Spokane Valley Health And Rehabilitation Of Cascad
Inspection history, citations, penalties and survey trends for this long-term care facility in Spokane Valley, Washington.
- Location
- East 17121 Eighth Avenue, Spokane Valley, Washington 99016
- CMS Provider Number
- 505099
- Inspections on file
- 39
- Latest survey
- November 24, 2025
- Citations (last 12 mo.)
- 25
Citation history
Health deficiencies cited at Spokane Valley Health And Rehabilitation Of Cascad during CMS and state inspections, most recent first.
Multiple residents reported frequent delays in receiving assistance with ADLs and restorative care due to inadequate staffing. Residents described waiting extended periods for help with toileting and bathing, with some missing showers for days or weeks. Staff interviews confirmed that there were not enough nursing assistants to consistently provide care, and restorative aides were sometimes reassigned to cover floor duties, resulting in missed restorative services.
Three cognitively intact residents requiring ADL assistance did not consistently receive scheduled bathing as outlined in their care plans, with significant gaps between documented baths and no records of refusals or alternative care. Resident and staff interviews confirmed inconsistent bathing, and documentation was maintained only electronically.
Multiple residents experienced lapses in care due to staff not fully assessing, implementing, or documenting physician orders and interventions. This included unaddressed constipation, lack of timely blood sugar monitoring, improper insulin injection site rotation, delayed response to changes in condition, and incomplete documentation and follow-through on IV therapy orders.
A resident with complex medical needs experienced pain and distress during a transfer when only one staff member assisted, despite a care plan requiring two-person assistance with a mechanical lift. The incident, witnessed by a family member, was not thoroughly investigated by the facility, as key witnesses were not interviewed, staff statements were incomplete, and the reasons for not following the care plan were not explored.
Three residents with cognitive and physical impairments experienced repeated falls and injuries due to the facility's failure to develop and implement effective interventions for fall prevention and safe transfers. Care plans were not updated to address cognitive decline, impulsivity, or unsafe footwear, and staff frequently did not follow care plan instructions for supervision and assistance, resulting in unsupervised ambulation, inappropriate footwear use, and single-person transfers when two-person assistance was required.
A resident dependent on staff for bed mobility and transfers did not consistently receive the required two-person assistance with a mechanical lift, as staff frequently performed these tasks alone due to inadequate staffing levels. Staff reported high resident assignments and difficulty obtaining help, while ancillary staff with expired credentials were sometimes used for assistance. Additionally, the DON did not maintain a valid RN license for the state, resulting in a lapse in authorized nursing leadership.
A resident with advanced kidney disease was administered fluconazole at double the prescribed dose for several days due to a failure in the facility's medication administration process. The error was not documented in progress notes, and staff were unable to provide information on the discrepancy. The DON confirmed the error after reviewing the resident's records.
A resident with cognitive impairments experienced a fall during an external appointment, resulting in a hospital transfer. The facility failed to notify the resident's representative, who was responsible for medical decisions. The DON confirmed the incident should have been reported, but it was not communicated, and an investigation was still ongoing.
A resident with cognitive impairments and high fall risk was sent unaccompanied to an external appointment, despite needing staff assistance for daily activities. The care plan required close monitoring, but there was no assessment for safety during the appointment. Staff interviews revealed a lack of communication and coordination regarding the need for accompaniment.
A resident with severe cognitive impairment and a history of wandering and poor boundaries was found in another resident's room, engaging in inappropriate behavior. Despite a care plan requiring monitoring, the resident was able to enter the room and act without immediate intervention, leading to a deficiency in protecting residents from abuse.
The facility inaccurately submitted staffing data to CMS for Q1 2024, reporting levels below mandated requirements. The DON noted changes during this period might have led to incorrect reporting, and the Operations Director found unreported data from external staffing agencies.
The facility failed to provide appetizing and palatable food, affecting six residents who reported the food as horrible, tasteless, and sometimes unidentifiable. Observations confirmed meals were unappetizing and not at safe temperatures. The Dietary Manager was unaware of complaints and suggested a new cook might be hesitant to use spices.
