Spokane Health & Rehabilitation
Inspection history, citations, penalties and survey trends for this long-term care facility in Spokane, Washington.
- Location
- North 6025 Assembly, Spokane, Washington 99205
- CMS Provider Number
- 505322
- Inspections on file
- 51
- Latest survey
- March 5, 2026
- Citations (last 12 mo.)
- 3
Citation history
Health deficiencies cited at Spokane Health & Rehabilitation during CMS and state inspections, most recent first.
A resident admitted with a right hip surgical incision and staples had orders for daily or PRN dressing changes and an orthopedic follow-up for an incision check and x-rays, but no follow-up appointment was scheduled and there was no documentation of incision care on the MAR/TAR. Facility policy required weekly licensed nurse skin assessments and documentation of non-pressure wounds, yet shower sheets repeatedly noted groin and other skin redness without consistent nurse signatures or subsequent assessment or treatment orders. Over several weeks, nursing skin assessments and progress notes did not address the documented reddened areas, and when the resident was later hospitalized, staples from the prior hip surgery were still in place with overgrown tissue and mild irritation, and intertrigo with macerated, inflamed skin was identified in body folds.
The facility did not provide adequate nursing staff to meet all residents' needs and failed to have a licensed nurse in charge on every shift, as required by regulations.
The facility did not consistently assess or supervise residents' smoking abilities, resulting in multiple residents smoking unsafely on the premises, including one with Parkinson's disease and another with COPD. Staff were unaware of residents' smoking status, failed to secure smoking materials, and did not update care plans with necessary safety interventions, leading to unsafe conditions and activation of the fire alarm.
The facility required residents to sign admission agreements and inventory forms that included language waiving potential facility liability for losses of personal property, despite regulations prohibiting such waivers. Three cognitively intact residents signed these documents, and in one case, a resident's cell phone was broken after an incident with staff, with no reimbursement or proper grievance documentation. Staff interviews confirmed the use of these forms and acknowledged the waiver language.
The facility did not have a full-time RN serving as DON, as required. Instead, an RN focused mainly on MDS coordination while most DON duties were handled by an LPN/ADON. Payroll documentation was not provided to confirm full-time DON coverage, and after-hours responsibilities were managed by the LPN/ADON.
Surveyors found that the facility did not have a written transfer agreement with any local hospital certified by Medicare or Medicaid, as confirmed by the Regional Director of Clinical Operations during interviews and record review.
The facility did not maintain an effective QA&A program, resulting in repeated deficiencies in areas such as ADLs, falls monitoring, care conferences, and admission procedures. Several residents did not consistently receive scheduled showers, oral care, or nail care, and staff interviews confirmed lapses in care and documentation. Additionally, monitoring after falls, completion of care conferences, and admission documentation were not consistently performed or sustained.
Multiple residents with high care needs were not checked or changed in a timely manner, experienced long call light wait times, and did not receive assistance with ADLs as required by their care plans. Staff and residents reported frequent short staffing, especially on the LTC unit, leading to missed transfers, residents left soiled, and unmet care needs. Incident logs and interviews confirmed ongoing issues with inadequate staffing, resulting in numerous allegations of neglect and long response times.
The facility did not consistently inform residents or their representatives about care and services upon admission, nor did it obtain timely consents for routine care or psychotropic medications. Several residents, including those with cognitive impairment and those able to verbalize their needs, were not provided with or did not recall receiving information about their care or signing consent forms. In multiple cases, psychotropic medications were administered before obtaining informed consent, and required information about serious side effects was missing from the consent forms.
Several residents with conditions such as COPD, chronic pain, high blood pressure, anxiety, and hip fracture were not provided with written information or documentation regarding their right to formulate an advance directive. Staff interviews revealed confusion about responsibilities and inconsistent processes for informing residents, with only a small fraction of recent admission packets containing the required information. Staffing vacancies contributed to incomplete admission documentation, resulting in residents not being fully informed of their rights.
The facility did not consistently provide required oral and written information on how to apply for and use Medicare and Medicaid benefits to residents or their representatives at admission. Several residents, including those with cognitive impairment and those able to verbalize their needs, did not receive or recall receiving this information, and documentation was lacking in admission records. Staff interviews confirmed delays and incomplete admission packets due to staffing issues, resulting in most new admissions not being fully informed about their Medicare and Medicaid options.
The facility did not consistently inform residents or their representatives about nursing service charges, potential costs for non-covered services, or provide required Medicare beneficiary notices. Several residents did not recall receiving information about charges or services at admission, and required documentation was missing for most recent admissions. Additionally, two residents were not given the necessary SNF ABN forms when their Medicare Part A coverage ended, due to staffing shortages and incomplete processes.
The facility did not develop baseline care plans with resident-specific goals and interventions within 48 hours of admission for several residents, including those with hospice needs, malnutrition, Multiple Sclerosis, and complex medical conditions requiring procedures like paracentesis. Staff confirmed that immediate care needs were not documented in the care plans, and individualized interventions were missing.
The facility did not ensure care plans included resident-specific goals and interventions for three residents, including the absence of nail care instructions for a dependent resident, lack of documentation of shaving preferences for another, and missing delineation of hospice versus facility care for a resident on hospice. Staff interviews confirmed these omissions in the care plans.
Annual performance evaluations were not completed or documented for three nursing assistants, as required, with the Administrator confirming the absence of these evaluations during review.
The facility did not consistently post daily nurse staffing information in a location accessible to residents, families, or visitors over several months. Observations and staff interviews revealed confusion about responsibility for posting, and record review showed numerous days with missing documentation, resulting in a lack of transparency regarding current staffing levels and census information.
Surveyors found that two medication carts contained expired and improperly labeled medications, including opened insulin vials and unlabeled emergency drugs. A resident was observed with unsecured, unauthorized medications at bedside, brought in by family, and staff confirmed there were no physician orders for these. In the medication room, emergency kits with controlled substances were unsealed and not counted for diversion, and controlled drugs awaiting destruction were not inventoried during storage.
The facility did not complete timely and accurate nutritional assessments, failed to monitor and document significant weight changes, and did not ensure required nutritional supplements were provided as ordered. For example, a resident experienced severe weight loss without prompt re-weighing or provider notification, another resident on dialysis did not receive the prescribed supplement and staff were unaware of refusals, and other residents did not receive comprehensive assessments or individualized care plans. Staff interviews revealed gaps in communication, documentation, and follow-through on nutritional care requirements.
Multiple residents, all cognitively intact, reported that meals were often served at improper temperatures, lacked variety, and were bland or unappetizing. A test tray confirmed these issues, with food found to be dry, flavorless, and sometimes difficult to eat. The dietary manager acknowledged complaints and linked them to a recent change in food suppliers and menu, as well as the timing of tray delivery affecting food temperature.
Surveyors identified multiple deficiencies in food storage, labeling, and kitchen cleanliness, including improperly labeled and expired food items, unclean surfaces, and lack of a cleaning schedule. Dietary staff did not consistently wear required hair and beard coverings or perform hand hygiene when indicated. Additionally, nourishment refrigerators contained items without proper resident identification or open dates, contrary to facility policy.
Staff failed to follow infection prevention protocols, including Enhanced Barrier Precautions, hand hygiene during medication administration and wound care, and proper equipment sanitization. Several residents with indwelling devices or wounds did not have required EBP signage, and staff did not consistently use PPE or perform hand hygiene as required. Shared equipment was not sanitized between uses, and improper food service practices, such as blowing on food and lack of hand hygiene, were observed during meal assistance.
The facility did not follow its Antibiotic Stewardship Program for new admissions or residents prescribed antibiotics by community providers, as shown by incomplete or missing documentation of McGeer Criteria in infection surveillance logs over several months. The Infection Preventionist confirmed the ASP process was not applied in these cases, assuming hospitals ensured compliance.
Two residents with significant mobility and cognitive impairments were repeatedly found without accessible call lights, as the devices were either out of reach or on the floor. Staff and administration acknowledged that call lights should have been left within reach, but multiple observations confirmed this was not consistently done.
The facility did not consistently provide newly admitted residents or their legal representatives with information on resident rights, facility rules, and Medicaid obligations at admission. Several residents, including those who were cognitively intact and those with cognitive impairment, did not receive or recall receiving this information, and record reviews showed missing documentation. Staff interviews confirmed that admission packets were not completed timely due to staffing issues, resulting in residents not being fully informed as required.
The facility did not consistently follow professional standards for nursing care, resulting in failures to assess and treat skin conditions, manage constipation, and implement fall prevention and monitoring protocols. Several residents with wounds or skin conditions did not receive proper assessment or treatment, and residents at risk for constipation went days without interventions or monitoring. Additionally, residents who experienced falls were not consistently monitored for injuries, and required neurological checks were often incomplete or missing.
A resident with moderate cognitive impairment and a history of Parkinson's disease and acid reflux was found self-administering Tums without a provider order or documented assessment of their ability to do so safely. The medication was present at the bedside over several days, and the Medication Administration Record did not reflect any administrations, indicating a lack of oversight and required documentation.
Three residents experienced deficiencies in environmental cleanliness and comfort, including a resident with a persistently dirty call light button, another with an unclean wheelchair, and a third whose bed sheets were not changed regularly. Staff interviews revealed inconsistent cleaning practices and a lack of clear documentation or responsibility for routine cleaning of high-touch surfaces, wheelchairs, and linens.
Two residents admitted under an exempted hospital discharge with mental health diagnoses remained in the facility beyond 30 days without the required PASARR Level II referrals. Both residents had documented mental health conditions and continued to reside in the facility past the exemption period, but no Level II assessments were initiated as mandated.
The facility did not update care plans in a timely manner for two residents after significant changes in their care needs, including the development of a new pressure ulcer and the discontinuation of a urinary catheter. Additionally, a resident was not invited to a required care conference, with documentation showing only one conference held months prior. Staff confirmed these omissions, and records did not reflect the necessary updates or meetings.
A resident with heart failure, COPD, and OSA was unable to use their CPAP machine because it was not working, and staff did not assist in obtaining a replacement or accurately document its use. Despite provider orders and care plan interventions, staff failed to follow up on the equipment's functionality, and documentation inaccurately reflected that the CPAP was being used and maintained.
A resident with a leg amputation did not receive appropriate care and assistance to use their prosthesis, as staff did not routinely apply the device or include its management in the care plan or provider orders. The prosthesis was often left unused, and staff only applied a shrinker daily, despite the resident's desire to improve mobility. Documentation and staff interviews confirmed the absence of instructions or support for prosthesis use outside of therapy sessions.
A resident receiving dialysis care did not have dialysis treatment documentation (logs) from the dialysis center in their medical record, and there were discrepancies between the care plan, physician orders, and the resident's actual dialysis access site and schedule. Staff confirmed the orders were inaccurate and that dialysis logs had not been received.
Three residents did not receive meals consistent with their documented food preferences or dietary needs, including repeated instances of incorrect meal items and lack of alternatives. Staff and dietary management acknowledged issues with menu collection, transcription, and tray card accuracy, resulting in residents being served unwanted or inappropriate foods.
Two residents with complex medical conditions were not screened or offered influenza and pneumococcal vaccines as required, despite having signed consent forms. Documentation showed that neither resident received the influenza vaccine during the vaccination season, and one did not receive the pneumococcal vaccine within the required timeframe. Staff acknowledged these failures during interviews and record reviews.
A resident with intact cognition reported a call light/TV cord with exposed wires in their room, but despite notifying staff and requesting a replacement, the issue was not addressed for several days. Multiple observations confirmed the unsafe condition, and staff interviews indicated a breakdown in the facility's maintenance reporting process.
A resident was subjected to persistent foul odors and unclean conditions in a shared room, with repeated staff awareness but no effective intervention. The situation involved two residents, one of whom frequently refused personal care, leading to ongoing unsanitary conditions and discomfort for the roommate. Staff confirmed the odor and cleanliness issues, but did not address the concerns of the affected resident.
Three residents with central venous access devices did not receive proper monitoring, documentation of maintenance flushes, or timely dressing changes. Care plans and medical records lacked instructions for IV device management, and staff demonstrated inconsistent knowledge and documentation regarding device care, leading to lapses in required infection control practices.
An LPN left topical medications unsecured on a treatment cart, with multiple medication cups containing creams and powders placed in food boats labeled with forenames. The LPN admitted to forgetting to lock the medications due to distraction, and the ADON confirmed that all topical medications should be secured in locked carts.
A resident with a history of heart failure and fluid overload was admitted with orders for twice-weekly kidney function labs while on diuretic therapy. Facility staff failed to enter and complete lab orders as required, and did not promptly escalate the resident's complaints of decreased urination and fluid overload to a provider. When critical labs eventually showed acute kidney failure, the results were not acted upon in a timely manner, and the resident remained in the facility for about 12 hours before being transferred to the hospital, where they later died.
