law enforcement. Another time, the resident left with another resident without signing out and returned after midnight. There were also episodes where the resident returned to the facility exhibiting signs of intoxication, and documentation was lacking regarding their whereabouts and the duration of their absence. Staff and family interviews confirmed the resident's ongoing confusion, lack of safety awareness, and inability to make safe decisions independently. Despite therapy and nursing notes indicating the resident's cognitive impairment and safety concerns, there was no timely update to the elopement risk assessment or care plan. The resident was not consistently identified as an elopement risk until months after the initial incidents, and interventions such as wander guard devices were not effectively implemented or documented. The lack of updated assessments and care planning contributed to the resident's repeated unsupervised departures from the facility.
Failure to Conduct N-95 Fit Testing for All Employees
Penalty
Summary
The facility failed to ensure that N-95 mask fit testing was performed for all 103 employees in accordance with applicable federal regulations. During interviews, the Administrator acknowledged that the facility was out of compliance, stating that the last building-wide N-95 fit testing occurred in the spring of 2024 and that, despite having a plan, the process of fit testing all employees had not yet begun. When asked for documentation of employees who had been fit tested, the Infection Preventionist was unable to provide any records, confirming that such information did not exist. The Infection Preventionist also stated that they had only recently received certification to administer N-95 fit testing and had not yet started the process for facility employees.
Failure to Provide Timely Pain Management on Admission
Penalty
Summary
The facility failed to provide timely and appropriate pain management for two residents who required such services upon admission. One resident, admitted after a below-the-knee amputation, reported severe pain rated at 10 out of 10, described as throbbing, stabbing, and burning, both at rest and with movement. Despite the resident's ability to communicate their needs and a clear pain assessment indicating severe pain, pain medication was not administered until approximately six hours after admission. The resident stated they requested pain medication upon arrival but experienced a significant delay before receiving it, resulting in prolonged, uncontrolled pain. Another resident, admitted following spine surgery with two surgical wounds, also reported pain at a level of 10 out of 10 in their lower back and right leg. This resident did not receive prescribed pain medications until over three hours after admission. The resident expressed dissatisfaction, stating they were told the facility had run out of their pain medication and that no alternative pain management interventions, including non-pharmacological options, were offered. Interviews with staff confirmed that pain medication should have been provided promptly and that procedures existed to obtain medications from the facility's dispensing system if not immediately available from the pharmacy.
Failure to Report Allegations of Abuse and Neglect
Penalty
Summary
The facility failed to identify and report potential allegations of abuse and/or neglect to the State Survey Agency as required for three residents. Resident 1, who had a lower leg amputation and was able to communicate needs, filed a grievance stating that their roommate was left in feces all night without being changed, and reported other incidents where it took up to two hours for staff to respond. This allegation of potential neglect was not logged or reported to the State Survey Agency. Resident 2, with diabetes and depression, also filed a grievance indicating they were left on a bedpan from morning until the evening shift and not checked on again until the following morning, despite needing regular changes due to risk of skin breakdown. This concern was similarly not reported as required. Resident 3, admitted after spine surgery and able to communicate needs, reported excessive delays in call light response and a significant delay in receiving pain medication upon admission, stating their pain was severe and the facility had run out of their medication. This grievance was also not logged or reported to the State Survey Agency. Interviews with facility staff confirmed that these allegations of potential abuse and/or neglect were not properly documented or reported, as required by regulation.
Failure to Provide Required Bathing and Nail Care for Dependent Residents
Penalty
Summary
The facility failed to provide the required number of baths or showers per week for five out of six dependent residents reviewed for Activities of Daily Living (ADLs). Multiple residents, including those with significant medical conditions such as cancer, multiple fractures, diabetes, malnutrition, and post-surgical needs, did not receive regular showers or bed baths as documented in their records. In several cases, the intervals between baths or showers extended from seven to fourteen days, and in one instance, a resident received only one shower nearly four weeks after admission. Staff interviews confirmed that due to staffing shortages and high resident acuity, it was not always possible to complete all scheduled showers, and some residents had not received a shower since admission. In addition to bathing deficiencies, the facility did not provide adequate grooming, specifically nail care, for four out of six dependent residents reviewed. Residents with conditions such as diabetes and physical limitations were observed with long, yellow, or jagged toenails, and in some cases, residents or their family members reported that nail care had not been provided since admission. Documentation showed no record of nail care being completed for these residents during the review period. For diabetic residents, care plans indicated the need for podiatry referrals, but there was no evidence that such referrals or appointments had been made. Staff interviews revealed that nail care was expected to be performed during showers unless the resident was diabetic, in which case nurses or a podiatrist would be responsible. However, staff acknowledged that nail care was often not completed due to time constraints and lack of resources. There was also confusion among staff regarding the scheduling of showers and the process for documenting refusals or missed care. The lack of consistent hygiene and grooming placed residents at risk for poor hygiene and diminished quality of life, as directly observed and reported by residents and staff.
Failure to Investigate Alleged Verbal Abuse
Penalty
Summary
The facility failed to investigate an allegation of potential verbal abuse involving a resident with a history of stroke and left-sided weakness, who was able to communicate their needs. The resident reported that a staff member entered their room, yelled, and argued with them, leading the resident to ask the staff member to leave. Another staff member present during the incident confirmed that the situation escalated into an argument and felt it reached the level of verbal abuse. This staff member reported the incident to the Director of Nursing immediately after it occurred. Despite the report, there was no documentation in the facility's incident log indicating that an investigation into the alleged verbal abuse took place. The administrator stated they were only aware that the resident no longer wanted the staff member in their room and was not informed about the alleged yelling. The Director of Nursing at the time was no longer employed at the facility, and no further information about an investigation was available.
Failure to Assess and Document Non-Pressure Skin Conditions
Penalty
Summary
The facility failed to properly assess, monitor, and document non-pressure related skin conditions for two residents. For one resident admitted with multiple skin impairments, including wounds on the abdomen, groin, lower legs, and a G-tube site with moisture-associated skin damage, there was no documentation of wound type, measurements, or appearance upon admission. The care plan identified a risk for pressure ulcers and directed staff to document changes in skin status, but there was no record of the resident's current wounds or treatments. The Treatment Administration Record initially lacked wound care orders, and subsequent documentation was inconsistent, with some skin evaluation forms omitting details about the wounds. Interviews revealed delays in dressing changes and concerns about proper wound care practices. Another resident, admitted after surgery for a fractured leg and with a history of diabetes, had multiple wounds documented in hospital transfer orders, including a venous ulcer, fragile skin, and surgical incisions. The facility's admission assessment noted several wounds but did not provide details on type, measurements, or appearance. The care plan addressed pressure ulcer risk and general skin care but did not specify the resident's current wounds. Skin evaluation forms recorded the presence of wounds but lacked further description or evidence of ongoing monitoring and assessment. Staff interviews indicated that weekly skin checks and documentation of wounds with descriptions and measurements were expected practices. However, the records reviewed did not consistently reflect these practices, as there was a lack of detailed documentation regarding the residents' wounds, their progression, and the care provided. This failure to follow facility policy and document wound assessments and care placed the residents at risk for worsening skin conditions.