The facility failed to implement enhanced barrier precautions for residents at risk of transmitting MDROs, with staff not using appropriate PPE during care. Infection prevention policies were outdated, and the water management plan was not specific to the facility. Hand hygiene practices were inadequate, and a resident with a positive TB skin test did not receive follow-up testing.
The facility failed to provide education and documentation for influenza and pneumococcal vaccines for four residents, despite policies requiring such actions. Residents with conditions like COPD, diabetes, and malnutrition were not documented as having received or been offered the vaccines, and staff were unable to locate necessary records.
The facility failed to document COVID-19 vaccination status and provide education on the vaccine for several residents with conditions like COPD and diabetes. Staff interviews revealed a lack of record audits and challenges in managing immunization processes.
The facility failed to maintain resident dignity for three individuals. A resident with a brain injury was undignifiedly referred to as a 'feeder' by staff. Two residents with urinary catheters had their collection bags uncovered, compromising their privacy. Staff interviews confirmed these actions were not in line with maintaining resident dignity.
A resident who required assistance with daily activities fell while being helped to the toilet, but the incident was not investigated or reported according to facility policy. Staff failed to document the fall, and the physician's assistant was notified five days later. The DON confirmed the incident should have been reported as a fall.
A facility failed to complete an accurate and timely PASARR for a resident with a mental health diagnosis. The resident was admitted with paranoid personality disorder, but the PASARR was completed four days late and did not reflect this diagnosis. Additionally, when the resident's diagnoses changed to include anxiety and depression, the PASARR was not updated to assess the need for specialized mental health services.
The facility failed to implement care plan interventions for three residents, leading to deficiencies in their care. A resident at risk for choking was observed eating without supervision, another with hemiplegia was not assisted out of bed for meals, and a third with ulcers did not receive required offloading of pressure. Staff were unaware or did not adhere to care plan instructions.
A facility failed to provide a complete discharge summary for a resident, omitting the recapitulation of care and services received. The resident, who was cognitively intact and required assistance with daily activities, was discharged after receiving therapy for a urinary tract infection and sepsis. The discharge summary lacked details on the destination and care provided, as confirmed by the DON.
The facility failed to provide consistent bathing and grooming for three residents, leading to poor personal hygiene. A resident with paraplegia was observed with greasy hair and facial stubble, despite a care plan for regular bathing. Another resident reported infrequent baths, and documentation confirmed irregular bathing schedules. A third resident, with obesity and candidiasis, kept a personal record showing significant gaps between showers. Staff interviews revealed challenges in completing bathing tasks due to time constraints and the absence of a dedicated bath team.
A resident with cognitive impairment and depression did not receive an adequate program of activities that matched their interests, leading to boredom and diminished quality of life. The facility's activity program was limited due to staffing issues, and staff acknowledged the need for more engaging activities.
A resident with a history of pressure ulcers did not consistently receive pressure-relieving interventions, leading to the reopening of a wound on their left heel. Despite a care plan that included repositioning and the use of a foam boot, staff often failed to apply these measures when the resident was in bed, contributing to the deterioration of the heel condition.
A facility failed to maintain consistent communication with a dialysis clinic for a resident with kidney disease and diabetes, as required by an agreement. The absence of dialysis communication forms on multiple occasions in July 2024 led to a lack of coordination in the resident's care. Staff interviews confirmed the importance of these forms for collaboration, highlighting a significant deficiency in the facility's processes.
The facility failed to ensure timely physician visits for two residents, leading to potential unmet medical needs. One resident with kidney disease and chronic UTIs had not seen a physician within the required timeframe, while another resident with anxiety and insomnia experienced issues with medication changes. Staff interviews revealed confusion about the required frequency of physician visits.
The facility did not complete annual performance reviews for three nursing assistants, AA, BB, and CC, as required. Staff AA, hired in May 2022, and staff BB and CC, hired in July 2023, lacked documentation of their evaluations. The Director of Nursing confirmed the absence of these reviews, placing residents at risk of receiving care from inadequately trained staff.
Two residents with severe mental health conditions did not receive necessary behavioral health services. One resident, with psychosis and schizoaffective disorder, lacked specific care plan interventions and had minimal psychiatric visits. Another resident, with major depressive disorder, had an incomplete care plan and unaddressed requests for increased medication and counseling. Staff were unaware of these needs, and the facility lacked a dedicated behavioral health provider.