The facility failed to monitor for psychosocial harm after abuse and neglect allegations for four residents, despite having policies in place. Incidents included a staff member allegedly taking photos of a resident, a resident not being changed during a shift, a call light response delay, and a nursing assistant declining to assist a resident to the bathroom. Nursing staff did not consistently complete required charting to assess for psychosocial harm.
The facility failed to maintain complete and accurate medical records for several residents, including incomplete psychotropic consent forms, unsigned nutrition assessments, inaccurate progress notes, and conflicting code status information. These deficiencies were acknowledged by the facility's administration.
The facility failed to obtain accurate and timely consents for psychotropic medications for two residents. One resident received sertraline for 21 days before consent was discussed with their Power of Attorney. Another resident's consents for Lexapro and mirtazapine lacked documentation of their choice, yet the medications were administered for 28 days. The Assistant DON acknowledged the issue.
A resident with severe cognitive impairment experienced a significant weight loss of 17.3 pounds, or 9.67%, within a week. Despite this, the facility failed to notify the resident's Power of Attorney (POA) about the weight loss, as confirmed by the Assistant Director of Nursing.
A facility failed to conduct a thorough investigation into a neglect allegation involving a resident found in soiled conditions. Although a skin check was noted in the investigation, no documentation was found in the resident's medical record for the date of the incident. The DON acknowledged the need for a skin check, but no evidence was provided. The nurse involved was an agency staff member who was not allowed to return.
The facility failed to provide adequate shower care for five dependent residents, leading to poor hygiene and diminished quality of life. Residents with various medical conditions, including stroke, fractures, and infections, received fewer showers than scheduled, with some receiving only one shower or bed bath over several weeks. Staff interviews revealed inconsistencies in shower scheduling and handling of refusals.
The facility failed to obtain timely weights for six residents and did not provide necessary meal assistance for a resident with a recent stroke, risking unrecognized weight loss and nutritional complications. Observations and interviews revealed discrepancies in weight documentation and lack of feeding assistance, with staff citing time constraints. The Director of Nursing acknowledged the failure to adhere to weight monitoring protocols.
The facility failed to follow medical orders for two residents. One resident, with a recent stroke and on enteral nutrition, did not have full vital signs monitored as ordered. Another resident, with heart failure, had a fluid restriction order but no monitoring of fluid intake was documented. These oversights were confirmed by staff interviews.
The facility failed to properly manage contaminated laundry for several residents, with soiled linens found improperly stored in rooms. Staff interviews revealed a lack of adherence to infection control protocols, as soiled items were not promptly taken to the dirty utility room, risking the spread of infection.
Two residents with diagnosed conditions affecting mobility did not receive adequate monitoring and treatment for range of motion limitations. One resident with Parkinsonism had a therapy referral that was not communicated, while another with Cerebral Palsy lacked interventions despite worsening contractures. The facility's failure to ensure proper assessments and follow-up on therapy orders led to a risk of avoidable decline.
The facility failed to administer physician-ordered medications as prescribed for multiple residents, including those with Clostridium difficile, schizophrenia, COPD, and shingles. Delays and omissions in medication administration were due to pharmacy issues and lack of proper tracking, impacting residents' care and treatment.
Failure to Monitor Surgical Incision and Non-Pressure Skin Conditions
Penalty
Summary
The deficiency involves the facility’s failure to assess, evaluate, and monitor non-pressure skin conditions and a surgical incision according to physician orders and facility policy for one resident. The facility’s undated Non-Pressure Injury/Ulcer Management policy required staff to identify and investigate non-pressure wounds, report changes in skin integrity including surgical wounds, conduct weekly skin observations by a licensed nurse, and document wound characteristics in the medical record. The resident was admitted with a right hip fracture and a surgical wound with staples, with hospital transfer orders directing daily or as-needed dressing changes and orthopedic discharge instructions calling for a follow-up incision check and x-rays 12–14 days after surgery. The resident’s care plan identified a right hip surgical incision and called for weekly skin observations and treatments as ordered, but there was no documentation that a follow-up orthopedic appointment was scheduled. Shower sheets used by CNAs documented multiple instances of skin issues in the resident’s groin and other areas, but these findings were not consistently followed up by nursing staff. On one shower sheet, the area between the buttocks and the groin was marked as red and chapped, and on another, the groin was documented as red; neither of these forms had a nurse’s signature. A later shower sheet showed redness on both arms, the groin, and both lower legs and did have a nurse’s signature. Despite these documented skin concerns, the Medication Administration Record and Treatment Administration Record for the month contained no entries for treatment of the surgical incision with staples or for the reddened areas identified on the shower sheets. Review of nursing skin assessment sheets and progress notes from admission through early February showed no documented assessment or monitoring of the resident’s groin redness or other identified reddened areas. When the resident was later sent to the hospital with altered mental status, hospital records documented that the surgical staples from the December surgery were still in place, with overgrown tissue and mild irritation at the incision site, and that the resident had intertrigo in skin folds with inflamed, irritated, and macerated skin. Interviews with facility staff confirmed that the process for non-pressure skin issues should have included nurse assessment, risk management initiation, provider notification, and placement of wound care orders on the TAR, and the DNS acknowledged that the required orthopedic follow-up appointment for incision check and x-rays had not been scheduled.
Insufficient Nursing Staff and Lack of Licensed Nurse in Charge
Penalty
Summary
The facility failed to provide enough nursing staff each day to meet the needs of every resident and did not ensure that a licensed nurse was in charge on each shift. This deficiency was identified through surveyor observation and review of facility staffing practices. The report specifically notes the lack of adequate nursing coverage and the absence of a licensed nurse in charge during certain shifts, which did not meet regulatory requirements.
Failure to Assess and Supervise Resident Smoking, Leading to Immediate Jeopardy
Penalty
Summary
The facility failed to consistently and accurately assess residents' smoking abilities and implement safety interventions to prevent smoking-related injuries for three residents. Despite having a policy that prohibited smoking on facility grounds and required staff to secure smoking materials found with residents, the facility did not ensure that these procedures were followed. Staff were often unaware of which residents smoked, and there was a lack of clear documentation and care planning regarding residents' smoking status, supervision needs, and the storage of smoking materials. One resident with Parkinson's disease and diabetes was observed smoking unsupervised in the facility's patio area, near a propane tank, and without access to proper safety equipment such as ashtrays or fire blankets. This resident had a history of fluctuating consciousness and required assistance with mobility, yet was able to keep cigarettes and a lighter in their possession and smoke multiple times a day. The care plan for this resident did not include specific interventions to address their inability to manage smoking supplies safely, nor did it document where smoking materials were kept. Additionally, although a nicotine patch was recommended as part of a smoking cessation plan, it was not provided as indicated. Another resident with COPD and a history of tobacco abuse continued to smoke on facility property and in their room, even after being educated about the non-smoking policy and offered nicotine patches, which they refused. This resident set off the fire alarm by smoking in their bathroom and repeatedly refused to relinquish smoking materials, resulting in the need for increased supervision. A third resident with severe cognitive impairment had a history of daily smoking, but the facility's assessment failed to identify their tobacco use, and staff did not discuss smoking or the facility's policy with them. These failures led to unsafe conditions and represented an immediate jeopardy to resident health and safety.
Removal Plan
- Placed Resident 73 on one-to-one surveillance.
- Secured Resident 73's smoking paraphernalia.
- Re-assessed Resident 73's ability to smoke.
- Revised Resident 73's care plan to show the level of assistance and supervision required to smoke safely.
- Closed access to unsupervised patio areas.
- Added a fire blanket and an outdoor ashtray to the designated smoking area.
- Interviewed other residents and staff to identify other residents who smoked.
- Completed smoking safety evaluations of all residents in the facility and for any residents identified as a smoker/tobacco user.
- Developed or revised care plans for residents identified as smokers/tobacco users to show individualized interventions and supervision levels related to smoking preference.
- Completed a facility-wide sweep to remove unauthorized smoking materials.
- Notified residents of the smoking policy.
- Educated staff on the smoking policy, and identifying, managing, and reporting unsafe smoking behaviors.
Failure to Protect Resident Rights Regarding Personal Property Liability Waivers
Penalty
Summary
The facility failed to ensure that residents were not required to waive potential facility liability for losses of personal property upon admission, as evidenced by the admission agreements and inventory forms signed by three cognitively intact residents. The admission agreements for these residents included language stating the facility would not be responsible for valuables or personal effects stored in residents' rooms or on their person beyond the exercise of reasonable care. The inventory forms further urged residents not to keep valuables at the facility and stated the facility was not responsible for items of value kept unlocked, with residents signing these forms upon admission. For one resident, documentation showed that a cell phone was brought into the facility and later reported as broken after an incident involving a nursing assistant. The resident stated that staff broke the phone and that they had reported the issue to Social Services, but the facility did not replace or reimburse the phone. There was no documentation of a grievance related to the broken phone, and staff interviews revealed uncertainty about whether the facility reimbursed residents for lost or broken items. Multiple staff members, including the Director of Business Development, Resident Care Manager, and Social Service Director, acknowledged that the language in the admission agreement and inventory sheet appeared to waive potential facility liability for personal property losses. Staff also confirmed that these documents were completed with every new admission and that the process for addressing lost or broken items involved checking the inventory sheet and filling out a grievance form, though this was not consistently documented in the case reviewed.
Failure to Designate Full-Time RN as Director of Nursing
Penalty
Summary
The facility failed to designate a Registered Nurse (RN) to serve as the Director of Nursing (DNS) on a full-time basis, as required by regulation. Interviews with the administrator and staff revealed that the interim DNS, an RN, was primarily focused on MDS (Minimum Data Set) coordination duties and not consistently performing DNS responsibilities. The interim DNS stated that while they worked a 40-hour week, their main focus was on MDS tasks, and most DNS duties were handled by an LPN/Assistant Director of Nursing. The administrator confirmed that the interim DNS was available to work 40 hours per week as DNS if needed, but there was no documentation provided to support that the DNS duties were being fulfilled on a full-time basis. Payroll data for the interim DNS was requested but not provided, and staff interviews indicated that the LPN/ADON was the primary contact for after-hours emergencies and incident reviews. The lack of a full-time RN DNS resulted in the absence of required RN oversight for care provided to residents. No nurse staffing waivers were in place at the time of the survey.
Lack of Hospital Transfer Agreement
Penalty
Summary
The facility failed to establish and maintain a written transfer agreement with at least one area hospital that is approved for participation in Medicare or Medicaid programs. During an interview, the Regional Director of Clinical Operations confirmed that the facility did not have a transfer agreement with any local hospital. This deficiency was identified through interviews and record review, and it was noted that the facility was unable to provide documentation of such agreements when requested by surveyors. No specific residents or their medical conditions were mentioned in the report, and the findings were based on staff interviews and the absence of required documentation.
Failure to Sustain Effective QA&A Program for ADLs, Falls, Care Conferences, and Admissions
Penalty
Summary
The facility failed to implement an effective Quality Assessment and Assurance (QA&A) program to ensure that corrective actions for identified problem areas were monitored and sustained. The QAPI Committee was responsible for analyzing data, establishing benchmarks, and monitoring performance improvement plans (PIPs), but repeated deficiencies were found in several areas, including activities of daily living (ADLs), falls/monitoring, care planning conferences, and admission procedures. These deficiencies were identified during a recertification survey and had also been cited in previous complaint and recertification surveys. In the area of ADLs, multiple residents with chronic health conditions and physical limitations did not consistently receive the required assistance with showers, oral care, and nail care as documented in their care plans. For example, one resident with COPD, seizures, and chronic pain did not receive two showers per week on several occasions, and another resident with similar needs also missed scheduled showers. A third resident, dependent on staff for oral and nail care, was repeatedly observed with foul-smelling breath and dirty fingernails, indicating a lack of daily oral care and nail hygiene. Staff interviews confirmed that care was not provided as scheduled, and documentation was inconsistent with actual care delivered. Deficiencies were also found in falls monitoring, care conferences, and admission processes. The facility did not consistently monitor residents after falls, and the reduction in falls was not sustained or fully analyzed. Care conferences were not consistently offered or held, with only one out of twelve scheduled conferences completed in a given period. Admission documentation was not completed as required, and the monitoring of corrective actions in this area was not sustained. Staff interviews revealed a lack of awareness and follow-through regarding these ongoing issues.