Failure to Ensure Timely and Accurate Weight Monitoring for Residents at Nutritional Risk
Penalty
Summary
The facility failed to ensure timely and accurate weight monitoring and appropriate interventions for residents at nutritional risk. For one resident with liver disease and diabetes, there was a significant discrepancy in admission weights, with an initial weight recorded at 130 lbs and another at 286 lbs on the same day. The inaccurate weight was later struck out, but subsequent weights showed a substantial loss over several months, totaling an 18% decrease. Despite this significant weight loss, the only interventions noted were related to anticipated fluctuations due to edema and diuretic therapy, and no new nutritional concerns or interventions were documented. The resident's intake was generally fair to good, and the weight loss was attributed to a combination of fluid loss and previous high-calorie intake from alcohol, but no re-weighs or further assessments were documented in response to the ongoing weight loss. Another resident, admitted with cancer and multiple pathological fractures and receiving enteral nutrition via G-tube, did not have an admission weight documented. The resident's weights were only recorded twice over a month, with a significant increase noted, but weekly weights as required for residents on tube feedings were not obtained. The care plan required weekly weight monitoring, but this was not consistently followed. Staff interviews confirmed that weights should be taken weekly and then monthly unless otherwise indicated, and that re-weighs were requested but not always completed. Facility policy required accurate and timely weight measurements, with re-weighs for significant changes and daily review of weight alerts by nutritional services. However, the facility did not consistently follow these protocols, as evidenced by missed or inaccurate weights, lack of timely re-weighs, and insufficient monitoring for residents at nutritional risk or on enteral nutrition. These failures placed residents at risk for significant weight loss and unmet nutritional needs.
Infection Control and Water Management Deficiencies
Penalty
Summary
The facility failed to implement Enhanced Barrier Precautions for two residents, Resident 35 and Resident 61, who were on these precautions due to their medical conditions. Resident 35, who had a history of Clostridium difficile infection and an indwelling medical device, was observed with a sign indicating the need for gown and gloves upon room entry. However, a nursing assistant, Staff EE, entered the room without wearing the required protective equipment, straightened the resident's linens, and touched the resident's hair. Staff EE admitted to not being aware of the current precaution requirements due to a lack of recent education and frequent assignment changes. Resident 61, who had prostate cancer with brain metastasis and an indwelling urinary catheter, was also on Enhanced Barrier Precautions. During a dressing change, Staff G, an LPN, did not wear a gown as required by the precautions, although gloves were used. The Infection Preventionist, Staff T, acknowledged a gap in monitoring compliance with the precaution policies, which was crucial to preventing infections among staff and residents. Additionally, the facility failed to ensure proper hand hygiene during medication administration. Staff H, an LPN, did not perform hand hygiene before dispensing medications to a resident, only washing hands after completing the task. Furthermore, the facility's Water Management Plan was found to be incomplete and not comprehensive, lacking a filled-in CDC Legionella assessment form and a specific plan for interventions to prevent waterborne illnesses. The Maintenance Director, Staff N, confirmed the plan's deficiencies and was unsure about the Water Management Team's composition and review frequency.
Failure to Inform Residents of Rights and Responsibilities
Penalty
Summary
The facility failed to routinely inform both cognitively intact residents and the legal representatives of cognitively impaired residents about the facility rules, resident rights, and responsibilities, including Medicaid rights. This deficiency was identified for 10 out of 14 sampled residents. The lack of proper documentation and timely review of admission agreements placed residents at risk of not being fully informed of their rights, unmet care needs, and diminished quality of life. For Resident 27, who was cognitively intact, there was no documentation of an admission agreement being reviewed or discussed upon their admission. Similarly, Resident 28, who had severe cognitive impairment, signed the admission agreement 43 days after admission, without any documentation that it was reviewed with their representative. Other residents, such as Resident 30 and Resident 44, also experienced delays in signing their admission agreements, with no evidence of prior discussion or review upon admission. Interviews with staff members, including the Medical Records staff, Resident Care Manager, and Director of Nursing, revealed inconsistencies in the completion and review of admission paperwork. Staff acknowledged that some residents did not have their admission paperwork completed upon admission, and some even discharged before completion. The Administrator expected admission paperwork to be completed within 24-72 hours of admission, but this expectation was not consistently met, leading to the deficiency.
Failure to Provide Advanced Directive Information
Penalty
Summary
The facility failed to routinely provide written information, including the facility policy on advanced directives, to residents or their legal representatives upon admission. This deficiency was identified for six of the twelve sampled residents. The facility's policy required staff to provide residents and/or their representatives with information on their rights to formulate advanced directives, both in writing and orally, prior to or upon admission. However, this was not consistently done, as evidenced by the lack of documentation and signed agreements in the residents' records. Resident 20, who was admitted with paralysis and malnutrition, was found to have no documentation of their Durable Power of Attorney (DPOA) in their record, despite being competent and expressing a desire to change their DPOA. The resident's sibling, who was listed as the DPOA, had not provided the necessary documentation, and the facility had not followed up adequately. Similarly, Resident 218, who was cognitively intact, had no admission agreement or documentation that advanced directives were offered, and they left the facility against medical advice without this being addressed. Other residents, such as Resident 68 and Resident 44, also did not receive the required information on advanced directives upon admission. In some cases, forms were signed without the necessary attachments or explanations, and in others, cognitively impaired residents signed documents without their legal representatives being involved. Interviews with staff revealed a lack of clarity and consistency in the process of reviewing and explaining admission paperwork, including advanced directives, to residents and their representatives.