An LPN administered incorrect doses of Azelastine and Mesalamine to a resident and omitted Acetylcysteine, Spiriva Respimat, and Ipratropium-Albuterol, resulting in a medication error rate of 12.5%. The LPN acknowledged the errors, citing the resident's preference and unawareness of the correct dose, as well as a delay in medication delivery.
During a survey, a facility was found to have expired medications and undated multi-dose vials in a medication room, along with missing refrigerator temperature logs. Unsecured insulin needles were also discovered in a closed unit, posing a risk of needlestick injuries. Staff were unsure of responsibilities for medication management and temperature logging.
A dietary staff member at the facility did not have the required Washington State Food Worker Card, instead possessing a non-approved certificate from Food Handler Solutions. The staff member worked several shifts in the kitchen without the appropriate credentials. The HR Manager was unaware of the certificate's invalidity in Washington State, leading to the staff member being barred from work until obtaining the correct credential.
A nursing assistant failed to perform hand hygiene during meal service, as observed in one of four meals. The staff member, identified as Staff JJ, was seen delivering meal trays and assisting residents with eating without washing hands between tasks. This included handling food items and utensils for multiple residents without proper hand hygiene. Staff JJ admitted to forgetting the procedure due to being busy, and the infection preventionist confirmed the requirement for hand hygiene between tasks.
The facility failed to provide necessary pharmacy services for three residents, leading to deficiencies in medication management. A resident with anemia did not receive Procrit injections due to incomplete pharmacy forms. Another resident with diabetes did not receive long-acting insulin, glargine, due to unavailability and lack of follow-up. A third resident with Multiple Sclerosis did not receive tizanidine and L-Lysine due to communication failures and unrequested pharmacy orders.
A resident did not receive prescribed medications, tizanidine and L-Lysine, due to improper discontinuation by nursing staff without proper authorization. The facility's Director of Nursing was unaware of the discontinuation, and Medical Records staff confirmed no unscanned orders existed. A signed provider order did not include these medications, highlighting a lapse in medication management procedures.
A facility failed to maintain complete and accurate medical records for a resident receiving Procrit for anemia treatment. The resident's MAR indicated an order for Procrit, but it was not documented as administered. Interviews revealed the resident received the medication at a nephrologist's office, but there was no documentation of this in the electronic medical record. Staff confirmed the lack of records and stated that information would need to be manually entered.
A resident with a history of dementia and aspiration was served an inappropriate meal texture, leading to a choking incident. Despite being on an L3 diet, which excludes certain textures, the resident was given tater tots, resulting in coughing and gagging. The dietary staff failed to follow the diet spread sheet, leading to the incident.
The facility failed to provide CPR in accordance with national standards to a resident with a Full Code status, moving the resident to a bed instead of performing CPR on a firm surface. Additionally, two staff members lacked current CPR certification credentials.
Insufficient Staffing Leads to Delays in ADL and Restorative Care
Penalty
Summary
The facility failed to provide sufficient nursing staff to meet the care needs of residents, specifically in the areas of activities of daily living (ADLs) and restorative nursing services. Multiple residents reported frequent delays in receiving assistance, including waiting extended periods for help with toileting and bathing. During a Resident Council meeting, all attendees stated they often had to wait a long time for care due to inadequate staffing, with some residents reporting missed showers for days or even weeks. One resident described using their cell phone to call the facility for help when their call light was not answered, and still experienced significant delays. Observations and interviews confirmed that residents were left waiting for basic care, such as being assisted off a bedpan or to the bathroom, and some residents were not receiving restorative programs for conditions like hand contractures. Staff interviews revealed that the facility had attempted to reassign duties among nursing assistants to address bathing needs, but this approach was ineffective and led to further staffing challenges. Staff members, including the Human Resource Director and LPNs, acknowledged that there were not enough nursing assistants to consistently complete showers and restorative services. The staffing coordinator confirmed that restorative aides were sometimes pulled to work the floor, resulting in restorative services not being provided. Facility leadership stated that staffing was based on resident census and state minimum requirements, but acknowledged issues with residents not being bathed. The deficiency was attributed to insufficient staffing rather than staff unwillingness to perform care.