Failure to Provide Sufficient Nursing Staff to Meet Resident Needs
Penalty
Summary
The facility failed to provide sufficient nursing staff to meet the needs of residents, as evidenced by multiple incidents where residents were not checked or changed in a timely manner, experienced excessively long call light wait times, and were not assisted with activities of daily living (ADLs) according to their care plans. Several residents, including those with severe cognitive impairment, incontinence, and high assistance needs, reported or were observed to have been left soiled for extended periods, not repositioned or transferred as required, and not provided with timely toileting assistance. Incident investigations and interviews revealed that residents frequently waited up to an hour or more for assistance, and staff were often unable to find help for two-person care tasks due to inadequate staffing levels. The facility's own assessment indicated a high proportion of residents with incontinence and mobility impairments, yet staffing decisions were based on census rather than acuity, as confirmed by the staffing coordinator and administrator. Staff interviews and observations showed that nursing assistants were responsible for caring for a high number of residents, and agency staff were used daily to fill gaps. Staff and residents consistently reported that the facility was short staffed, especially on the North (100 hall, LTC) unit, which was described as "heavy care" and not adequately staffed to meet resident needs. Residents were observed eating meals in bed and not being gotten out of bed as care plans required, with documentation showing missed transfers and lack of adherence to physician orders for out-of-bed time. Incident logs from several months documented numerous allegations of neglect, abuse, and resident-to-resident altercations, many of which were related to unmet care needs and long response times. Resident council meeting minutes and interviews with residents and family members further corroborated concerns about insufficient staffing, long wait times, and unmet care needs. Staff statements confirmed difficulty in obtaining assistance for care tasks requiring two staff, and the inability to provide timely care due to being "way behind" or unable to leave other residents unattended. The facility's failure to ensure adequate staffing placed all residents at risk for avoidable accidents, unmet care needs, and diminished quality of life.
Failure to Inform Residents and Obtain Timely Consents for Care and Psychotropic Medications
Penalty
Summary
The facility failed to ensure that residents and/or their representatives were fully informed about their health status, care, and treatments upon admission, as well as about the risks and benefits of psychotropic medications prior to their use. For four out of five sampled residents reviewed for admission, there was no documentation that the Admission Agreement or supporting documents had been reviewed or discussed at the time of admission. These residents included individuals with diagnoses such as muscle weakness, bacterial blood infection, dementia, failure to thrive, weakness, wound infection, and hip fracture. Some of these residents were cognitively intact and able to verbalize their needs, while others had severe cognitive impairment. Interviews with residents confirmed that they were not informed about the type of care they would receive or who would provide it, and they did not recall signing any consent forms for care and treatment. A review of facility records revealed that, out of 36 admissions in the past 30 days, only two admission packets contained a consent for routine nursing care or other services. Staff interviews indicated uncertainty about the required timeframe for completing admission consents, and staff acknowledged that residents would not be fully informed if admission documents were not reviewed in a timely manner. The facility had identified that admission documents and consents were not being completed on time, partly due to staffing vacancies, including the absence of an Admissions Director/Coordinator. The facility also failed to obtain informed consent for psychotropic medications prior to administration for three of five sampled residents reviewed for unnecessary medications. In one case, a resident's representative was not contacted for consent before an antipsychotic medication was administered, and the medication was later discontinued after the representative declined it. In another case, a resident received a psychotropic medication before the consent was completed, and in a third case, consents for psychotropic medications were obtained 49 days after the medications had already been administered. Additionally, the consents did not include information about serious side effects or black box warnings. Staff interviews confirmed that consents should have been obtained prior to the first dose of medication.
Failure to Inform Residents of Right to Formulate Advance Directives
Penalty
Summary
The facility failed to consistently inform and provide written information to residents regarding their right to formulate an advance directive, as required by policy. Record reviews for four residents with various diagnoses, including COPD, chronic pain, high blood pressure, anxiety, and hip fracture, showed no documentation that these individuals had been informed of their right to create an advance directive or had been offered assistance in doing so. Interviews with staff revealed that while advance directives were supposed to be addressed upon admission and during care conferences, there was no evidence that this occurred for the affected residents. Staff interviews indicated confusion and inconsistency regarding the process and responsibility for providing information about advance directives. The Assistant DON believed Social Services were responsible, while the Social Service Director stated the topic was discussed during care conferences and documented in progress notes, but could not provide proof for the residents in question. The Social Service Assistant was unsure of the required timeframe for completing admission packets, and the Director of Business Development acknowledged ongoing difficulties in completing admission paperwork due to staffing vacancies, resulting in incomplete documentation for recent admissions. Further review showed that out of 36 admissions in the past month, only two admission packets containing information on advance directives could be produced. One resident confirmed that staff did not review or discuss advance directives with them upon admission. Staff acknowledged that without timely review of admission paperwork, residents and their representatives would not be fully informed of their rights regarding advance directives, as required by facility policy and state regulations.
Failure to Provide Medicare/Medicaid Benefit Information at Admission
Penalty
Summary
The facility failed to consistently provide residents and/or their representatives with both oral and written information on how to apply for and use Medicare and Medicaid benefits at the time of admission. This deficiency was identified for four out of five sampled residents, each of whom had varying medical conditions such as muscle weakness, bacterial blood infection, dementia, failure to thrive, weakness, wound infection, and hip fracture. Some residents were cognitively intact and able to verbalize their needs, while others had severe cognitive impairment, necessitating communication with their representatives. Record reviews revealed that there was no documentation indicating that the admission agreement, which should include information on Medicare and Medicaid benefits, was reviewed or discussed with the residents or their representatives upon admission. Nursing progress notes and admission packets lacked evidence that this required information was provided. Interviews with residents confirmed that they did not recall receiving or discussing this information at the time of their admission. Further investigation showed that out of 36 admissions in the past 30 days, only two admission packets contained the necessary information regarding Medicare and Medicaid benefits. Staff interviews indicated a lack of clarity about the timeframe for completing admission packets and acknowledged that the process had been delayed due to staffing vacancies, particularly in the admissions director/coordinator position. Staff confirmed that without timely review of admission paperwork, residents and their representatives would not be fully informed about their Medicare and Medicaid options.
Failure to Inform Residents of Charges and Provide Required Medicare Notices
Penalty
Summary
The facility failed to consistently inform residents and/or their legal representatives about items and services included in nursing services, which may or may not be charged for, and the potential costs for services not covered under Medicare, Medicaid, or the facility's per diem rate. For four out of five sampled residents reviewed for admission, there was no documentation that the admission agreement, which includes information on basic charges, payments, interest on late payments, and the facility's discharge check-out time and associated fees, was reviewed or discussed with the resident or their representative upon admission. Several cognitively intact residents stated they did not recall staff reviewing these items and services or potential charges with them at admission. Additionally, the facility was unable to provide complete admission packets for the majority of recent admissions, and staff interviews confirmed that admission paperwork was not being completed or reviewed in a timely manner due to staffing vacancies in the admissions department. The report also found that the facility failed to provide required beneficiary notices related to Medicare coverage. Specifically, two residents who had their Medicare Part A services end did not receive the required Skilled Nursing Facility Advanced Beneficiary Notice (SNF ABN), which informs residents of their financial responsibility if they choose to continue receiving services that may not be covered by Medicare. Staff interviews revealed that the absence of a Business Office Manager (BOM) contributed to these notices not being provided, as the duties were divided among remaining staff and corporate oversight. These failures resulted in residents not being fully informed of their rights, financial responsibilities, and facility rules at the time of admission or when Medicare services ended. The lack of timely and complete communication regarding charges, fees, and coverage placed residents at risk of not understanding their obligations and the costs associated with their care.
Failure to Develop Timely, Resident-Specific Baseline Care Plans Upon Admission
Penalty
Summary
The facility failed to develop baseline care plans containing resident-specific goals and interventions with the minimum healthcare information necessary to properly care for residents within 48 hours of admission for four out of six sampled residents. For one resident with malnutrition, adult failure to thrive, dementia, and receiving hospice services, there was no documentation of a baseline care plan for hospice and nutrition within the required timeframe. Another resident with weakness and Multiple Sclerosis (MS), who was cognitively intact, did not have a baseline care plan to instruct staff on immediate care needs related to MS. Similarly, a second resident with MS and weakness, also cognitively intact, lacked a baseline care plan addressing MS-related needs. Staff confirmed that baseline care plans had not been completed for these residents. A fourth resident admitted with surgical aftercare following a hip fracture, cirrhosis, and ascites, and who was alert and able to communicate needs, did not have a baseline care plan reflecting the need for weekly paracentesis and daily diuretics, despite significant weight loss and relevant physician orders. The nutrition care plan for this resident was not individualized and did not address the specific interventions required for their condition. Staff interviews confirmed the omission of these critical care needs from the care plan.
Failure to Develop Resident-Specific Care Plans for Hygiene and Hospice Needs
Penalty
Summary
The facility failed to develop and implement individualized care plans that addressed specific care needs for three residents. For one resident with a history of stroke and traumatic brain injury who was dependent on staff for personal hygiene, there were no care plan interventions or instructions related to nail care, despite observations of unclean fingernails. Staff interviews confirmed that care plans should include such interventions, but this was not present in the resident's documentation. Another resident, who was cognitively intact and required assistance with personal hygiene, expressed a preference for being shaved by their spouse, with staff to assist if the spouse was unavailable. However, the care plan and Kardex lacked instructions regarding this preference, and staff were unaware or did not consistently offer shaving assistance. Additionally, a resident on hospice care with moderate cognitive impairment had no care plan interventions specifying the division of care responsibilities between facility staff and hospice, nor was hospice contact information included. Staff acknowledged that this information was missing and should have been documented.
Failure to Complete Annual Staff Performance Evaluations
Penalty
Summary
The facility failed to complete annual performance evaluations for three nursing assistants, as required by regulation. Personnel files for these staff members, who were hired on various dates in 2023, did not contain documentation of any performance evaluations. During an interview, the Administrator confirmed that these evaluations had not been completed or filed, despite the expectation that they occur yearly. This deficiency was identified through interview and record review, and was found to affect three out of five sampled staff members reviewed for performance evaluations.
Failure to Consistently Post Daily Nurse Staffing Information
Penalty
Summary
The facility failed to consistently post daily nurse staffing information in a prominent and accessible location, as required, over a four-month period. Observations on multiple dates revealed that the daily staffing sheets were not posted in areas accessible to residents, families, or visitors. Interviews with staff indicated confusion regarding responsibility for posting the information, with the staffing coordinator and assistant director of nursing each believing the other was responsible. The administrator confirmed the expectation that staff should post the daily staffing information as required. A review of the facility's records showed significant gaps in the documentation of daily staffing sheets from January through April, with multiple days missing each month and no documentation at all after mid-March. As a result, residents, families, and visitors were not fully informed of the facility's current staffing levels and resident census information during this period.
Medication Labeling, Storage, and Security Deficiencies
Penalty
Summary
Surveyors observed that the facility failed to ensure proper labeling, storage, and disposal of medications on two of three medication carts. Specifically, opened insulin vials were found to be kept beyond their 28-day expiration period, and staff acknowledged these should have been discarded. Additionally, a medication cart contained a cup with six unidentified medications labeled only with a resident's handwritten name, as well as an unlabeled bottle of nitroglycerin and an EpiPen in a plastic bag with only a handwritten name, lacking required pharmacy labeling. Staff confirmed these medications were not properly labeled and should have been returned to the emergency cart if not needed. Further deficiencies were identified in medication security and storage. One resident was found to have multiple tablets of Imodium AD and generic loperamide unsecured at their bedside, with no physician orders for their use or for keeping medications at bedside. The resident reported that the medications were brought in by a family member, and staff confirmed that such medications should not be kept in resident rooms. In the medication storage room, two emergency medication kits containing controlled substances (Ativan) were found unsealed, and staff stated that these were not being counted to monitor for diversion. Additionally, controlled medications awaiting destruction were stored in a locked safe, but staff reported that no counts were performed on these medications during the waiting period.
Failure to Complete Timely Nutritional Assessments and Provide Required Supplements
Penalty
Summary
The facility failed to ensure accurate and timely completion of nutritional assessments, weight monitoring, and provision of required nutritional supplements for multiple residents. For one resident, there was a significant delay in obtaining an initial weight after admission, with the first weight recorded seven days post-admission, showing a severe weight loss compared to hospital records. There was no documentation of re-weighing to confirm the loss, no investigation into the cause, and no evidence that the provider or resident representative was notified. The resident also reported not being involved in dietary decisions, and staff interviews revealed uncertainty about the reasons for weight refusals and lack of reconciliation of hospital and facility weights. Another resident with dialysis needs had orders for a specific nutritional supplement (Nepro) prior to dialysis, but documentation was inconsistent regarding administration and consumption. The resident reported disliking the supplement and instead consumed a different product brought from outside the facility. Staff were unaware of the resident's refusal and the substitution, and there was no documentation of the facility addressing the refusals or ensuring the prescribed supplement was provided as ordered. The dietary manager and nursing staff demonstrated a lack of clarity about the supplement's provision and documentation, and the registered dietitian was unaware of the resident's non-compliance with the prescribed supplement. Additional deficiencies included a resident with significant weight loss who did not receive a comprehensive nutritional assessment as required, and another resident with severe cognitive impairment and diagnoses of malnutrition and failure to thrive who experienced frequent meal refusals. The care plan for this resident lacked individualized interventions, and the nutritional assessment was completed late. There was no documentation of alternative interventions or communication with the resident's representative regarding preferences, and the dietary profile was missing from the record. Staff interviews confirmed delays in assessment and a lack of resident-specific interventions.