Deficiencies in Admission Process and Documentation
Penalty
Summary
The facility failed to establish and implement an effective admission policy, which resulted in several deficiencies related to the admission process for residents. Specifically, the facility did not ensure that admission paperwork, including the admission agreement and other essential documents, was completed and reviewed with residents or their legal representatives upon admission. This failure was observed in 10 out of 14 sampled residents, including those who were cognitively intact and those with cognitive impairments. The lack of proper documentation and review of admission agreements placed residents at risk of not being fully informed of their rights and care needs. For cognitively intact residents, such as Resident 27 and Resident 30, the admission agreements were not reviewed or signed until several days after their admission. In some cases, like Resident 68, there was no documentation of an admission agreement being completed at all. For residents with cognitive impairments, such as Resident 28 and Resident 42, the agreements were signed by the residents themselves rather than their legal representatives, which is not in compliance with the required procedures. This oversight indicates a systemic issue in the facility's admission process, where the necessary paperwork was not completed in a timely manner, and residents or their representatives were not adequately informed of their rights and responsibilities. Interviews with staff members, including the Medical Records staff, Resident Care Manager, and Director of Nursing, revealed a lack of clarity and consistency in the admission process. Staff members were unsure of their responsibilities regarding the completion and review of the 29-page electronic admission paperwork. The Administrator expected the paperwork to be completed within 24-72 hours of admission, but this expectation was not consistently met. The failure to complete and review admission paperwork upon admission was acknowledged by staff, highlighting a significant gap in the facility's procedures and communication regarding resident admissions.
Failure to Provide Bed Hold Policy Information Upon Admission
Penalty
Summary
The facility failed to provide written information regarding bed hold policies to residents or their representatives upon admission, as required by their policy. This deficiency was identified for eight out of fourteen sampled residents, including both cognitively intact and severely cognitively impaired individuals. The facility's policy, implemented in September 2022, mandates that residents or their representatives receive written notice of the bed hold policy at the time of admission. However, documentation and interviews revealed that this was not consistently done. For several residents, including those who were cognitively intact, there was no documentation that the admission agreement, which includes information on bed hold, was reviewed or discussed upon admission. In some cases, the agreement was signed days or even weeks after admission, and in one instance, it was signed by a cognitively impaired resident instead of their representative. Interviews with staff indicated confusion and uncertainty about who was responsible for reviewing and completing the admission paperwork, which includes the bed hold policy. Staff interviews further highlighted a lack of clarity and consistency in the process of reviewing and explaining the admission paperwork. Staff members, including a Licensed Practical Nurse, Medical Records personnel, and the Director of Nursing, provided varying accounts of who should be responsible for this task. The Administrator expected the paperwork to be reviewed and completed within 24-72 hours of admission, but this expectation was not met, leading to residents and their representatives being uninformed about their bed hold rights.
Deficiencies in Monitoring and Protocol Implementation
Penalty
Summary
The facility failed to appropriately monitor and address subtherapeutic blood values for a resident on Coumadin, a blood thinner. Resident 268, who was admitted with conditions including heart failure and aortic valve stenosis, was supposed to have daily PT/INR tests to ensure their blood clotting levels were within the therapeutic range of 2-3. However, after an initial test on 11/26/2024 showed a subtherapeutic level of 1.89, no further PT/INR results were documented, and the provider was not notified of the low result. This oversight placed the resident at risk for blood clots and other serious complications. The facility also failed to implement a bowel protocol for Resident 27, who had a history of constipation. Despite having orders for a bowel protocol that included administering a liquid oral laxative on the third day without a bowel movement, the resident went several days without documented bowel movements, and the protocol was not followed. The resident's medical records showed significant gaps between bowel movements, with no interventions documented, and the provider was not informed of the constipation issues. Additionally, the facility did not adhere to oxygen and blood pressure medication parameters for Resident 29, who had COPD and hypertension. The resident's oxygen saturation levels frequently exceeded the prescribed range, and the staff failed to consult the physician. Furthermore, the resident was administered Lisinopril despite blood pressure readings that were below the ordered parameters, without rechecking or documenting a second reading. These failures to follow medical orders and protocols could have led to adverse health effects for the residents involved.
Deficiencies in Dialysis Care and Fluid Management
Penalty
Summary
The facility failed to provide comprehensive dialysis care for four residents, leading to several deficiencies. For Resident 30, the care plan lacked specific instructions regarding the dialysis access site, and there were omissions in medication administration on dialysis days. Additionally, a non-functioning fistula was used for a blood draw, potentially causing a large hematoma. The resident was aware of the restrictions on using the arm with the fistula but was unsure how to proceed when the lab staff could not draw blood from the other arm. Resident 32's care plan did not include critical information from the dialysis center, such as restrictions on blood pressure measurements and blood draws in the access arm. The resident exceeded their fluid restriction on multiple occasions, and there was confusion about whether the resident took their medication at the dialysis center. The dialysis center confirmed that they did not administer medications brought by residents, and the resident reported only receiving a vitamin after meals. Residents 35 and 63 also experienced issues with fluid intake monitoring, exceeding their prescribed fluid restrictions on several days. The care plans for these residents did not adequately address the management of dialysis access sites or fluid intake monitoring. Staff interviews revealed a lack of clarity and communication regarding care plans, fluid restrictions, and medication administration, contributing to the deficiencies in dialysis care.
Failure to Conduct Annual Staff Evaluations and Competency Checks
Penalty
Summary
The facility failed to ensure that nursing assistants and licensed nurses had their competencies, skill sets, or performance evaluations completed yearly as required. This deficiency was identified for 6 out of 10 sampled employees, including a Resident Care Manager, nursing assistants, an LPN, and an RN. Interviews revealed that evaluations and skills fairs had not been conducted for about two years. The Director of Nursing acknowledged that these evaluations should be done annually, and the Human Resources department confirmed that no documentation of evaluations or competencies was found for the requested employees. The facility was in the process of auditing and completing these evaluations.
Failure to Administer Medications During Dialysis Sessions
Penalty
Summary
The facility failed to ensure that significant medications were administered as ordered for four residents who were undergoing dialysis. These residents, who had various medical conditions including end-stage renal disease, diabetes, and malnutrition, did not receive their prescribed medications on multiple occasions when they were absent from the facility for dialysis sessions. The medications omitted included gabapentin, acetaminophen, sevelamer, cholecalciferol, escitalopram, ferrous gluconate, levetiracetam, vitamin C, carvedilol, lactobacillus, torsemide, creon, apixaban, lantus insulin, lisinopril, metoclopramide, aspirin, atorvastatin, and midodrine. The medication administration records (MAR) for these residents showed codes indicating that the medications were not given because the residents were absent from the facility without medications. Staff interviews revealed that it was a common practice to skip doses of medications under the assumption that they would be dialyzed out of the residents' systems. However, this practice was not based on provider consultation, and the staff acknowledged that missed doses could negatively impact the residents' health. The Resident Care Manager was unaware that medications were being omitted during dialysis sessions and stated that the physician should be consulted to determine which doses could be omitted and to adjust medication administration times. The staff were expected to communicate any issues with medication administration so that alternative plans could be made, but this communication did not occur, leading to the deficiency.