Failure to Consistently Provide Scheduled Bathing for Residents Requiring ADL Assistance
Penalty
Summary
The facility failed to consistently provide bathing or showers for three of six sampled residents who required assistance with activities of daily living (ADLs), specifically bathing. Each of these residents was cognitively intact and able to make decisions regarding their care, and their care plans specified that they were to receive assistance with bathing at least twice a week, with bed baths to be provided if they refused or could not tolerate a shower. Documentation reviews revealed significant gaps between baths, with some residents going up to 28 or 34 days without a documented bath. There was no documentation indicating that the residents had refused baths or that alternative care, such as bed baths, was offered as per their care plans. Interviews with residents confirmed that they were not being bathed as scheduled, and one resident attributed the lack of bathing to insufficient staffing. Staff interviews corroborated that bathing was not being provided consistently, and all documentation was maintained electronically with no paper logs. The lack of consistent bathing and incomplete documentation of refusals or alternative care directly contradicted the interventions outlined in the residents' care plans.
Failure to Implement and Document Physician Orders and Interventions
Penalty
Summary
The facility failed to fully assess, implement, and document physician orders and interventions for multiple residents, resulting in unaddressed changes in condition and lack of appropriate care. For one resident with a history of constipation, there were repeated prolonged periods without bowel movements, with medical records showing gaps of up to 12 days. Despite standing and as-needed orders for various laxatives and enemas, documentation showed these interventions were not consistently administered or followed up on, and staff did not document the administration or effectiveness of these treatments. Additionally, after a dangerously low oxygen saturation was recorded, there was no documentation of frequent monitoring or administration of oxygen as ordered by the provider. Another resident with complex medical needs, including diabetes, did not have blood sugar checks performed as ordered, with staff only obtaining readings at bedtime instead of before meals and at bedtime. When blood pressure readings were out of range, the nurse withheld medication without a provider order or documented notification to the provider. For a resident receiving insulin, nurses continued to use the same injection site despite provider instructions to rotate sites due to bruising and tissue trauma, and there was no documentation of refusal to use alternative sites. Additionally, persistent complaints about a toenail were not escalated or monitored until the condition worsened and required medical intervention. The facility also failed to clarify and document orders related to intravenous therapy. One resident had an IV saline lock in place for a week after a one-time fluid administration, but there was no order or documentation for routine flushing and site maintenance as required by facility policy. Staff interviews confirmed that documentation and order transcription for IV care were incomplete, and the facility did not follow its own policy or provider orders for IV maintenance.
Failure to Conduct Thorough Abuse Investigation and Adhere to Care Plan
Penalty
Summary
The facility failed to conduct a complete and thorough investigation of an allegation of abuse involving a resident with complex medical conditions, including muscle weakness, difficulty walking, and right foot drop. The resident, who was dependent on staff for bed mobility and transfers, reported experiencing pain during a transfer when only one staff member assisted, contrary to the care plan requiring two-person assistance with a mechanical lift. The resident described being handled roughly and yelled at by the staff member during the incident, which was witnessed by a family member present in the room. A collateral contact also reported hearing the resident scream and noted that they had never observed two staff assisting the resident, despite frequent visits. The facility's investigation into the incident was incomplete. Although the investigation included interviews with the resident, a collateral contact, the staff member involved, other residents, and staff, there was no documentation of an interview with the family member who witnessed the event. Additionally, the investigation did not include a statement from the LPN assigned to the unit at the time of the incident. The staff interviews that were conducted were unsigned, undated, and mostly lacked staff titles, and the questions asked did not address the specifics of the incident or the staff member's conduct during the event. Furthermore, the investigation did not address why the staff member failed to follow the resident's care plan requiring two-person assistance, nor did it explore whether this practice was common among other staff or shifts. There was also no documentation that the facility inquired about the staff member's treatment of other residents or any observations of yelling. These omissions resulted in a lack of evidence demonstrating a thorough investigation as required by facility guidelines.