Failure to Provide Palatable, Appetizing, and Properly Temperature-Controlled Food
Penalty
Summary
The facility failed to provide appetizing, palatable, and appropriately temperature-controlled food to eight of nine sampled residents. Multiple residents, all cognitively intact and able to express their needs, reported that hot foods were often served cold or lukewarm, cold foods were sometimes warm, and meals lacked variety and flavor. Several residents described the food as bland, unappetizing, and sometimes unidentifiable, with some stating they resorted to eating sandwiches or ordering outside food due to dissatisfaction with the meals provided. Observations confirmed that food was sometimes delivered at improper temperatures, and portion sizes were described as small. A test tray sampled by the survey team further substantiated these complaints. The meal consisted of roasted chicken, mashed potatoes, corn, ravioli, and peach cobbler. The chicken was found to be dry, bland, and colorless, the mashed potatoes were unseasoned, and the ravioli had dried edges, making it difficult to cut. The peach cobbler was watery but had acceptable flavor. The dietary manager acknowledged the issues, noting that a recent change in food suppliers and menu may have contributed to the problems, and that initial preparation followed supplier directions before adjustments were made with the dietician. Staff interviews revealed ongoing complaints about the food's lack of flavor and improper temperatures. The dietary manager stated that food was cooked to proper temperatures and placed on hot plates, but the timing of tray delivery by nursing staff affected the food's temperature upon arrival to residents. Occasional complaints about cold food were acknowledged, and meals were sometimes replaced when issues were reported. The deficiency was cited under WAC 388-97-1100 (1),(2), with reference to F806 for additional information.
Deficient Food Storage, Labeling, Cleanliness, and Staff Hygiene in Dietary Services
Penalty
Summary
The facility failed to store and prepare food in accordance with professional standards for food safety, as evidenced by multiple observations of improper food labeling, storage, and cleanliness in the kitchen and nourishment refrigerators. Surveyors found several opened food items, such as bags of shredded cheese, spice containers, and sauces, that were not labeled with the date opened or contents. Some items, including sauces and powders, were past their manufacturer expiration dates or lacked clear identification. Additionally, food crumbs, debris, and spills were noted on various kitchen surfaces, carts, and floors, and there was no cleaning schedule or log sheet for these tasks. Dietary staff did not consistently wear appropriate hair coverings, with some staff members' beards only partially covered or not covered at all while working in food preparation areas. The facility's policy required hair and beard coverings past a designated red line in the kitchen, but this was not consistently followed. Staff also failed to perform hand hygiene when indicated, such as after touching their face or headphones and before returning to food handling tasks. These lapses were acknowledged by the kitchen manager and other dietary staff during interviews. In the nourishment refrigerators on both the North and South halls, several food items were found without proper labeling, including missing resident names, open dates, or identification of contents. Some items were only labeled with room numbers or last names, and others had no labeling at all. The facility's policy required perishable foods brought by family or visitors to be labeled with the resident's name and a use-by date, but this was not consistently implemented. These findings were confirmed by staff interviews and direct observation.
Infection Control Failures in Hand Hygiene, EBP, Equipment Sanitization, and Food Service
Penalty
Summary
The facility failed to implement and maintain effective infection prevention and control practices in several key areas, as evidenced by direct observations, interviews, and record reviews. Staff did not consistently follow Enhanced Barrier Precautions (EBP) for residents with indwelling medical devices, wounds, or multidrug-resistant organism (MDRO) colonization or infection. Multiple residents who required EBP, including those with urinary catheters, central lines, and feeding tubes, did not have appropriate signage posted to alert staff to don personal protective equipment (PPE) before providing high-contact care. Staff were observed performing resident care activities, such as medication administration and tube feeding, without wearing gowns or performing hand hygiene as required by EBP protocols. Hand hygiene practices were not followed during medication administration and wound care. Staff were observed donning gloves without prior hand hygiene, failing to change gloves or sanitize hands between tasks, and touching non-sterile items before proceeding with sterile procedures. For example, during wound care and PICC line medication administration for a resident, staff did not remove gloves or perform hand hygiene after handling potentially contaminated surfaces and before proceeding with invasive procedures. Staff interviews confirmed awareness of proper protocols, but these were not consistently practiced during observed care. Additional deficiencies included failure to sanitize shared equipment, such as mechanical lifts, between resident uses, and improper food service practices during meal assistance. Staff were observed delivering meal trays, adjusting residents, and assisting with feeding without performing hand hygiene between tasks. One staff member was seen blowing on a resident's food to cool it, which was acknowledged by staff and administration as an infection control issue. Furthermore, a resident's PICC line dressing was not changed within the required timeframe, resulting in a nine-day interval between changes, contrary to provider orders and care plan instructions.
Failure to Implement and Document Antibiotic Stewardship for New Admissions and Community-Prescribed Antibiotics
Penalty
Summary
The facility failed to follow its established Antibiotic Stewardship Program (ASP) for newly admitted residents or those prescribed antibiotics by community providers over a three-month period. According to the facility's policy, the ASP should include the use of McGeer Criteria to determine the appropriateness of antibiotic use. However, review of the Monthly Infection Surveillance Logs for January, February, and March 2025 revealed that for a significant number of residents who received antibiotics for community-acquired infections, there was either no documentation or incomplete documentation regarding whether McGeer's minimum criteria were met prior to antibiotic administration. During interviews, the Infection Preventionist acknowledged that the ASP process was not applied to new admissions or residents prescribed antibiotics by outside providers, under the assumption that hospitals ensured compliance with McGeer Criteria. This lack of implementation and documentation was observed for multiple residents across the reviewed months, with numerous instances where the required criteria were not addressed or recorded as not applicable.
Failure to Ensure Resident Call Lights Were Accessible
Penalty
Summary
The facility failed to ensure that call lights were readily accessible to residents in multiple observed instances. For one resident with muscle weakness and a left below-knee amputation, who was dependent on staff for most activities of daily living and had moderate cognitive impairment, the call light cord was repeatedly observed to be out of reach. The cord was draped across the overbed light fixture and dangled down the wall, making it inaccessible from the resident's wheelchair on the left side of the bed. This was observed on several occasions over multiple days. The resident confirmed they could not reach the call light and would have to wait for staff to pass by and call out for help if needed. A registered nurse acknowledged that the call light should have been within the resident's reach. Another resident, admitted with a history of syncope, falls, and functional impairments, also had their call light placed out of reach on multiple occasions. The call light was either pinned to the wall cord or found on the floor behind the bed, making it inaccessible from the resident's position. This resident had a documented history of falls both prior to and after admission. Staff observed the call light on the floor and acknowledged it should have been left within the resident's reach. The facility administrator stated that staff were expected to leave call lights accessible to residents.
Failure to Inform Residents of Rights and Facility Rules at Admission
Penalty
Summary
The facility failed to consistently inform residents and/or their legal representatives of the facility's rules, regulations, resident rights, and Medicaid rights and responsibilities at the time of admission. This deficiency was identified through interviews and record reviews for four out of five sampled residents, all of whom were recently admitted. The records for these residents did not contain documentation that the admission agreement, which includes information on resident rights, facility rules, and Medicaid obligations, was reviewed or discussed with them or their representatives as required. Specifically, residents with varying cognitive abilities, including those who were cognitively intact and those with severe cognitive impairment, were not provided with or did not recall receiving information regarding their rights and facility expectations upon admission. Interviews with these residents confirmed that they were not informed about the facility rules, resident rights, or Medicaid rights and responsibilities. Additionally, a review of the facility's admissions over a 30-day period revealed that only two out of 36 admission packets contained the required information, further indicating a systemic issue. Staff interviews revealed uncertainty regarding the timeframe for completing admission paperwork and acknowledged that the process had not been completed timely due to a vacancy in the admissions director/coordinator position. Staff responsible for admissions confirmed that the lack of timely completion of admission packets resulted in residents and/or their representatives not being fully informed of their rights, facility rules, and responsibilities at the time of admission.
Failure to Meet Professional Standards in Skin, Constipation, and Fall Management
Penalty
Summary
The facility failed to ensure that nursing services consistently met professional standards of practice for multiple residents, particularly in the areas of skin condition management, constipation, and fall prevention. For several residents with non-pressure skin conditions, such as abrasions and skin tears, staff did not consistently assess, monitor, or implement physician or wound consultant orders. For example, one resident with a history of skin abrasions and tears had no documented care or monitoring for a significant skin tear that required hospital treatment, and another resident with extremely dry skin and a history of psoriasis did not have interventions or treatments documented or implemented despite visible symptoms and resident complaints. In another case, a resident who sustained a skin tear after a fall did not have the wound monitored or treated for over a week, despite increasing pain and signs of possible infection. The facility also failed to follow established protocols for the assessment and management of constipation. Multiple residents with a history or risk of constipation, some of whom were on medications known to cause constipation, went several days without a bowel movement without staff implementing standing orders or as-needed medications as directed by care plans and physician orders. Documentation showed that staff did not consistently track bowel movements, administer prescribed interventions, or notify providers when residents experienced extended periods without a bowel movement. Residents reported not being asked about their bowel movements and not receiving interventions unless specifically requested. Additionally, the facility did not consistently implement or document fall prevention and post-fall monitoring protocols. Residents identified as high risk for falls experienced multiple unwitnessed falls, with incomplete or missing documentation of neurological checks and vital sign monitoring as required by facility policy. In several instances, there was no evidence that new interventions were implemented after repeated falls, and progress notes lacked follow-up on potential latent injuries. Staff interviews confirmed that required monitoring and documentation were not consistently performed after falls, and that these omissions could jeopardize resident health and safety.
Failure to Assess Resident for Safe Self-Administration of Medication
Penalty
Summary
A resident with diagnoses including Parkinson's disease and acid reflux, and documented moderate cognitive impairment, was observed to have a bottle of Tums chewable tablets at their bedside and reported taking the medication as needed. Multiple observations confirmed the ongoing presence of the Tums on the resident's overbed table over several days. The resident's medical record included a provider order for Tums to be taken as needed, but there was no documentation of an order permitting self-administration, nor was there an assessment indicating the resident's ability to safely self-administer the medication. Additionally, the Medication Administration Record for the relevant month did not reflect any administrations of Tums. Facility staff confirmed that residents wishing to self-administer medications are required to have a provider assessment, an order, and a completed self-medication assessment, none of which were present for this resident. The lack of assessment and documentation meant the resident was self-administering medication without the necessary clinical evaluation or oversight.
Failure to Maintain Clean and Homelike Environment for Multiple Residents
Penalty
Summary
The facility failed to provide a clean, comfortable, and homelike environment for three residents as evidenced by multiple observations and interviews. One resident with COPD and depression, who had contracted fingers and refused hand care due to pain, was found with a call light button covered in brown, crusty matter on several occasions. Staff interviews revealed that while housekeeping and nursing assistants were aware of the need to clean high-touch surfaces like call lights, cleaning was only performed when dirt was noticed, rather than on a consistent schedule. Another resident with COPD and heart failure, who used a wheelchair, was observed multiple times with dried fluid on the left side of the wheelchair and seat cushion. There was no documented schedule for routine wheelchair cleaning, and staff were unclear about whose responsibility it was to clean and document wheelchair maintenance. A third resident, who was cognitively intact and had high blood pressure and anxiety, was reported by a family member to have had the same sheets on their bed for two weeks, with subsequent observations confirming unchanged bedding. Staff interviews indicated that sheets were only changed on shower days or when visibly soiled, with no evidence of more frequent changes.
Failure to Complete PASARR Level II Referrals After 30-Day Exempted Hospital Stay
Penalty
Summary
The facility failed to ensure that two residents admitted under an exempted hospital discharge were properly referred for a PASARR Level II evaluation after remaining in the facility for more than 30 days. For one resident, the quarterly assessment documented admission from the hospital with diagnoses including traumatic brain injury, muscle weakness, malnutrition, and the use of anti-depressant medications. The Level I PASARR completed prior to admission indicated serious mental health indicators, but a Level II PASARR was not initiated after the resident stayed beyond the 30-day exemption period. Record review confirmed the resident continued to reside in the facility past the expected discharge date, with no evidence of a Level II referral as required. Similarly, another resident was admitted with diagnoses of dementia, anxiety, and depression, and had severely impaired cognition. The Level I PASARR indicated the resident met criteria for an exempted hospital discharge, with instructions that a Level II evaluation was necessary if the resident remained beyond 30 days. The resident stayed in the facility for over 60 days, but no referral for a Level II PASARR was made. Staff interviews confirmed that the required referrals were not completed for either resident after the 30-day period elapsed.