Deficiencies in Admission Documentation and Resident Rights
Penalty
Summary
The facility administration failed to effectively use its resources to maintain compliance with Federal regulatory requirements, impacting several residents in areas such as Advance Directives, Admission and resident rights, and bed hold notification. Specifically, the facility did not ensure that the Admission Agreement, which includes information on advance directives, resident rights, and the facility's bed hold notification/policy, was completed upon admission. This failure placed residents at risk of not being informed of their rights, unmet care needs, and diminished quality of life. The survey identified deficiencies in informing residents and/or their representatives about facility rules and their rights, providing written information regarding the right to form an Advance Directive, and ensuring the facility's admission policy was effectively implemented. Interviews with facility staff revealed gaps in the management of admission paperwork and resident records. The business office manager, who was responsible for completing admission packets, had left the facility, and the responsibility was transferred to medical records. However, due to staffing changes and a gap in the Medical Records department, some documents were not scanned into resident records. The Administrator acknowledged being aware of the backlog in document scanning but was not fully aware of the extent of missing documents until the survey team raised concerns. The absence of a dedicated Medical Records staff member for several months contributed to incomplete resident records, including missing admission documentation and advance directives.
Failure to Maintain Dignity for Resident with Urinary Catheter
Penalty
Summary
The facility failed to maintain the dignity of a resident requiring a urinary catheter by not using a privacy cover for the urine collection bag. Resident 61, who had diagnoses including prostate cancer that had spread to the brain and urinary retention, was observed multiple times with their urinary catheter tubing and urine collection bag hanging on the bed frame, with the urine visible from the doorway. A blue privacy bag, intended to cover the urine collection bag, was not in use, compromising the resident's dignity. The facility's Bowel and Bladder Program policy did not address dignity concerns related to urinary catheters. Observations over several days showed the urine collection bag and dignity bag in the same positions, with the catheter tubing and clamp resting on the floor, which was also a cleanliness issue. Staff I, a Nursing Assistant, confirmed that urine collection bags were supposed to be kept in dignity bags, and Staff B, the Director of Nursing, stated that the staff was expected to ensure this practice was followed.
Failure to Obtain Informed Consent for Psychotropic Medications
Penalty
Summary
The facility failed to ensure informed consents were obtained prior to administering psychotropic medications to two residents. Resident 60, diagnosed with depression, was prescribed Paroxetine, a psychotropic medication, on 10/18/2024. Despite receiving the medication daily as documented in the November and December 2024 Medication Administration Records, there was no documentation of an informed consent explaining the risks and benefits of the medication being completed with the resident or their representative. Interviews with staff confirmed that informed consents should have been obtained before the medication was administered, but this was not done for Resident 60. Similarly, Resident 20, who had diagnoses including stroke, failure to thrive, and depression, was prescribed quetiapine, an antipsychotic medication, on 10/30/2024. The consent for this medication, which included the risks and benefits, was not signed until 11/22/2024, 23 days after the resident began receiving the medication. Staff interviews revealed that the consent process was supposed to be initiated during admission or when a new medication was ordered. However, due to an error during the admission assessment, the consent was not obtained in a timely manner for Resident 20.
Failure to Assess Resident for Safe Self-Administration of Medications
Penalty
Summary
The facility failed to ensure that the interdisciplinary team (IDT) assessed and determined a resident's ability to safely self-administer medications or store medications at the bedside. This deficiency was identified for one resident, who was part of a sample of 14 residents reviewed for resident rights. The facility's policy required that residents requesting to self-administer medications be evaluated for their ability to do so safely, with the evaluation analyzed by the IDT. However, there was no documentation in the resident's care plan or progress notes indicating that such an evaluation had been conducted. The resident in question, who had diagnoses including failure to thrive and mild cognitive impairment, was observed with an over-the-counter antacid on their bedside table, which they used without notifying staff. The resident did not have a provider's order for the antacid, and staff members, including a Licensed Practical Nurse and the Resident Care Manager, acknowledged that the proper procedures for self-administration and bedside storage of medications had not been followed. The Director of Nursing and the Administrator confirmed that the necessary evaluations and care planning had not been completed, and the medication should not have been left unattended.
Facility Fails to Maintain Functional Sink Faucets for Residents
Penalty
Summary
The facility failed to ensure that sink faucets were safe and functional in resident rooms, affecting two residents. Resident 38, who was independent in completing activities of daily living (ADLs) with some assistance, had their sink water turned off for several weeks due to a leak that caused water to flow into an adjacent room. This issue was not reported in the facility's maintenance app, and staff were unaware of the problem until it was brought to their attention during the survey. Staff had to use alternative methods to provide care, such as filling basins with water from other rooms. Resident 23, who was on hospice care and had a loose faucet in their room, experienced a similar lack of communication and action. Although the faucet was functional, it was not secured to the sink, and staff were unaware of the issue until it was reported during the survey. Despite claims that work orders had been submitted, no maintenance tickets were found in the system. The lack of awareness and communication among staff contributed to the delay in addressing these maintenance issues.
Inconsistent Mail Delivery Affects Resident Rights
Penalty
Summary
The facility failed to ensure consistent mail delivery, including on Saturdays, for four of the eight sampled residents, which compromised their rights to receive and send communication through the mail. The facility's Resident Rights policy, dated August 2022, stated that residents have the right to privacy in written communication, including the right to send and promptly receive mail. However, interviews with residents and staff revealed that mail was not distributed on weekends due to staffing issues. Resident 13 reported that mail was not delivered on weekends because there was no staff available to distribute it. This was confirmed during a group interview with the Resident Council, where other residents agreed that the lack of weekend mail delivery was problematic. Staff interviews further corroborated this issue, with the Director of Nursing and Staff O, the Life Enrichment Assistant, acknowledging that Staff O was the only person responsible for mail distribution and was not available on weekends. This situation resulted in residents not receiving their mail promptly, as required by their rights.