Failure to Develop and Implement Effective Fall Prevention and Transfer Interventions
Penalty
Summary
The facility failed to develop and implement adequate interventions to prevent falls and injuries for three residents with significant cognitive and physical impairments. For one resident with dementia, stroke, and right knee pain, the care plan did not address the resident's cognitive decline, impulsivity, or changes in bed mobility and transfer needs, despite multiple falls and documented confusion. Staff interviews revealed inconsistent awareness of care plan changes, and the care plan lacked specific interventions to address the resident's increasing tendency to self-transfer and not use the call light. Observations showed the resident wearing ill-fitting slippers and experiencing falls in various settings, including the dining room and their own room, with injuries such as head bumps and lacerations. The care plan was not revised to address the resident's mental decline, interrupted sleep, or the need for increased supervision during high-risk times. Another resident with severe cognitive impairment, a history of falls, and muscle weakness experienced multiple falls while ambulating unsupervised and wearing inappropriate footwear, such as open-toed sandals. The care plan instructed staff to provide direct supervision and use a walker for transfers, but the resident was observed walking independently and propelling themselves in a wheelchair without staff assistance. After falls, the only new intervention was to ask if the resident wanted to eat in a less stimulating environment, and there was no documentation of collaboration with the resident's representative to address unsafe footwear. Staff acknowledged that sandals were not appropriate but did not document efforts to replace them, and therapy notes regarding footwear assessment were unavailable. A third resident with muscle weakness and right foot drop required substantial assistance and the use of a sit-to-stand lift for transfers and bed mobility. However, staff interviews and observations revealed that transfers and bed mobility were frequently performed by a single staff member, contrary to the care plan's requirement for two-person assistance. Staff admitted to transferring the resident alone, sometimes physically lifting them without mechanical assistance, and not always following the care plan. The resident and a collateral contact confirmed that two-person assistance was rarely provided, and staff rationalized single-person transfers based on their own physical strength or convenience.
Failure to Provide Adequate Staffing and Maintain Valid RN Licensure
Penalty
Summary
The facility failed to provide adequate nursing staff to meet the needs of all residents, specifically for those requiring assistance with bed mobility and mechanical lift transfers. One resident with complex medical conditions, including muscle weakness, difficulty walking, and right foot drop, was dependent on staff for bed mobility and transfers. The resident's care plan required substantial or maximal assistance of two persons and the use of a sit-to-stand mechanical lift for transfers and repositioning. However, interviews and observations revealed that staff routinely performed these tasks alone, without the required second person, and staff reported being assigned to care for 14 to 18 residents per shift, making it difficult to comply with care plans and ensure resident safety. Multiple staff members confirmed that they often performed two-person transfers alone due to insufficient staffing, and that it was challenging to find assistance from other staff, including nurses who were occupied with other duties. Staff described situations where they had to physically move residents by themselves or seek help from ancillary staff, some of whom had expired credentials. Staff also reported that the nurse assigned to the unit was frequently unavailable to assist with transfers, and that the overall workload was too high for the number of staff present. Additionally, the facility failed to ensure that the Director of Nursing (DON) maintained a valid RN license authorizing them to work in the state. The DON's multi-state RN license had expired, and a temporary license issued in another state did not permit practice in the facility's state. This lapse in licensure was confirmed by both the state licensing board and the DON, who was unaware that the temporary license was not valid for practice in the facility's state. The administrator was informed of the invalid credentials and confirmed the need for a current state or multi-state license for the DON role.
Significant Medication Error Due to Incorrect Administration
Penalty
Summary
The facility failed to ensure that a resident received medication as ordered by the physician, resulting in significant medication errors. Resident 6, who was discharged from the hospital with orders to receive fluconazole 600mg daily until a specified date, was administered the medication twice daily for several days, effectively doubling the prescribed dose. This error occurred from 10/11/2024 to 10/15/2024, during which the resident was under the facility's care. The resident had advanced kidney disease and was to be closely monitored by nephrology, making the accurate administration of medication critical. The error was not addressed in the resident's progress notes, and the facility's staff were unable to provide information related to the discrepancy. The Director of Nursing, who began working at the facility after the incident, identified issues with the admission medication process and confirmed that the fluconazole administered did not match the hospital discharge orders. This constituted a significant medication error, as the facility did not ensure the resident's medication was administered according to the physician's orders.