Failure to Revise Care Plans and Conduct Required Care Conferences
Penalty
Summary
The facility failed to ensure timely and accurate revisions to care plans and did not consistently conduct required care plan conferences for three residents. For one resident, after a significant change in condition and the identification of a new Stage II pressure ulcer on the coccyx following readmission, the care plan was not updated to include specific interventions or treatments for the new wound. Although the resident had existing skin care interventions, the care plan did not reflect the new care needs associated with the coccyx ulcer, as confirmed by the Assistant Director of Nursing (ADON). Another resident's care plan was not updated in a timely manner after the discontinuation of an indwelling urinary catheter. The resident's catheter was removed, and there were no active orders for its use for several months, yet the care plan continued to list catheter-related interventions until it was finally updated over four months later. Both the resident and the ADON confirmed the catheter had been discontinued well before the care plan was revised, and the administrator acknowledged the importance of care plans accurately reflecting current needs. Additionally, a third resident, who was cognitively intact and able to express their needs, was not invited to a care conference as required. Documentation showed only one care conference had been held several months prior, with no evidence of subsequent conferences or invitations. Staff interviews confirmed that care conferences should have been offered quarterly and that the resident should have been invited to participate.
Failure to Ensure Functional CPAP and Accurate Documentation
Penalty
Summary
Facility staff failed to ensure that a resident's CPAP machine was functional and did not accurately document its use, despite provider orders and care plan interventions requiring nightly use and regular maintenance. The resident, who had diagnoses of heart failure, COPD, and obstructive sleep apnea, brought a non-working CPAP machine from home and reported to staff that it was not functioning. Staff informed the resident that they did not repair such equipment and did not assist in obtaining a replacement. Documentation in the Treatment Administration Record (TAR) and nursing progress notes indicated that the CPAP was being used and maintained, but provider notes contradicted this, stating the resident had not used the CPAP for over six months. Interviews with staff revealed that no one had initiated the process to obtain a replacement CPAP, and key personnel, including nursing and central supply, were unaware of the equipment's non-functionality. Staff responsible for respiratory care did not follow up on the resident's inability to use the CPAP, and discrepancies in documentation were acknowledged by facility leadership as a failure in practice. The lack of action and inaccurate documentation placed the resident at risk for health complications related to untreated sleep apnea.
Failure to Provide Care and Assistance for Resident with Prosthesis
Penalty
Summary
The facility failed to provide appropriate care and assistance for a resident with a leg prosthesis, as required by facility policy and the resident's care needs. The resident, who was cognitively intact and dependent on staff for activities of daily living, had received a prosthetic leg and expressed a desire to use it to improve mobility and facilitate discharge. Despite this, observations showed the prosthesis was not in use, often left on the windowsill, and staff interviews confirmed that the prosthesis was not routinely applied. Instead, staff only applied a shrinker in the morning and removed it at night, with no regular support for prosthesis use. Record review revealed that the resident's care plan did not address the presence or use of the prosthesis, nor did it include instructions for wear time, fit, care, or the use of associated components like the limb sock and shrinker. Provider orders and progress notes also lacked any mention of the prosthesis or its management, despite documentation from the prosthesis clinic indicating the resident had received education on its use and care. The clinic also instructed the facility to report any issues with fit, pain, or skin integrity, but there was no evidence these instructions were incorporated into the resident's care plan or daily care routines. Interviews with therapy and nursing staff indicated that the resident only wore the prosthesis during therapy sessions and not as part of daily care, with therapy discontinued after a period of time. Staff cited the resident's reluctance to be out of bed and discomfort as reasons for limited use, but there was no documentation of care refusals or efforts to encourage or assist with prosthesis use outside of therapy. The lack of a comprehensive care plan and absence of provider orders addressing the prosthesis contributed to the resident not receiving the necessary support to use the device, contrary to facility policy and best practices for prosthesis management.
Failure to Obtain and Maintain Accurate Dialysis Documentation and Orders
Penalty
Summary
The facility failed to ensure complete and accurate dialysis care for a resident requiring such services. Upon review, the facility did not obtain or maintain dialysis treatment documentation (dialysis logs) from the dialysis center for a resident with a central line for dialysis access. The resident, who was cognitively intact and admitted with complex medical conditions, reported that the facility did not communicate with the dialysis center and relied on the resident to provide records. Observation confirmed the presence of a central line, and the resident described their dialysis schedule and location, which matched the care plan but not the physician orders. Further review revealed discrepancies in the resident's medical record, including conflicting information about the dialysis access site, treatment days, and dialysis center location. The physician orders incorrectly referenced an AV fistula and related assessments, which were not applicable to the resident's actual central line access. Facility staff confirmed the inaccuracies and acknowledged the absence of dialysis logs in the resident's record.
Failure to Honor Resident Food Preferences and Dietary Needs
Penalty
Summary
The facility failed to honor food preferences for three residents, resulting in multiple instances where residents received meals that did not align with their documented choices or dietary needs. One cognitively intact resident repeatedly received incorrect meals despite filling out menus and communicating their preferences, including being served barbequed ribs instead of shrimp scampi, scrambled eggs instead of boiled eggs, and fish and rice which they did not eat. Another cognitively intact resident did not receive yogurt and apple juice as indicated on their tray card, and was instead given orange juice and oatmeal. Staff interviews confirmed that residents' menu selections were sometimes lost, not returned to the kitchen in a timely manner, or not accurately transcribed onto meal tickets. A third resident, with moderate cognitive impairment and a diagnosis of failure to thrive, was served foods listed as dislikes on their dietary profile, such as scrambled eggs and potatoes, and was not offered alternatives. Staff acknowledged that meals were often returned to the kitchen due to incorrect orders, and that inconsistencies existed between menu selections and tray card information. The dietary manager noted that issues could arise from hurried or inexperienced kitchen staff, or from lapses in the menu collection process. These failures were observed through direct resident statements, meal observations, and staff interviews.
Failure to Provide Consented Influenza and Pneumococcal Vaccinations
Penalty
Summary
The facility failed to ensure that two residents, both with medically complex conditions, were properly screened and offered influenza and pneumococcal vaccinations as required by facility policy and state regulations. For one resident, the admission assessment documented that neither the influenza nor the pneumococcal vaccine was offered, despite the resident not being up to date and having signed consent for both vaccines. There was no documentation of screening for vaccine eligibility or offering the vaccines, and the pneumococcal vaccine was only ordered after the issue was identified, well past the required timeframe. No evidence was provided to show that the influenza vaccine was offered during the remaining influenza season. For the second resident, records showed that the influenza vaccine was not offered during the vaccination season, despite a signed consent form requesting the vaccine. Review of the medication administration records for the relevant months confirmed that the resident did not receive the influenza vaccine as requested. Staff acknowledged that the resident should have received the vaccine but did not. These findings were confirmed through interviews and record reviews.
Failure to Maintain Safe Call Light/TV Cord for Resident
Penalty
Summary
A deficiency was identified when a resident, who was cognitively intact and able to communicate their needs, was found to have a call light/TV cord in their room with exposed colored wires near the control. The resident reported having informed staff about the damaged cord and requested a replacement, but no action was taken to address the issue. Multiple observations over several days confirmed the presence of the exposed wires on the cord. Staff interviews revealed that the maintenance director was not made aware of the issue until it was brought to their attention during the survey, and that the facility's process for reporting non-urgent maintenance issues involved staff submitting a work order on the computer. The assistant DON stated that staff were expected to notify maintenance of such issues and escalate urgent matters to management. The failure to promptly replace the damaged call light/TV cord resulted in the equipment not being maintained in a safe operational condition.
Failure to Maintain Sanitary and Comfortable Resident Environment
Penalty
Summary
The facility failed to maintain a sanitary, comfortable, and homelike environment for a resident, resulting in persistent foul odors and unclean conditions in a shared room. Observations over several days documented a strong odor resembling sweat and urine, particularly on one side of the room. One resident, who was cognitively intact, reported being bothered by the odor and stated they had informed staff multiple times without resolution. The other resident in the room, who had moderate cognitive impairment, was observed with greasy hair and admitted to infrequent showers, with staff confirming that this resident often refused personal care. The room was also noted to have an unclean tray table with old food items and spilled fluids on the floor. Multiple staff interviews confirmed awareness of the foul odor, with some staff noting that the mattress had been replaced several times and that the resident often refused showers. Despite these ongoing issues, there was no evidence that staff had addressed the concerns of the resident who was bothered by the odor, nor had social services or nursing leadership discussed the impact of the environment with them. The failure to address the unsanitary and uncomfortable conditions persisted over several days, as documented by repeated observations.
Failure to Provide Safe and Appropriate IV Device Care and Documentation
Penalty
Summary
The facility failed to provide appropriate care and treatment for three residents with surgically inserted intravenous (IV) access devices, including peripherally inserted central catheters (PICCs) and a Medi-port. For each resident, there was a lack of adequate monitoring of the IV site, insufficient documentation of maintenance flushes, and failure to change site dressings as required by facility policy and CDC guidelines. These lapses were identified through observation, interview, and record review. One resident was readmitted with a PICC line for IV antibiotics, but there were no instructions in the medication or treatment records regarding PICC line management, such as dressing changes, flushing, or monitoring. The care plan did not mention the presence of a central line or interventions for its care. Progress notes indicated the PICC line was flushed without an order, and the dressing was not changed for an extended period. During observation, the dressing was found to be dated from before admission, and staff were unclear about the meaning of the labeling or their responsibilities for changing the dressing. Another resident with a Medi-port for antibiotic administration had no documentation in the MARs, TARs, or care plan regarding central line management. Staff documentation was inconsistent, sometimes referring to a "midline port" or a PICC line, and at one point incorrectly stating there were no IV sites present. The dressing on the port was undated, and the resident reported concerns about improper scrubbing of the port during medication administration. A third resident with a PICC line had a dressing that had not been changed since admission, despite documentation indicating otherwise. Staff acknowledged the missed dressing change and described the required procedures for central line care, but records and observations showed these were not consistently followed.
Unsecured Topical Medications Left on Treatment Cart
Penalty
Summary
Staff failed to secure topical medications on one of four units observed. During an observation, an LPN was seen leaving a resident room and approaching a medication cart, while a treatment cart nearby had four food boats on top, each labeled with a forename and containing medication cups with various creams and powders. The LPN acknowledged forgetting to lock the medications in the drawer due to being distracted. The Assistant Director of Nursing confirmed that all topical medications should be locked in the treatment or medication cart and that the LPN had stepped away and forgotten about the medications.
Failure to Timely Monitor and Respond to Critical Lab Results
Penalty
Summary
A deficiency occurred when the facility failed to order and monitor laboratory tests as required for a resident admitted with a history of heart failure, pulmonary hypertension, and fluid overload. The resident was discharged from the hospital with normal kidney function and an order to monitor kidney function twice weekly while on oral diuretic therapy. Despite these orders, the facility did not enter the lab orders upon admission, and subsequent labs were not completed as scheduled. Nursing documentation indicated the resident expressed concerns about fluid overload and decreased urination over several days, but these concerns were not promptly escalated to a medical provider, and the resident was not seen by a provider on the day issues were first reported. When labs were eventually collected and resulted, they showed critical values indicating acute kidney failure. The nurse on duty provided the lab results to the resident and contacted the on-call ARNP, who did not provide further orders but deferred follow-up to the next day. There was no documentation that the resident refused hospital care, and the resident's spouse was not contacted by the facility regarding the critical results. The resident remained in the facility for approximately 12 hours after the critical lab results were available before being transferred to the hospital, during which time their condition continued to deteriorate. Interviews with staff revealed lapses in communication and failure to follow protocols for urgent medical concerns. The nurse manager confirmed that the provider book was used for non-urgent issues and that staff should have called the medical provider directly for acute changes in condition. The lack of timely action and communication regarding the resident's change in condition and critical lab results ultimately resulted in harm to the resident, who was later diagnosed with acute kidney failure and died after transfer to the hospital.
Failure to Monitor Psychosocial Harm After Abuse Allegations
Penalty
Summary
The facility failed to implement its written abuse policies and procedures related to monitoring for psychosocial harm after allegations of abuse and/or neglect for four residents. The policy required immediate assessment of residents following an allegation or observation of abuse, with revisions to the care plan to minimize recurrence and address any identified harm. However, for Residents 7, 8, 9, and 10, there was no evidence of monitoring or assessment for psychosocial harm after incidents were reported. These incidents included a staff member allegedly taking photos of Resident 7, Resident 8 not being changed during a shift, a call light response delay for Resident 9, and a nursing assistant declining to assist Resident 10 to the bathroom. Interviews with facility staff revealed that the process involved placing residents on alert for 72 hours, during which nursing staff were expected to complete progress notes each shift to monitor and assess for psychosocial harm. Despite this protocol, the nursing staff did not consistently complete the required charting in the residents' progress notes. This lack of documentation and follow-through on the facility's procedures placed residents at risk for unmet care needs related to possible psychosocial harm.