Failure to Conduct Timely PASRR Evaluations and Referrals
Penalty
Summary
The facility failed to ensure that residents with newly evident mental conditions were referred for a Preadmission Screening and Resident Review (PASRR) and for behavioral health services as needed. Specifically, three residents were affected by this deficiency. Residents 35 and 60 were diagnosed with depression and started on psychotropic medication therapy, but a PASRR level I screening and referral for level II was not completed. Resident 54 had PASRR level II recommendations for behavioral health services, but these recommendations were not implemented in a timely manner. Resident 60 was admitted to the facility without any mental health diagnoses, and a level I PASRR was completed prior to admission. However, a quarterly assessment later documented a diagnosis of depression and the prescription of a psychotropic medication, Paroxetine. Despite this change in mental health status, the facility did not complete a new level I PASRR or refer the resident for a level II assessment. Staff E, the Social Services Director, believed that a depression diagnosis did not require a new PASRR or referral, which led to the oversight. Resident 35 was initially admitted with no serious mental illness and did not require a level II evaluation. However, after a hospitalization, the resident was prescribed escitalopram for depression, and a significant change assessment documented symptoms of depression. Despite this, no second PASRR evaluation was completed. Resident 54, who had a PASRR level II completed prior to admission, required behavioral health services, but these services were delayed. Staff E admitted to being unsure of the PASRR process, which may have contributed to the delay, and Staff B, the Director of Nursing, acknowledged the untimely referral for behavioral health services.
Failure to Conduct Required PASRR Level II Evaluations
Penalty
Summary
The facility failed to ensure that residents with histories of mental disorders were appropriately screened for the need for specialized behavioral health services prior to admission, as required by the Pre-Admission Screening and Resident Review (PASRR) process. Specifically, two residents, identified as Resident 20 and Resident 61, were admitted without the necessary PASRR Level II evaluations. Resident 20, who had diagnoses including depression and adult failure to thrive, was taking antipsychotic medication daily. Despite this, the PASRR Level I screening completed at the hospital did not identify a serious mental illness, and no Level II evaluation was conducted prior to admission. Similarly, Resident 61, diagnosed with prostate cancer that had spread to the brain and depression, was receiving antidepressant medication daily. The PASRR Level I screening also failed to identify a serious mental illness, and no Level II evaluation was conducted. During an interview, the Social Services Director, Staff E, acknowledged that there was a list of diagnoses that required a Level II evaluation, maintained by the Director of Nursing, Staff B. Staff E admitted that Resident 20 should have had a Level II evaluation due to the diagnosis of major depressive disorder. Additionally, Staff E initially believed that Resident 61's depression did not warrant a Level II evaluation but later agreed that the Level II evaluator should determine the seriousness of the depression. This oversight placed the residents at risk for unmet behavioral health needs and potential decline in their psycho-social well-being.
Failure to Develop Timely Dialysis Care Plans
Penalty
Summary
The facility failed to develop baseline care plan goals and interventions related to dialysis needs within the required 48-hour timeframe for two residents, both of whom were dependent on dialysis due to end-stage renal disease (ESRD). Resident 63 was admitted with diagnoses including ESRD and was dependent on dialysis, yet the comprehensive care plan addressing dialysis needs was not initiated until nearly a month after admission. The initial nursing admission evaluation did not document the type of dialysis access or its location, and there was no baseline care plan developed within the required timeframe. Similarly, Resident 220, who was admitted with diagnoses including cardiac arrest and ESRD, did not have any goals or interventions related to dialysis needs documented in the comprehensive care plan during their stay. The nursing admission evaluation left questions regarding dialysis blank, and the resident had previously experienced a cardiac arrest likely due to missed dialysis sessions. Interviews with facility staff revealed that the care plan development process was multi-step, but the initial basic care plan failed to address the immediate dialysis care needs of the residents.
Failure to Document Discharge Summary and AMA Form
Penalty
Summary
The facility failed to complete a discharge summary with all the required components for Resident 66, who was reviewed for discharge. The necessary documentation, including a recapitulation of the resident's stay, the resident's status at the time of discharge, a medication reconciliation, and a discharge plan of care, was not completed. This deficiency was identified during a review of Resident 66's medical records, which showed no progress notes or AMA form, despite the resident leaving the facility against medical advice (AMA) due to dissatisfaction with their room. Interviews with facility staff revealed that there was an expectation for documentation of a discharge summary, AMA form, and progress notes when a resident chose to discharge AMA. Staff members, including the Resident Care Manager, Medical Records staff, and the Director of Nursing Services, acknowledged the absence of such documentation. Additionally, the Social Service Director stated that the facility's protocol was to notify Adult Protective Services when a resident discharged AMA, but no documentation was found to confirm this notification was made.
Deficiencies in Resident Assessment and Monitoring
Penalty
Summary
The facility failed to adequately assess and monitor residents for substance use disorder (SUD), safe smoking abilities, and post-fall evaluations, leading to potential safety hazards and unmet care needs. Resident 68, who had a history of alcohol abuse and tobacco use, was not properly assessed for SUD risks upon admission. Despite having a diagnosis of alcohol cirrhosis and alcohol abuse, the resident's care plan lacked specific goals or interventions for SUD. Additionally, Resident 68 was found to possess marijuana cigarettes, which were not allowed in the facility, indicating a lapse in monitoring and enforcement of facility policies. Resident 20, who had hemiplegia and cognitive impairments, was assessed as being able to smoke independently. However, observations showed that the resident struggled to navigate their wheelchair over a door jamb to re-enter the facility after smoking, posing a safety risk. Despite being observed in distress and needing assistance to return inside, the facility's smoking evaluation did not account for these challenges, and staff were unaware of the resident's difficulties, highlighting a gap in the assessment process. Resident 23, who was on hospice care with diagnoses including cancer and dementia, experienced an unwitnessed fall. The facility's documentation did not include neuro checks or thorough assessments for latent injuries following the fall, as required by their policy. Staff interviews revealed a lack of awareness regarding the need for alert charting and neuro checks after unwitnessed falls, resulting in inadequate post-fall monitoring and documentation for Resident 23.
Delayed UTI Intervention for Resident
Penalty
Summary
The facility failed to implement timely interventions for a resident, identified as Resident 218, who exhibited symptoms of a urinary tract infection (UTI). The resident, who had a history of left below the knee amputation and was occasionally incontinent of urine, reported symptoms of urinary frequency and urgency. Despite these symptoms, the care plan did not include goals or interventions related to the resident's elimination patterns. A urine sample was ordered on 12/01/2024, but there was a delay in sending the sample to the lab due to the facility's lab service not performing routine labs on weekends. The sample was collected and sent late on 12/01/2024, and the results indicating a UTI were not received until after the resident had left the facility against medical advice. Interviews with staff revealed that the facility's process for handling potential UTIs was inadequate. Staff CC, an LPN, noted that the lab did not perform STAT labs on weekends, which contributed to the delay. The Medical Director, Staff V, expressed concerns about the facility's criteria for diagnosing UTIs and advocated for a more immediate testing method, such as a urine dipstick. The Director of Nursing, Staff B, acknowledged that the delay in sending the urine sample was not timely and that preliminary results were not received for Resident 218. These procedural shortcomings placed the resident at risk of worsening infection and deterioration of health.