Failure to Notify Resident's Representative of Fall and Hospital Transfer
Penalty
Summary
The facility failed to notify the resident's representative of an incident involving a fall and subsequent hospital transfer for a resident with significant cognitive impairments. The resident, who was dependent on staff for assistance with activities of daily living, had a surrogate decision-maker responsible for all medical and financial decisions. On a specific date, the resident experienced a fall during an external appointment, resulting in low back pain and necessitating a hospital transfer for evaluation. Despite the incident, there was no documentation indicating that the resident's representative was informed of the fall or the hospital transfer. Interviews conducted during the investigation revealed that the resident's representative was unaware of the fall and the appointment, expressing that they would not have consented to the appointment due to the resident's confusion and history of refusal with the type of provider involved. The Director of Nursing confirmed that the fall, which occurred outside the facility, should have been reported to all responsible parties. However, the incident had not been communicated to them, and an investigation was still ongoing more than a month after the event. The lack of notification to the resident's representative was a significant oversight in the facility's duty to inform responsible parties of incidents affecting the resident.
Failure to Provide Supervision for Cognitively Impaired Resident
Penalty
Summary
The facility failed to ensure adequate supervision for a resident with significant cognitive impairments and a high risk of falls during an external appointment. The resident, who was dependent on staff for assistance with activities of daily living and had a history of seizures and involuntary movements, was sent to an appointment unaccompanied. The care plan required close monitoring and assistance from two staff members for transfers, yet there was no documentation of an assessment to determine the resident's safety in their wheelchair without accompaniment. Interviews revealed that the resident arrived at the appointment alone and confused, unable to provide their medical history or residence information. The resident's representative was not informed of the appointment and expressed concerns about the resident's safety. Staff interviews indicated a lack of communication and coordination regarding the need for accompaniment, with responsibilities for scheduling and assessing the need for supervision not clearly executed. The Director of Nursing and other staff members were unsure of the resident's needs for accompaniment, leading to the oversight.
Failure to Protect Resident from Sexual Abuse
Penalty
Summary
The facility failed to protect a resident from sexual abuse by another resident, which was identified during an investigation. Resident 2, who was severely cognitively impaired and had a history of wandering and poor physical boundaries, was found in Resident 1's room by Staff D, a Nursing Assistant. Resident 2 was observed with one hand on Resident 1's clothed breast and the other hand under the blankets. Despite being told to stop, Resident 2 responded aggressively, necessitating the assistance of two additional staff members to separate the residents. Resident 1, also severely cognitively impaired, did not recall the incident and showed no changes in behavior following the event. The investigation revealed that Resident 2 had a history of wandering into other residents' rooms and could be aggressive, as noted by Staff C, a Registered Nurse. Resident 2's care plan required staff to monitor their behavior due to poor physical boundaries. However, on the day of the incident, Resident 2 was able to enter Resident 1's room and engage in inappropriate behavior without immediate intervention. The facility's failure to adequately monitor Resident 2 and prevent the incident placed Resident 1 and potentially other residents at risk for harm.
Inaccurate Staffing Data Submission to CMS
Penalty
Summary
The facility failed to ensure accurate submission of direct care staffing information to the Centers for Medicare and Medicaid Services (CMS) for Quarter 1 of 2024. This deficiency was identified through a review of the Payroll Based Journal (PBJ) submission, which is mandatory for reporting staffing information based on payroll data. The Certification and Survey Provider Enhanced Reports (CASPER) PBJ Staffing Data Report indicated that the facility reported staffing levels lower than the mandated requirements. During an interview, the Director of Nursing acknowledged that there were significant changes in the facility during this period, which may have led to incorrect reporting of hours. Additionally, the Operations Director later documented that there was unreported staffing data from external staffing agencies, supported by invoices from these agencies.