Incomplete and Inaccurate Medical Records
Penalty
Summary
The facility failed to maintain complete and accurate medical records for nine out of ten sampled residents, which included issues with psychotropic consent forms, nutrition assessments, progress notes, discharge paperwork, assessments, and monitoring. For Resident 2, the consent forms for psychotropic medications like Lexapro and mirtazapine were incomplete, lacking documentation of who reviewed the forms with the resident and missing necessary staff input. Resident 3's records showed informed consents for Xanax and mirtazapine without the resident's signature. Nutrition assessments for multiple residents were unsigned, lacking documentation of who completed them. Resident 1's records contained inaccuracies in progress notes and incomplete discharge paperwork, with discrepancies in the Notice of Medicare Non-Coverage and missing documentation of verbal consent for discharge. Resident 12's records lacked evidence of monitoring after a potential medication error, and Resident 13's records showed no skin assessment or progress notes for a surgical dressing change. Resident 14's medical chart had conflicting information regarding code status, and their weight records showed significant fluctuations without re-weighs to confirm accuracy. These deficiencies were acknowledged by the facility's administrator and assistant director of nursing.
Inadequate Psychotropic Medication Consents
Penalty
Summary
The facility failed to ensure that psychotropic medication consents were accurate and obtained prior to administration for two residents. Resident 1 was admitted with orders for sertraline, a psychotropic medication, which was administered daily from December 12, 2024, through January 16, 2025. However, the consent for sertraline was only discussed with Resident 1's Power of Attorney for healthcare on January 1, 2025, 21 days after the resident's admission, indicating a delay in obtaining proper consent. For Resident 2, the facility had undated consent for Lexapro and a dated consent for mirtazapine, both psychotropic medications. The consents included Resident 2's signature but lacked documentation of the resident's choice regarding the use of these medications. Despite this, the medications were administered daily from January 10, 2025, and January 11, 2025, respectively, through February 6, 2025. The Assistant Director of Nursing acknowledged the inadequate consents and confirmed that consents should be completed before medication administration.
Failure to Notify Resident Representative of Significant Weight Loss
Penalty
Summary
The facility failed to notify the resident representative of a significant weight loss experienced by a resident reviewed for nutrition. The resident, who had severe cognitive impairment and required assistance for eating, was admitted to the facility with a weight of 178.9 pounds. A week later, the facility recorded the resident's weight at 161.6 pounds, indicating a significant weight loss of 17.3 pounds or 9.67%. Despite this, there was no documentation in the medical record that the facility notified the resident's Power of Attorney (POA) of the significant weight loss. This oversight was acknowledged by the Assistant Director of Nursing, who confirmed that the staff should have notified the resident's representative.
Failure to Conduct Thorough Investigation into Neglect Allegation
Penalty
Summary
The facility failed to conduct a thorough investigation into allegations of neglect for a resident, specifically neglecting to complete a required skin assessment. The incident involved a resident who was found soaking wet with brown urine rings on their bedding and stool stuck to their bottom. Although the facility's investigation noted that a skin check was completed with no issues found, there was no documentation of a skin check on the date of the incident in the resident's medical record or the facility's investigation records. A skin assessment was documented two days prior to the incident and again two days after, with no skin concerns noted. The Director of Nursing acknowledged that a skin check should have been completed following the neglect allegation, but no evidence of such an assessment on the date of the incident was provided. The nurse involved in the incident was an agency staff member who was not allowed to return to the facility.
Inadequate Shower Care for Dependent Residents
Penalty
Summary
The facility failed to ensure that five of twelve dependent residents received the appropriate number of showers per week, as required for their hygiene and quality of life. Resident 1, who was admitted with a recent stroke and an ileostomy, was scheduled for showers twice a week but only received two showers over a three-week period. Observations noted that Resident 1 had oily hair and food residue in their hair, indicating inadequate hygiene care. Resident 2, admitted with hip and elbow fractures, was also scheduled for showers twice a week but only received two showers over a four-week period. Despite being able to communicate their needs, Resident 2 expressed a desire for more frequent showers but refrained from complaining due to staff being busy. Similarly, Resident 3, who was admitted with heart failure and a leg amputation, received only two showers during their stay, with several scheduled days marked as not applicable. Residents 6 and 7 also experienced deficiencies in shower care. Resident 6, with kidney disease and a skin infection, received only one bed bath in thirteen days, while Resident 7, in isolation for COVID and with arm and leg fractures, received one shower in fifteen days. Interviews with staff revealed inconsistencies in the shower schedule and procedures for handling refusals, contributing to the inadequate care provided to these residents.
Failure to Monitor Resident Weights and Provide Meal Assistance
Penalty
Summary
The facility failed to ensure accurate and timely weight measurements for six of twelve sampled residents, which included not obtaining weights on admission or ongoing weights as per medical provider orders. This deficiency was observed in residents with various medical conditions, such as recent stroke, heart failure, and severe protein-calorie malnutrition, placing them at risk for unrecognized weight loss and nutritional complications. For instance, Resident 1, who had a recent stroke and required enteral nutrition, had discrepancies in recorded weights and lacked consistent weight monitoring, with only two weights recorded over a 15-day period. Additionally, the facility did not provide necessary assistance with meals for Resident 1, who was unable to make their needs known due to their medical condition. Observations revealed that Resident 1 was left without assistance during meals, despite having an order for feeding assistance. The resident was seen struggling to eat and drink independently, often appearing confused and unable to consume the provided food and liquids effectively. Interviews with family members and staff confirmed the lack of assistance, with staff citing time constraints as a reason for not helping the resident. The report also highlighted the absence of admission weights for several other residents, with delays ranging from a week to 21 days after admission. This lack of timely weight documentation was acknowledged by the facility's Director of Nursing, who stated that residents should be weighed on admission and regularly thereafter. The failure to obtain and document weights as required compromised the ability to monitor and address potential weight loss and nutritional issues effectively.
Failure to Monitor Vital Signs and Fluid Intake
Penalty
Summary
The facility failed to provide care according to medical provider orders for two residents. Resident 1, who was admitted with a recent stroke, colon perforation, and required enteral nutrition, had a medical provider order for vital signs to be monitored twice daily. However, the Electronic Medication Administration Record (EMAR) showed that only blood pressure and pulse were recorded, while other vital signs such as temperature, respirations, and oxygen saturation were not documented from the start of the order until its end date. This lack of documentation was confirmed by a registered nurse who acknowledged the importance of full vital sign monitoring for residents on enteral nutrition to detect early signs of aspiration. Resident 3, admitted with acute on chronic heart failure, had a dietary order for an 1800 ml fluid restriction. Despite this, there was no evidence of monitoring or recording the resident's fluid intake in the EMAR. The hospital discharge orders recommended the fluid restriction, but no orders were found to record the fluid intake, and the Resident Care Manager confirmed the absence of such documentation. This oversight in monitoring fluid intake is critical for residents with heart failure to prevent fluid overload.
Inadequate Handling of Contaminated Laundry
Penalty
Summary
The facility failed to consistently implement infection control standards related to the handling of contaminated laundry for five out of thirteen residents. During observations, it was noted that residents had soiled linens improperly stored in their rooms. For instance, a collateral contact of one resident was seen collecting dirty laundry from the resident's wheelchair and closet, including wet sweatpants, indicating that the facility was not managing the resident's laundry as expected. Other residents were observed with visibly soiled linens in clear plastic bags placed on the floor or under sinks in their rooms. Interviews with staff revealed a lack of adherence to infection control protocols. A Nursing Assistant confirmed that they were trained not to leave soiled clothing or linens on beds, chairs, or room surfaces, and that such items should be taken directly to the dirty utility room. The Director of Nursing also stated that leaving soiled linen in bags on the floor or room surfaces was not acceptable practice, as it could lead to the spread of infection. These observations and interviews highlight a significant lapse in the facility's infection prevention and control program, as outlined in WAC 388-97-1320(3).
Failure to Monitor and Treat Range of Motion Limitations
Penalty
Summary
The facility failed to provide adequate monitoring and consistent treatment for range of motion (ROM) limitations for two residents, leading to a risk of avoidable decline. Resident 7, diagnosed with Parkinsonism and generalized muscle weakness, was admitted with functional limitations in their lower extremities. Despite a care plan indicating the need for assistance with transfers, there was no mention of a program to prevent ROM decline. A therapy referral was made due to concerns about contractures, but the order for physical therapy was not forwarded to the therapy department, resulting in a lack of intervention. Resident 8, diagnosed with Cerebral Palsy and quadriplegia, was also not receiving necessary ROM interventions. Their quarterly assessment indicated functional limitations in both upper and lower extremities, yet no restorative programs were in place. The resident's care plan acknowledged contractures but lacked interventions to prevent further decline. Observations and interviews revealed that the resident's condition had worsened, impacting their ability to use a motorized wheelchair, which was confirmed by a physical therapist's assessment. The deficiencies in care for both residents were due to a lack of proper assessments, communication, and follow-up on therapy referrals. The facility's failure to implement and document appropriate interventions for maintaining or improving ROM placed the residents at risk for further decline, as evidenced by the observations and interviews conducted during the survey.
Medication Administration Deficiencies
Penalty
Summary
The facility failed to ensure that physician-ordered medications were available and administered as prescribed for several residents, leading to deficiencies in care. Resident 1, who was readmitted from the hospital with multiple diagnoses including Clostridium difficile infection, diabetes, and end-stage renal disease, did not receive their prescribed antibiotic Fidaxomicin, anti-nausea patch Scopolamine, and diabetes medication Tresiba as ordered. The resident also received constipation medications despite having diarrhea, which was contraindicated given their condition. This oversight resulted in the resident being unable to attend dialysis due to persistent diarrhea. Resident 4 was admitted with conditions such as diverticulitis, asthma, COPD, and schizophrenia. The facility failed to administer the correct number of doses of an antibiotic and did not provide timely doses of medications for schizophrenia, pain, and respiratory conditions. The facility had to request the resident's home medication for schizophrenia due to a lack of a written prescription for a controlled medication, which delayed treatment. Resident 5, diagnosed with COPD and shingles, did not receive a prescribed medication for a cough and experienced a delay in starting antiviral treatment for shingles due to pharmacy issues. Resident 6, with congestive heart failure and a bacterial infection, missed a dose of their prescribed antibiotic, and there was no evidence that the provider was notified. Staff interviews revealed ongoing issues with timely medication delivery from the pharmacy and a lack of backup staff for tracking antibiotic courses, contributing to these deficiencies.
Latest citations in Washington
A resident with cerebral palsy and a court-appointed guardian experienced multiple episodes of nausea, vomiting, loose stools, abdominal discomfort, fatigue, and later refusal of meals and medications, leading to changes in the care plan including close monitoring, lab testing, and IV fluid administration. Despite a facility policy recognizing court-appointed guardians as resident representatives with decision-making authority, staff did not document any notification to the guardian during these changes in condition or treatment decisions. The guardian reported not being contacted when the resident stopped eating or developed stomach issues and felt the facility did not respect the guardianship, while the DON acknowledged there were multiple missed opportunities to notify the guardian of the resident’s change from baseline.
A resident with depression, anxiety, moderate cognitive impairment, and urinary incontinence, care-planned for q2h checks and assistance with toileting, was found by a visitor to be soaking wet, unusually agitated, and reporting they had been told to wait to be changed and referred to with a derogatory remark. The visitor filed a written grievance alleging abuse/neglect related to delayed incontinence care and removal of the resident’s tablet as a consequence. Although an incident report noted that the matter was reported to the state and that the resident was not soaking wet, a CNA who actually changed the resident later reported the resident’s brief, pants, wheelchair, and socks were soaked and that the resident was acting timid and repeatedly saying they had to sit for five minutes, but this CNA was never interviewed. The DON acknowledged not investigating the resident’s behavior or interviewing this CNA, and the grievance official acknowledged the facility did not fully investigate or communicate findings and resolution to the complainant, resulting in a failure to follow the facility’s grievance policy.
A resident with dementia, respiratory failure, and heart failure developed new shortness of breath with an O2 sat of 90%, and a physician ordered transfer to the ED for tx and eval. An RN completed an SBAR, notified the MD and family, and reported to the oncoming nurse that the resident needed ED transfer and that paramedics should be contacted, then left the facility. Instead of calling 911 for this emergent respiratory distress, staff arranged non-emergent transport through a contracted ambulance service, resulting in the resident remaining at the facility for several hours without pickup until the dispatcher later instructed staff to call 911. The DON stated that 911 is expected to be used for emergent conditions and the contracted service only for non-emergent transport.