Failure to Discontinue Previous Tube Feeding Orders
Penalty
Summary
The facility failed to ensure that physician orders for nutrition were transcribed completely for a resident who was receiving nutrition through a feeding tube. The resident, who had a history of stroke and received more than 51% of their calories and water through a feeding tube, was observed with a tube feeding formula bag and a water bag hanging on an IV pole. The tube feeding pump was set to deliver the formula at 250 ml per hour and water at 130 ml per hour. However, the facility did not discontinue previous physician orders for a different tube feeding formula and water flushes when new orders were obtained, leading to conflicting documentation in the Medication Administration Record (MAR). The MAR showed that the resident was receiving both the new and previous tube feeding formulas and water flushes simultaneously until the previous orders were discontinued. Interviews with staff revealed that the previous orders should have been discontinued when the new orders were received. Staff members believed that the resident did not receive both formulas and water flushes due to the correct programming of the tube feeding pump, which was a two-pump system. However, the documentation indicated that the amounts specified in both sets of orders were administered, suggesting a failure in accurately transcribing and following physician orders.
Failure to Implement Trauma-Informed Care System
Penalty
Summary
The facility failed to implement a system to identify residents who are survivors of trauma, which led to a deficiency in providing trauma-informed care for Resident 20. Resident 20, who had a history of hemiplegia, depression, and failure to thrive, was admitted without a comprehensive assessment of their social concerns or trauma history. The admission evaluation did not include an assessment by a social worker, and the care plan lacked goals or interventions addressing the resident's social concerns or factors impacting their psycho-social well-being. This oversight put Resident 20 at risk for re-traumatization and a decline in their psycho-social health. Interviews with facility staff revealed a lack of understanding and implementation of trauma-informed care practices. The Social Services Director admitted to not completing a social work evaluation for Resident 20 and was unsure of the procedure for identifying trauma in residents. A Nursing Assistant was unaware of trauma-informed care and stated that potential triggers for residents were not documented. The Director of Nursing acknowledged that all residents should be screened for trauma to implement appropriate services and prevent re-traumatization, but this was not done for Resident 20.
Failure to Provide Timely Behavioral Health Services
Penalty
Summary
The facility failed to provide timely and appropriate behavioral health services to a resident diagnosed with a stimulant-induced psychotic disorder. The resident was admitted with a PASRR Level II evaluation indicating the need for behavioral health services. However, the Social Services Admission Evaluation left critical sections regarding mood, behavior, and psychiatric services blank. The care plan noted the resident's verbally abusive behaviors and poor impulse control, yet there was no immediate follow-up to address these issues. The resident filed a grievance in June, expressing concerns about the lack of trauma-informed care and the absence of a trauma-related care plan. Despite the resident's documented needs, a behavioral health referral was not made until August, and the resident was not evaluated by a Behavioral Health Nurse Practitioner until September. Interviews with facility staff revealed a lack of understanding of the PASRR process and an acknowledgment that the referral process was not timely. This delay in providing necessary behavioral health services put the resident at risk of unmet behavioral health needs and deterioration of their psychosocial well-being.
Failure to Complete Timely Medication Regimen Reviews
Penalty
Summary
The facility failed to consistently complete monthly medication regimen reviews (MRR) and follow up on recommendations in a timely manner for three residents, leading to potential risks of unnecessary medication use. Resident 27, who was admitted with coronary artery disease and high blood pressure, was on both aspirin and Clopidogrel. The pharmacist recommended discontinuing Clopidogrel to reduce bleeding risks, but the medication was not discontinued until 52 days later, and the October MRR was missing. Staff interviews revealed a lack of understanding of the MRR process, and the Director of Nursing acknowledged a gap due to management changes. Resident 60, with a history of stroke and diabetes, continued to receive sliding scale insulin and a blood-thinning medication without timely physician evaluation or clarification, despite repeated requests from the pharmacist. The facility's documentation did not show a timely response to the pharmacist's recommendations, and staff interviews confirmed the delay in addressing these recommendations. Resident 29, diagnosed with anxiety, bipolar disorder, and dementia, had missing MRR documentation for several months. The facility provided records for only three months, with no information for July, August, and September. Staff interviews indicated that frequent changes in the Director of Nursing position contributed to lapses in the usual process for handling MRR reports. The administrator acknowledged the missing documentation but was unable to provide further records.
Expired Medications and Inadequate Narcotic Tracking in Medication Rooms
Penalty
Summary
The facility failed to ensure expired medications were removed from inventory in the South Hall medication storage room and medication cart. During an observation, expired medications, including Zinc Sulfate and Ocular Vitamin tablets, were found in the medication room, and expired lorazepam and Cath-flo activase were found in emergency kits within a locked refrigerator. Staff G, an LPN, acknowledged that the lorazepam was not counted during narcotic reconciliation, and the pharmacy was responsible for monitoring expiration dates in the emergency kits. Additionally, the emergency kits were not properly sealed with the required zip ties, and Staff B, the Director of Nursing, was unaware of the expired medications in the refrigerator. In the North Hall medication room, a bottle of liquid Ativan was found in the medication refrigerator without being logged into the narcotic tracking-controlled substance book, which is necessary for shift counts. Staff C, the Resident Care Manager, confirmed that the Ativan had not been logged until the day of the observation. The facility's policy required controlled drugs to be logged and counted at each shift change, but this was not adhered to, leading to a lack of accurate medication reconciliation. The Administrator expected staff to store and track controlled medications properly, but this expectation was not met, resulting in deficiencies in medication management.
Dietary Manager Lacks Required Certification
Penalty
Summary
The facility failed to ensure that the dietary staff had the proper qualifications, specifically concerning the Dietary Manager's certification. During an interview, the Regional Registered Dietician stated they were only part-time at the facility, typically two days per week. The Dietary Manager, who had been in their position for almost three years, admitted during a phone interview that they did not have the required dietary manager certification, although they had been approved to take the class. A review of dietary staff records confirmed that the Dietary Manager only possessed a current food handler card and no other qualifications. The facility's Administrator acknowledged that due to the dietician not being full-time, the Dietary Manager was required to have the certification, which they did not possess.