Facility Fails to Provide Palatable and Appetizing Food
Penalty
Summary
The facility failed to provide appetizing and palatable food for six out of seven sampled residents, which placed them at risk for decreased nutritional intake and a diminished quality of life. Observations and interviews revealed that residents consistently described the food as horrible, lacking taste, and sometimes unidentifiable. Specific complaints included meals that seemed incomplete, such as missing vegetables, and dishes that were unappetizing in appearance and taste, like mushy meat and lasagna without cheese or meat. Residents also reported that the food was often cold, and one resident described a meal where the meat was so fused to the bones that it was inedible. A test tray observation confirmed that the food was not colorful or appetizing, with temperatures outside acceptable parameters. The meal consisted of brown meatloaf, white mashed potatoes, white cauliflower, off-white banana cream pie, and a dark purple fruit-flavored drink, all of which were bland in taste. The Dietary Manager, when informed of the complaints, was unaware of any issues and suggested that a new cook might be hesitant to use available spices and seasonings. Despite claiming to taste the food during preparation, the manager's statements did not align with the residents' experiences.
Inadequate Infection Control and Prevention Measures
Penalty
Summary
The facility failed to implement enhanced barrier precautions (EBP) for four residents who were at risk of transmitting multi-drug resistant organisms (MDROs). Resident 69, who had a stage 4 pressure ulcer and an indwelling urinary catheter, was observed without proper signage or personal protective equipment (PPE) in place. Staff members were seen entering the room and providing care without wearing gowns, contrary to the care plan instructions. Similarly, Resident 1, who required EBP due to an indwelling catheter, was not provided with the necessary PPE during care activities, as staff only used gloves and not gowns. Resident 7, who had a feeding tube and required EBP, was also not provided with the appropriate PPE during medication administration and personal care. Staff members failed to wear gowns, and one staff member was unaware of the EBP requirements. Resident 73, who had a PICC line, was not given the necessary precautions during medication administration, as staff did not wear gowns despite the presence of EBP signage. These lapses in infection control practices placed residents at risk of cross-contamination and infection. The facility also failed to maintain its infection prevention policies and water management plan. The infection prevention policies had not been reviewed annually as required, and the water management plan was outdated and not specific to the facility. Additionally, hand hygiene practices were inadequate during wound care and medication administration, as staff did not perform hand hygiene when changing gloves. Furthermore, a resident with a positive tuberculosis skin test did not receive appropriate follow-up testing, indicating a lapse in tuberculosis surveillance.
Failure to Provide Vaccine Education and Documentation
Penalty
Summary
The facility failed to ensure that residents were provided with education regarding the risks and benefits of influenza and pneumococcal immunizations, and that they received the immunizations or did not receive them due to contraindications or refusals. This deficiency was identified for four out of five sampled residents. The facility's policies, revised in 2022 and 2023, required that residents and family members receive education about the benefits of these vaccines, and that residents be offered the vaccines unless contraindicated, already received, or refused. However, a review of resident records revealed a lack of documentation for education, consent, or refusal for the vaccines. Resident 36, with diagnoses including COPD and diabetes, had no documentation of receiving or being offered the vaccines. Resident 48, with morbid obesity and diabetes, was not documented as having received the vaccines, and there was no explanation for their ineligibility. Resident 66, with malnutrition and diabetes, and Resident 69, with diabetes and pressure ulcers, also had no documentation of receiving or being offered the vaccines. The Director of Nursing was unable to locate the necessary documentation, and the Infection Prevention staff acknowledged that the immunization process was incomplete and that no audits had been conducted to ensure compliance.
Deficiency in COVID-19 Vaccination Documentation and Education
Penalty
Summary
The facility failed to ensure that resident records included evidence of COVID-19 vaccination status, education regarding the vaccine, and documentation of vaccine offers, refusals, contraindications, or administrations for four out of five sampled residents. This deficiency was identified during a review of resident records, which showed no documentation of COVID-19 vaccination or booster doses, complete immunization history, or education on the risks and benefits of the vaccine for Residents 36, 48, 66, and 69. These residents had various diagnoses, including chronic obstructive pulmonary disease, diabetes, morbid obesity, malnutrition, and pressure ulcers. Interviews with facility staff revealed that the Director of Nursing was unable to locate the necessary documentation for the residents in question. Additionally, the Registered Nurse responsible for Infection Prevention acknowledged that the facility had been working on the immunization process but had not been conducting record audits to ensure vaccines were offered or education was provided. The nurse also mentioned that they had been handling both Infection Prevention and Resident Care Manager duties, which hindered their ability to follow up on the vaccination process.