A resident with anoxic brain injury, dysarthria, and documented lack of decisional capacity alleged physical abuse and expressed fear of their identified representative, yet social services only reported the allegation to the state and did not complete an incident report, revise the care plan, or implement protective interventions. The same representative continued to be treated as the resident’s decision-maker and visited frequently, with staff noting suspicious odors of foreign substances and concerns about possible illicit substance use. Psychiatry later documented concern that the representative was providing illicit substances, and the resident was subsequently hospitalized for altered mental status and overdose, after which the representative was banned. Key staff, including the DON, unit manager, and administrator/abuse coordinator, were unaware of the initial abuse allegation, and social services did not timely explore or clarify legal decision-making authority or alternative representation for the resident.
A resident with severe cognitive impairment, osteoarthritis, and spinal spondylosis, care planned for 2-person Hoyer transfers, was being moved by two CNAs using a mechanical lift when one corner loop of the sling became disengaged, causing the resident to fall about four feet, strike the floor and the lift, and sustain head abrasion, multiple rib fractures, and lumbar vertebral fractures. Facility policy required staff to verify secure sling attachment, examine hooks, clips, fasteners, and strap stability, and ensure the sling bar was sound before lifting, but during this transfer the sling loop detached despite staff believing it was properly fastened and hearing it click into place; post-incident assessment showed the loop had come loose, the sling appeared in good condition, and a CNA later reported thinking one of the round metal disks on the lift might have been slightly loose, while maintenance logs documented no prior concerns with the lifts or slings.
The facility failed to revise and individualize care plans to reflect current needs and preferences for multiple residents, including one cognitively intact resident with hemiplegia, hemiparesis, and mononeuropathy who had bilateral shoulder surgery and could not tolerate BP measurements on the upper arms but preferred forearm readings. Despite repeatedly informing staff, this preference was not documented in the care plan or Kardex, and direct care staff and the RN/UM were unaware of it. Another cognitively intact resident with hemiplegia, contractures, and weakness reported they were supposed to get out of bed for two hours daily, but some NACs did not know this, even though the MAR/TAR contained an order to document times up and back to bed. The surveyors concluded that care plans were not accurately revised for several residents, placing them at risk for unidentified and unmet care needs and diminished quality of life.
Surveyors found that two residents with hemiplegia, hemiparesis, weakness, and contractures did not receive restorative nursing services, including ROM exercises and splint/brace or orthotic assistance, after therapy discharge. Although PT and OT discharge summaries documented established restorative ROM and transfer programs, recommended PROM to affected extremities, and recommended splint/brace use and assistance with orthotic wear, these recommendations were not entered as restorative referrals in the EHR. As a result, the residents’ care plans and records showed no restorative programs, and both residents reported that therapy and restorative exercises had stopped, while the DON, rehab director, and MDS coordinator confirmed they were unaware of and had not implemented the recommended restorative services.
A resident with cancer, cognitive impairment, and declining strength experienced multiple unwitnessed falls, most occurring while attempting to toilet or move toward the bathroom, culminating in a fractured ankle requiring ED treatment. Although assessments identified fall and incontinence risks and the facility’s policy required individualized interventions, the comprehensive care plan lacked a toileting plan and did not include several interventions that were discussed in incident investigations, such as consistent wheelchair placement and frequent rounding for bathroom assistance. Staff reported relying on verbal reminders and education to use the call light, despite acknowledging the resident’s impulsivity and failure to call for help, and the resident’s bed remained furthest from the bathroom while repeated bathroom-related falls occurred without the trend being recognized or addressed in the care plan.
A resident with a history of acute urinary retention and acute kidney injury had a Foley catheter deemed permanent by the hospital, with instructions that it not be removed in the SNF. At a later urology visit, the catheter was removed, and the resident returned with no new orders documented. Facility staff did not document bladder assessments, post-void residuals, or urine output, and CNA documentation showed the resident did not void that evening. Over the next day, the resident had vomiting, poor intake, altered level of consciousness, tachycardia, hypotension, and no documented wet briefs. A bladder scan eventually showed more than 2000–2500 mL of retained urine, and a new catheter drained a large volume. The resident and a roommate reported moaning, crying out in pain, and repeatedly alerting staff that the resident was not urinating and that the catheter was not draining, while nurses documented catheter care when no catheter was in place and later had to flush and replace the catheter due to continued complaints.
Surveyors found that nurses and nurse aides did not consistently administer medications according to professional standards and facility policy. Multiple residents reported that agency nurses were slow with medications, did not fully follow instructions, and often gave routine meds late. Observations showed an LPN administering expired Humalog/Lispro insulin well past the scheduled time, an LPN giving several scheduled meds (including Tizanidine) late and all at once, and an RN attempting to give sliding-scale insulin nearly two hours late, which a resident refused after already eating. Another resident received Methocarbamol two hours late after questioning the RN, and a resident on scheduled Tramadol had doses given without timely documentation, with a discrepancy between the narcotic count and pills remaining. These events demonstrated failures in timely administration, use of non-expired medications, and immediate, accurate MAR and narcotic documentation.
Failure to Notify Court-Appointed Guardian of Resident’s Clinical Changes
Penalty
Summary
The deficiency involves the facility’s failure to notify a resident’s court-appointed guardian of significant clinical changes and care decisions, contrary to its own policy and state requirements. The facility’s policy on Resident Representatives, revised 02/2021, states that a resident representative includes a court-appointed guardian or conservator and that the facility treats the representative’s decisions as those of the resident to the extent delegated or required by the court. Resident 1, admitted with cerebral palsy, had a Superior Court guardianship letter dated 02/07/2025 indicating a guardian of person and conservator of the estate with full authority, identifying Collateral Contact 1 (CC1) as the guardian. Despite this, multiple clinical events and changes in condition were documented without any corresponding documentation that CC1 was notified. Progress notes and provider notes show that Resident 1 experienced an episode of nausea and vomiting, frequent loose stools, abdominal discomfort, bloating, worsening fatigue, generalized weakness, and later refusal of meals and medications over at least a 24-hour period, with observations that the resident appeared frailer, more fatigued, and had no energy or interest to talk. The provider developed care plans including close monitoring for deterioration, sending stool to the lab, and later initiating IV fluids for rehydration, with a plan to call family/POA for discussion. However, there was no documentation that the guardian was notified at any of these points, including when IV fluids were started. CC1 reported that they were not contacted when the resident stopped eating or developed stomach issues, and expressed that the facility did not respect their guardianship and that involvement in care planning took too long. The DON confirmed on record review that there were many opportunities to notify the guardian when the resident’s condition changed from baseline and that there was no evidence staff did so.
Failure to Thoroughly Investigate and Resolve Resident Grievance Regarding Incontinence Care and Staff Conduct
Penalty
Summary
The deficiency involves the facility’s failure to thoroughly investigate and resolve a grievance alleging neglect and disrespect toward a resident, as required by its grievance policy. The resident had depression, anxiety, moderate cognitive impairment, occasional urinary incontinence, and required moderate assistance with toileting, with a care plan directing staff to check the resident every two hours, ask about toileting needs, and ensure they were clean and dry. A collateral contact reported arriving to visit the resident and finding them soaking wet and agitated, with behavior that was not typical for the resident. The collateral contact documented in a written grievance that the resident’s tablet was off, the resident appeared upset, and the resident reported being told they had to wait five minutes to be changed and that staff would change their “nasty *ss” in five minutes, leading the collateral contact to believe the resident had been given a consequence of no tablet and sitting in wet clothes, which they characterized as abuse/neglect and requested immediate removal of the responsible staff and a report filed. The facility documented receipt of the grievance and created an incident report indicating the matter was reported to the state agency, and that the unit manager interviewed the collateral contact and the resident, with the resident described as confused and denying being soaking wet. The incident report stated that a different nursing assistant was assigned to assist with the brief change and that the unit manager believed the resident was not soaking wet, and that the resident and collateral contact were satisfied when they left the room. However, a CNA who actually changed the resident reported that the resident’s brief was soaked through their pants onto the wheelchair and their socks were soaked, and that the resident was timid, repeatedly saying they had to sit for five minutes, and not acting like themselves; this CNA stated they were never interviewed or asked about the grievance or the resident’s condition. The DON acknowledged not interviewing this CNA or investigating the resident’s behavior and why they were upset, and the unit manager did not recall whether the collateral contact was present during follow-up and did not believe they followed up with the collateral contact regarding the grievance. The administrator, identified as the Grievance Official, stated the facility should have thoroughly investigated the grievance and discussed findings and resolution with the collateral contact, indicating the grievance process was not fully carried out in accordance with policy and WAC 388-97-0460.
Failure to Obtain Timely Emergency Transport for Resident in Respiratory Distress
Penalty
Summary
The deficiency involves the facility’s failure to obtain timely emergency medical services for a resident experiencing new-onset respiratory distress. The resident had dementia, respiratory failure, and heart failure, with severe cognitive impairment and a need for substantial assistance with activities of daily living. On the day the resident was sent to the hospital, a collateral contact observed the resident having difficulty breathing, appearing unable to get enough air, and looking as if they were sleeping or unconscious, and reported this to staff with a request to contact the doctor. An SBAR Communication Form documented that the resident was experiencing shortness of breath that had not occurred before, with an oxygen saturation of 90%. The physician was notified and ordered the resident sent to the emergency department for treatment and evaluation, and the collateral contact was notified shortly thereafter. Progress notes later documented that, despite the order for emergency department transfer, the resident was still awaiting pickup by Olympic transportation several hours later, with no estimated time of arrival. At approximately 3:30 AM, the dispatcher informed the facility that they could not provide transportation and instructed that 911 be called; only then was 911 contacted and the resident transported to the hospital via ambulance for respiratory distress. The RN caring for the resident stated they completed the SBAR, notified the physician and family, and at the end of their shift reported to the oncoming nurse that the resident needed to be sent to the emergency department for respiratory distress and that paramedics should be contacted, then left assuming 911 would be called. The DON stated that staff are expected to contact 911 for emergent conditions such as shortness of breath or respiratory distress, and that Olympic Ambulance is used only for non-emergent transport.
Failure to Provide Social Service Advocacy After Abuse Allegation and Questionable Representative
Penalty
Summary
The deficiency involves the facility’s failure to provide appropriate medically-related social services and advocacy for a resident following an allegation of abuse and concerns about the resident’s representative. The resident had an anoxic brain injury, dysarthria, moderate cognitive impairment, and was dependent on staff for activities of daily living. A hospital palliative care note documented that the resident lacked decisional capacity, had no DPOA, that the legal next of kin (CC4) did not want to be part of care decisions, and that care decisions were being deferred to another contact (CC5). CC5 accompanied the resident on admission, signed admission forms, and was listed as the primary contact in the medical record profile. On a date in February, during communication therapy, the resident reported that CC5 had done something to them, pounded their hands on their chest, recalled being hit in the back of the head by an unknown person, and stated they were sometimes afraid of CC5. A social services staff member reported this allegation to the state agency but did not complete a facility incident report, did not initiate care plan changes or interventions, and took no further action. CC5 continued to be treated as the resident’s representative, and progress notes documented CC5 at the bedside on multiple dates, including an entry noting the room smelled like foreign substances and that CC5 was seen waking the resident and then asking the nurse to administer pain medications. A psychiatry note later documented concern that CC5 was providing the resident with illicit substances and stated it would be prudent for the resident to identify a POA. Subsequently, the resident was found unresponsive, transported to the hospital, and later readmitted after altered mental status and overdose, with a provider note stating that CC5 posed a significant danger to the resident and was banned from visiting. After readmission, staff attempted to contact CC4 for consent to treat but initially reached someone who stated they were not CC4. The social service director acknowledged that, beyond reporting the initial allegation, no additional interventions were implemented, that CC5 continued to be used as the resident’s representative after the allegation, and that they had not explored legal authority for decision making following the abuse allegation or concerns about substances. The social service assistant reported they did not speak with the resident about the hospital stay or CC5 and did not complete an incident report or care plan changes after the allegation. The unit manager and DON were unaware of the initial abuse allegation, and the administrator, who served as abuse coordinator, also stated they were unaware of the allegation and that an investigation should have been initiated and a representative for the resident investigated at a minimum.