Failure to Provide Preferred Beverages to Residents
Penalty
Summary
The facility failed to provide residents with their preferred beverages, specifically coffee, upon request, which affected two residents, Resident 27 and Resident 68. Resident 27, who was cognitively intact and had a diagnosis of malnutrition, expressed frustration over not receiving coffee in the morning, despite it being their beverage of choice. The resident reported waiting for hours only to be informed that the facility was out of coffee. The resident council also noted that coffee service was cut off at certain times, which contributed to the issue. Similarly, Resident 68, who also had a diagnosis of malnutrition, expressed dissatisfaction with the unavailability of coffee, which was confirmed by staff who stated that the facility often ran out of coffee and limited its availability due to cost concerns. Interviews with staff revealed inconsistencies in the availability of coffee, with some staff indicating that coffee was supposed to be available 24/7, while others acknowledged that the kitchen's operating hours limited access. The facility's policy required gathering residents' food and beverage preferences upon admission, but records showed no documentation of coffee preferences for the affected residents. The lack of a consistent supply and the facility's operational limitations led to unmet care needs and diminished quality of life for the residents involved.
Inaccurate Allergy Documentation in Resident's Medical Record
Penalty
Summary
The facility failed to maintain accurate medical records for Resident 23, who was reviewed for unnecessary medications. Resident 23 had been inaccurately documented as having allergies to Acetaminophen (Tylenol/APAP), Baclofen, and Morphine in their electronic medical record (EMR). Despite these documented allergies, the resident was regularly administered Morphine and Tylenol as prescribed by the physician. The inaccuracies in the medical record were not corrected even after staff determined that the allergies were not true. Interviews and record reviews revealed that the inaccuracies persisted despite multiple staff members being aware of the issue. Staff U, an LPN, confirmed that Resident 23 was not allergic to Morphine and that Tylenol was avoided due to liver damage, not an allergy. The Pharmacist Director also noted that the allergies had been listed since June 2022 and that the facility staff, not pharmacists, entered the information into the system. The facility's Administrator acknowledged the inaccurate documentation, which placed the resident at risk of unmet care needs.
Failure to Explain Arbitration Agreement in Resident's Language
Penalty
Summary
The facility failed to properly explain the arbitration agreement to Resident 272, who was admitted on June 13, 2024. Resident 272's preferred language was Mandarin, and they had severe cognitive impairment, requiring an interpreter for communication. Despite this, the arbitration agreement was presented in English and signed by the resident, not their legal representative, on June 11, 2024. The communication care plan indicated the need for gestures, family, and an interpreter line to communicate with the resident, yet there was no documentation showing the arbitration agreement was explained in a language or manner understood by the resident or their representative. Interviews with facility staff revealed a lack of clarity and consistency in the process of reviewing arbitration agreements. Staff A, the Administrator, stated that the business office manager was responsible for this task, but due to the absence of a BOM, Staff F from Medical Records had taken over the responsibility. Staff F was unsure if the facility had arbitration agreements in languages other than English and could not confirm how non-English speaking residents or their representatives understood the agreements. Staff B, the Director of Nursing, mentioned that agreements were available in other languages and that interpreter services should be used, but there was no evidence of this practice being followed for Resident 272.
Lack of Coordination with Hospice Services
Penalty
Summary
The facility failed to consistently communicate and coordinate care with the hospice provider for a resident receiving end-of-life services. The facility did not designate an interdisciplinary team member in writing to coordinate care and communication with the hospice agency, as required. This lack of coordination was evident in the absence of a designated staff member in the facility's policy and agreements with hospice providers, which were outdated and did not reflect current staff roles. Resident 23, who had diagnoses of cancer, dementia, and heart failure, was on hospice services but experienced a lack of consistent care coordination. The resident's care plan included hospice services, but there was no documentation of the frequency of hospice nurse or aide visits. The resident reported infrequent visits from hospice staff, and there was a discrepancy in the documentation of bathing tasks, with facility staff assuming hospice was providing baths without verification. The last hospice note in the resident's record was outdated, and there were no notes regarding bathing services from hospice. Interviews with facility staff revealed confusion and assumptions about the hospice aides' responsibilities and schedules. Staff members were unsure of the hospice aides' visit frequency and relied on verbal communication rather than documented evidence. The hospice provider supervisor confirmed that bath aide services were optional and had not been utilized for Resident 23 until recently. This lack of communication and documentation led to unmet care needs for the resident.
Failure to Investigate Allegations of Abuse and Neglect
Penalty
Summary
The facility failed to thoroughly investigate allegations of abuse and/or neglect for two residents, which placed them at risk for abuse and/or neglect and a diminished quality of life. Resident 1, who had diagnoses of chronic pain and depression and was independent with most activities of daily living, reported ongoing inappropriate sexual comments from their roommate. Despite Resident 1's grievance and request for room separation, the facility did not conduct an investigation into the allegations of sexual abuse. Resident 1 expressed fear and discomfort due to the roommate's behavior, and no action was taken until much later. Resident 5, admitted with heart and lung disease, also experienced neglect as their care concerns were not addressed. The resident reported not receiving showers for the first two weeks after admission, wounds on their legs not being addressed, and labs not being properly drawn. Although a care conference was recommended, the interim Director of Nursing and Administrator did not attend, leaving the resident and their family dissatisfied. The facility's incident log showed no investigation into these grievances, and the Social Services Director confirmed that no investigations were conducted for the allegations made by Residents 1 and 5.
Failure to Maintain Required RN Coverage
Penalty
Summary
The facility failed to ensure that a Registered Nurse (RN) was on duty for at least eight hours a day, seven days a week, as required. A review of the staffing pattern revealed that there was no RN coverage for 18 full days in October 2024 and for 10 full days from November 1 to November 15, 2024. During interviews, the Staffing Coordinator confirmed the lack of RN coverage, noting that the facility had an RN working 16-hour shifts on weekends and until November 1, 2024, had an RN working one day during the week. The facility relied on agency staff, who typically sent Licensed Practical Nurses (LPNs) instead of RNs. The Administrator also confirmed the deficiency and stated that the facility was in the process of hiring RNs.
Failure to Protect Residents from Mental Abuse
Penalty
Summary
The facility failed to protect a resident from mental abuse when another resident made sexually inappropriate comments towards them. Resident 1, who had diagnoses of chronic pain and depression, was alert and oriented and could make their needs known. Despite Resident 1's grievance filed on 09/16/2024, reporting ongoing inappropriate sexual comments from Resident 2 and requesting a room change, the facility did not conduct an investigation or take timely action to separate the residents. This inaction left Resident 1 feeling uncomfortable and scared, as they feared potential harm from Resident 2. The situation escalated when an argument between Resident 1 and Resident 2 was reported on 10/29/2024, during which Resident 1 confronted Resident 2 about the inappropriate comments. Additionally, Resident 3 reported that Resident 2 had made similar lewd comments and had threatened to rape them, which they only reported when informed that Resident 2 would be moved into their room. Despite the Social Services Director reporting the grievance to the Administrator in September, no action was taken until late October, leaving residents at risk for psychosocial harm.
Medication Administration Error for Heart Medication
Penalty
Summary
The facility failed to follow physician orders for Resident 4, who was prescribed Carvedilol, a heart medication, to be taken twice daily. On July 11, 2024, the medication order was changed to once daily without a physician's order to authorize this change. This error was discovered during a cardiology appointment on September 30, 2024, when it was found that the resident had been receiving the medication at a lower dose and frequency than prescribed since July 2024. The Medication Administration Record (MAR) indicated that the resident had been taking Carvedilol twice daily since admission on June 26, 2024, until the order was altered on July 11, 2024. The new order was below the usual dose and frequency, and there was no documentation to justify the change or address the flagged concern in the system. Staff E, the Resident Care Manager, confirmed that the system flagged the change as a concern, but it was not addressed. The Licensed Practice Nurse (LPN) responsible for the change no longer worked at the facility, and the resident continued on the incorrect dosage until the cardiology visit.
Unsanitary Food Storage Conditions Due to Persistent Leak
Penalty
Summary
The facility failed to store dry and refrigerated food in sanitary conditions, which placed residents at risk for foodborne illness. During an inspection, surveyors observed towels soaked with water on the floor outside the walk-in refrigerator, with the refrigerator door open and water covering the floor along with food debris. The dry storage room, located next to the refrigerator, had about an inch of standing water on the floor. Canned goods were observed with water pooled on top, labels coming off, and cardboard boxes saturated with water. Water was dripping from pipes between the refrigerator and the dry storage room, being collected into a bucket. Staff G, the Maintenance Director, stated that the leak had been ongoing for about a month and had been reported to the administration, but the issue was not resolved. Staff G mentioned that they were instructed to use a shop vac to remove the water daily, sometimes more than once a day, and to keep towels on the floor due to water coming from under the refrigerator door. Staff H, the Dietary Manager, confirmed the ongoing issue and reported it to the Administrator and the corporate Maintenance Director. Staff F, the Infection Preventionist, also reported concerns about the pooling water to maintenance and dietary, emphasizing that sustained water should not be present in a food environment. The Administrator, Staff D, acknowledged the leak and stated that attempts to fix it had been unsuccessful.
Facility Fails to Maintain Homelike Environment During Construction
Penalty
Summary
The facility failed to maintain a quiet, comfortable, and homelike environment for residents during construction activities in all four hallways: Southwest, Southeast, Northwest, and Northeast. Observations revealed that construction workers used loud equipment such as air compressors and nail guns, causing significant noise disturbances. Residents were present in their rooms during these activities, and some reported the noise as being very loud and disruptive. Additionally, construction materials and tools were left in the hallways, obstructing residents' movement and requiring workers to move them to allow passage. Interviews with residents and staff confirmed the noise complaints, with some residents experiencing increased fatigue and headaches due to the disturbances. The construction activities, including sanding and painting, also produced strong fumes and dust, further contributing to the discomfort. Staff members acknowledged the residents' complaints about the noise and the prolonged duration of the construction work, which affected the residents' ability to rest and feel at home in the facility.
Medication Storage Temperature Deficiency
Penalty
Summary
The facility failed to maintain proper storage temperatures for medications in both the North and South medication rooms, as observed during a survey. In the South medication room, a thermometer indicated temperatures exceeding 80 degrees Fahrenheit, and staff admitted to not logging these temperatures. Staff A, an LPN, mentioned that the room often became hot and suggested using a fan and propping the door open as a temporary solution. However, there was no consistent logging of temperatures, and the Resident Care Manager, Staff L, was unaware of the thermometer's limitations. The lack of temperature logs and the absence of a policy for medication storage were noted. In the North medication room, similar issues were observed. The thermometer showed a maximum temperature of 80 degrees, and staff reported that the room often became extremely hot. Although refrigerator temperatures were checked, room temperatures were not consistently logged, and there was no documentation of actions taken when temperatures exceeded the acceptable range. The logs for both rooms showed frequent instances of temperatures above the recommended 77 degrees, with no evidence that the Director of Nursing was notified of these deviations. The facility administrator was unaware of the thermometer's limitations and could not provide a policy for medication storage.
Call Light System Malfunction During Construction
Penalty
Summary
The facility failed to ensure that functioning call lights were available in 10 out of 13 observed resident rooms, which placed residents at risk for unmet care needs and the inability to call for assistance. The issue was exacerbated by ongoing construction, which reportedly caused the call lights to malfunction. Staff interviews revealed that the call light system was old and frequently failed, with maintenance being notified of the outages. Residents were provided with bells as an alternative, but these were not always effective due to noise levels in the hallways. Several residents reported issues with their call lights, including long wait times for assistance and instances where the call lights did not work at all. One resident mentioned that the construction crew might have cut the wires, leading to the malfunction. Another resident expressed frustration over the lack of a bell to use when the call lights were out. Staff confirmed that the call light boxes in the rooms would light up, but the corresponding lights in the hallways did not, making it difficult for staff to respond promptly. The call light board at the nurses' station was observed to be sounding, indicating call lights were on in unoccupied rooms, while some occupied rooms showed prolonged activation times without hallway lights being lit. Staff were instructed to monitor the call light panel, but issues persisted, with some staff noting that the system was not fully operational. The administrator acknowledged the problem, attributing it to the construction and the age of the system, and noted that the sound on the South panel had been turned down, affecting staff's ability to hear alerts.
Failure to Maintain and Monitor IV Access Devices
Penalty
Summary
The facility failed to ensure proper maintenance and monitoring of Intravenous (IV) access devices for two residents receiving IV therapy. Resident 1, admitted with cellulitis and a blood infection, had a Peripherally Inserted Central Catheter (PICC) line in the left chest for administering antibiotics. The dressing on the PICC line had not been changed for 15 days, despite orders for weekly changes. Additionally, there was no documentation of the required measurements of the upper arm circumference and external catheter length, which were to be done on admission and with each dressing change. Resident 2, admitted with a bone infection, also had a PICC line for antibiotic administration. The dressing on the PICC line was undated, and the resident was unsure if it had been changed. The Treatment Administration Record (TAR) indicated that the dressing was to be changed weekly, but there was no documentation to confirm this. Furthermore, the order to flush the PICC line every 12 hours was not initiated until seven days after admission. Staff interviews revealed that only Registered Nurses (RNs) were responsible for dressing changes, but there was limited availability of RNs to perform these tasks.
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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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