Injury from Mechanical Lift Sling Detachment During Transfer
Penalty
Summary
The facility failed to ensure a safe mechanical lift transfer when a resident was being moved with a Hoyer lift and sling, resulting in a fall and injury. Facility policy for using a mechanical lifting machine required staff to securely attach sling straps to the sling bar according to manufacturer’s instructions, double-check the security of the sling attachment before lifting, examine all hooks, clips, or fasteners, check strap stability, and ensure the sling bar was securely attached and sound. Despite these requirements, during a transfer for dinner, two CNAs placed the sling under the resident, attached the loops at each corner of the sling to the lift, and raised the resident off the bed into the space between the bed and wheelchair when the bottom left corner of the sling became disengaged from the lift. The resident involved had multiple diagnoses including osteoarthritis, cervical and thoracic spondylosis, and Alzheimer’s disease, with the Minimum Data Set documenting severely impaired cognitive skills for daily decision-making. The resident’s care plan required the assistance of two staff during Hoyer lift transfers. During the transfer, the resident fell approximately four feet, landing on her buttocks, bouncing, and then falling backward and striking her head on the leg of the Hoyer lift. Hospital records documented that the resident sustained an abrasion to the back of the head, fractures of the 6th, 7th, 8th, and 10th ribs, and fractures of the 1st and 2nd lumbar vertebra. Staff interviews and observations showed that staff believed the sling loops had been securely fastened and reported hearing the loops click into place before lifting. One CNA stated that they had barely lifted the resident off the bed when the bottom left loop became disconnected and the resident fell. Another CNA reported being shocked and unable to figure out what had happened. A nurse who assessed the resident and then examined the equipment after the fall noted that one of the loops of the sling had become disengaged but stated the sling appeared to be in good condition. During a later demonstration, a CNA indicated she thought one of the round metal disks on the lift might have been a little loose. Maintenance logs for Hoyer slings and lifts for the preceding months documented no concerns with the slings or lifts, and the DON acknowledged expecting a citation due to the resident’s injury from the fall.
Failure to Revise Care Plans to Reflect Resident Needs and Preferences
Penalty
Summary
The deficiency involves the facility’s failure to revise and individualize comprehensive care plans to reflect residents’ current needs and preferences, as required by its own care planning policy. For one resident with hemiplegia, hemiparesis following cerebrovascular disease, and mononeuropathy of the upper limb, the admission MDS showed intact cognition and upper extremity impairment. This resident reported having bilateral shoulder surgery and an inability to tolerate blood pressure measurements on the upper arms due to pain, and stated a preference for BP measurements on the forearms. The resident reported having informed multiple nursing staff of this preference, but staff continued to place the cuff on the upper arms. Review of the resident’s care plan and Kardex showed no interventions or instructions regarding forearm BP cuff placement. A NAC confirmed they were unaware of the preference until the resident told them directly and that this instruction was not documented in the Kardex. The RN/Unit Manager, who stated they were responsible for revising and reviewing care plans when there were changes, also confirmed they were not aware of the resident’s preference and that it should have been updated in the care plan. Another resident, readmitted with hemiplegia and hemiparesis following a nontraumatic subarachnoid hemorrhage, contracture of the left hand, and weakness, was cognitively intact and required maximum assistance for bed mobility per a quarterly MDS. This resident stated they were supposed to get out of bed for two hours every day, but some NACs were not aware of this care requirement. Review of the resident’s March 2026 MAR/TAR showed an order to document the time the resident got up and the time they returned to bed daily. The report states that, overall, the facility failed to revise care plans accurately to reflect residents’ needs for three of four residents reviewed for care plan revision, placing them at risk for unidentified and unmet care needs and a diminished quality of life.
Failure to Implement Restorative Nursing and Splint/Brace Programs After Therapy Discharge
Penalty
Summary
The deficiency involves the facility’s failure to provide restorative nursing services, including range of motion (ROM) exercises and splint/brace assistance, to maintain or prevent decline in mobility and contractures for two residents with significant motor impairments. The facility’s undated Restorative Nursing Services policy stated that residents would receive restorative care as needed to achieve and maintain optimal functioning and that residents may initiate a restorative program upon discharge from rehabilitative care. Despite this, surveyors found that residents with documented hemiplegia, hemiparesis, weakness, and contractures were not placed on restorative programs and had no restorative interventions documented in their electronic health records (EHRs). Resident 1 was admitted with hemiplegia and hemiparesis following cerebrovascular disease, a left lower leg fracture, and weakness, and the admission MDS showed intact cognition, moderate assistance needs for bed mobility and transfers, and one-sided upper and lower extremity impairment. During observation, the resident was seen lying in bed with a bent inward left forearm and hand and reported no longer receiving therapy or nursing-assisted exercises. The care plan initiated in January showed no restorative services, and the care plan history and EHR contained no restorative nursing interventions. However, the PT discharge summary from February documented that restorative ROM and transfer programs had been established and trained, including PROM to the left upper and lower extremities and stand-by assist with transfers, and the OT discharge summary recommended a splint/brace to prevent contracture. The OT stated that the splint/brace was not tried due to lack of time before insurance was discontinued, and both the Director of Rehab and the MDS coordinator confirmed there was no restorative referral in the EHR and they were unaware of the recommendations. Resident 2 was readmitted with hemiplegia and hemiparesis following a nontraumatic subarachnoid hemorrhage, a left-hand contracture, and weakness, and the quarterly MDS showed intact cognition, maximum assistance needs for bed mobility, total assistance for transfers, bilateral upper and lower extremity impairment, and no therapy or restorative programs. The resident reported that therapy had been discontinued months earlier and that no restorative staff were assisting with exercises. The care plan and EHR showed no restorative services. OT evaluation documented left upper extremity ROM impairment, a left-hand contracture, and prior use of a left orthotic to manage flexion tone, and the OT discharge summary recommended restorative care and assistance with donning/doffing the orthotic. The PT discharge summary recommended restorative programs if Medicaid Part B services did not continue. The Director of Rehab confirmed therapy was discontinued and that restorative nursing programs were recommended, but both the Director of Rehab and the MDS coordinator stated there were no restorative referrals in the EHR after readmission, and the MDS coordinator confirmed the resident had no restorative programs since readmission.
Failure to Implement Effective Fall and Toileting Interventions for High-Risk Resident
Penalty
Summary
The deficiency involves the facility’s failure to provide adequate supervision, identify fall trends, and implement progressive, resident-centered interventions for a resident with multiple falls and declining strength. The facility’s own Falls and Fall Risk Management policy required staff to identify interventions related to residents’ specific risks and causes to prevent falls and minimize complications. The resident’s Care Area Assessment identified cancer-related risks for pain, falls, and ADL decline, and stated that falls and urinary incontinence would be addressed in the care plan with an objective of improvement and risk minimization. However, the comprehensive care plan did not include a urinary or ADL care plan and contained no toileting plan, despite the resident’s identified risks and prior fall history. Over a series of falls, the resident repeatedly fell while attempting to toilet or move toward the bathroom, yet the facility did not recognize or address this pattern in its investigations or care planning. The resident had multiple unwitnessed falls: next to the bed while getting up to use the restroom, in the bathroom while standing to use the toilet, and near or in the bathroom on several occasions. Incident investigations and post-fall assessments documented environmental factors such as clutter, items on the floor, water on the floor, and issues with footwear, as well as the resident’s increasing weakness, impulsivity, poor safety awareness, and poor insight into limitations. Interventions documented in investigations and risk reviews included encouraging use of the front-wheeled walker, keeping the wheelchair and walker accessible, ensuring proper footwear and non-skid socks, and providing resident education on safe transfers, ambulation, and assistive device use. However, several of these planned interventions, including placement of the wheelchair and frequent rounding/toileting assistance, were not added to or reflected in the care plan as stated. Staff interviews further showed that the resident frequently fell while trying to go to the bathroom and that staff relied on verbal education and reminders to use the call light, even though the resident often did not use it. Staff acknowledged the resident’s impulsivity and tendency to get up independently despite instructions, and one staff member stated that nursing assistants were verbally instructed to offer bathroom assistance, but this intervention was not documented in the care plan. The resident’s bed remained the one furthest from the bathroom throughout the stay, and none of the facility’s investigations identified the trend of bathroom-related falls or addressed toileting options in the care plan. Ultimately, the resident sustained a left ankle fracture after another bathroom-related fall, requiring transfer to the emergency department for evaluation and treatment, and later records documented additional fractures and a decline in condition. The surveyors concluded that the facility’s failures placed residents at risk of repeated falls and injuries.
Failure to Monitor Urinary Retention After Foley Removal Leading to Prolonged Pain
Penalty
Summary
The deficiency involves the facility’s failure to adequately assess and monitor a resident for complications associated with an indwelling urinary catheter and urinary retention, particularly after catheter removal. The resident had a history of acute kidney injury due to urinary retention, which improved after Foley catheter placement in the hospital. Hospital discharge documentation indicated the catheter was placed for acute urinary retention, was deemed permanent, and included instructions that, given the resident’s significant retention and acute renal failure, staff at the skilled nursing facility should not attempt Foley removal. The facility’s catheter care plan directed staff to empty the catheter as needed and record output in milliliters, but review of the last 30 days of documentation showed continence was not rated due to the indwelling catheter and there was no documented urinary output in milliliters on the treatment administration records. The resident had a scheduled urology appointment at which the urinary catheter was discontinued. Upon return from this appointment, nursing documentation initially indicated no new orders, and an alert note later stated the catheter was discontinued and staff were monitoring for retention or pain. However, there was no documented bladder assessment or urinary output following catheter removal. Nursing assistant documentation showed that the resident did not void on the evening shift that same day. Despite the catheter having been removed, the treatment administration record showed staff continued to document provision of catheter care on subsequent shifts when no catheter was in place. Over the next day, the resident experienced vomiting, decreased oral intake, and an altered level of consciousness, with vital signs showing tachycardia and low blood pressure, and staff documented decreased urine output. A bladder scan performed later revealed more than 2000–2500 milliliters of urine in the bladder, and an indwelling catheter was reinserted, initially draining a large volume of urine. The provider note indicated the resident had not eaten since the prior night, was unable to hold down fluids, and staff were unsure whether the resident had urinated in incontinence briefs, with no wet briefs reported since the resident’s return from the hospital after catheter removal. The provider expressed concern that the documented early-morning wet brief might not be accurate given the large bladder volume on scan and stated this should require further investigation. Subsequent notes described the resident moaning and complaining of pain, with limited urine output in the catheter bag and staff flushing and then replacing the catheter due to continued complaints. Interviews with the resident, the roommate, and staff indicated the resident was crying out and moaning in pain, the roommate repeatedly alerted staff that the resident was not urinating and that the catheter was not draining, and staff had to seek assistance to replace the catheter. Facility leadership and clinical staff later acknowledged that typical practice after catheter removal would include contacting the provider, placing the resident on alert, performing post-void residuals with bladder scans, and documenting monitoring, which was not done in this case.
Medication Administration Delays, Documentation Errors, and Use of Expired Insulin
Penalty
Summary
The deficiency involves the facility’s failure to ensure sufficient nursing staff with appropriate competencies and skill sets to administer medications according to professional standards of practice, facility policy, and prescriber orders. The facility’s medication administration policy required medications to be given as prescribed, in accordance with manufacturers’ specifications and good nursing principles, with no expired medications used, and doses administered within 60 minutes of the scheduled time and documented immediately after administration. Multiple residents reported that agency nurses often gave medications late, did not read full instructions, or were slow in bringing medications, and that routinely scheduled medications were not consistently provided without residents having to ask. Surveyors observed several specific medication administration failures. For a resident with diabetes, an LPN drew up and administered Humalog/Lispro insulin from a multi-dose vial that had been opened and dated “02/16” with no year, making it expired per policy, and administered the dose nearly 1 hour and 45 minutes after it was due. Another resident with care plan instructions to receive medications as ordered had multiple scheduled medications (Gabapentin, Oxybutynin, Baclofen, and Tizanidine) that were ordered at specific times throughout the day; the LPN was observed administering all four together and acknowledged that at least one (Tizanidine) was late, while the resident reported that receiving them together at that time was typical and not at their request. For another diabetic resident, an RN checked blood sugar and prepared sliding scale Humalog/Lispro insulin almost two hours after the scheduled time; the resident refused the insulin, stating they had already finished lunch. Additional deficiencies were identified with other residents’ pain and scheduled medications. One resident with a pain care plan and an order for Methocarbamol four times daily at set times approached the cart requesting Methocarbamol and Tylenol; the RN initially stated the Methocarbamol had already been given, but then administered it two hours after it was due when the resident pointed out the scheduled timing. For another resident with a risk for pain care plan and Tramadol ordered three times daily at specific times, an LPN retrieved a PRN pain medication while the electronic record showed no 8:00 AM medications documented; the LPN stated they had given them but had not yet documented. Later, an RN prepared the 2:00 PM Tramadol dose, and review of the narcotic count showed a discrepancy between the number of pills documented and the number remaining in the card. The RN stated they had given the 8:00 AM Tramadol but had not signed it out, then signed out both the 8:00 AM and 2:00 PM doses at that time. Residents interviewed consistently reported that medications were sometimes or frequently late, that agency nurses did not always follow instructions, and that they often had to request medications that were routinely scheduled.
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