Dignity Issues in Resident Care
Penalty
Summary
The facility failed to provide care in a dignified manner for three residents, leading to a deficiency in resident rights. Resident 4, who had a traumatic brain injury and spastic hemiplegia, was referred to as a 'feeder' by staff, which was considered undignified. During a meal observation, a staff member instructed others to serve residents needing assistance last, using the term 'feeders.' Interviews with staff revealed discomfort with this terminology, indicating a lack of awareness about appropriate language to use for residents requiring feeding assistance. Resident 58, who had an indwelling urinary catheter due to benign prostatic hyperplasia and neurogenic bladder, was observed with an uncovered urine collection bag during a meal. The resident expressed discomfort with the visibility of the urine and mentioned that the cover for the bag was sent to the laundry, leaving them without a replacement. This lack of privacy was noted as a dignity issue, as the resident felt exposed without the cover. Resident 67, diagnosed with prostate cancer and chronic urinary retention, also used a urinary catheter. Observations showed the urine collection bag was frequently left uncovered and placed on the floor. Staff interviews confirmed that the bag should have been stored in a privacy bag to maintain dignity. The Director of Nursing acknowledged this oversight, recognizing it as a dignity issue, as the resident often transferred themselves, leaving the catheter bag exposed.
Failure to Investigate Resident Fall
Penalty
Summary
The facility failed to investigate a fall involving a resident, identified as Resident 285, who required partial to moderate assistance with activities of daily living. According to the facility's policy on Fall Response and Management, nursing staff were required to complete a post-fall investigation, notify the physician, and communicate the event and any intervention changes to the staff. However, after Resident 285 fell on 08/02/2024 while being assisted to the toilet, these procedures were not followed. The fall was not documented in the accident and injury log, and the physician's assistant was not notified until five days later. Interviews with staff revealed discrepancies in the recognition and reporting of the fall. Staff D, a Nursing Assistant, witnessed the incident but did not classify it as a fall since the resident did not hit the ground. Staff E, an LPN, was unaware of any falls since the resident's admission and noted that an x-ray was conducted due to pain complaints, which showed no injury. The Director of Nursing later confirmed that the incident should have been reported and investigated as a fall, as it involved an unintentional change in position.
Failure to Complete Accurate and Timely PASARR
Penalty
Summary
The facility failed to ensure that a Pre-Admission Screening and Resident Review (PASARR) was completed accurately and prior to the admission of a resident with a mental health diagnosis. Specifically, Resident 23 was admitted with a diagnosis of paranoid personality disorder, but the PASARR completed by a social worker four days after admission did not indicate any serious mental health indicators, and the box for personality disorders was unchecked. Furthermore, when additional mental health diagnoses of anxiety and depression were added to Resident 23's record, the facility did not complete a new PASARR to assess the need for specialized mental health services. This oversight was confirmed during an interview with the Director of Nursing, who acknowledged the requirement for PASARR completion prior to admission and updates when changes occur.
Failure to Implement Care Plan Interventions for Residents
Penalty
Summary
The facility failed to implement care plan interventions for three residents, leading to deficiencies in their care. Resident 1, who was at risk for choking, was observed eating without the required supervision and assistance, despite care plan instructions to monitor and cue the resident for safety. Staff members were unaware of the need for supervision, indicating a lack of adherence to the care plan. Resident 4, diagnosed with hemiplegia and difficulty swallowing, was supposed to be assisted out of bed for meals in the dining room or supervised in the hallway. However, the resident was repeatedly observed eating in bed without the necessary supervision, contrary to the care plan. Staff were uncertain about the reasons for the dining room requirement and did not document refusals to get out of bed, showing a gap in following care plan directives. Resident 283, who had ulcers on their lower extremity, required offloading of pressure from their heels as per the care plan. Observations showed the resident's heel resting on the mattress without offloading, and staff acknowledged the need for reminders to ensure compliance. The Director of Nursing confirmed the necessity of offloading for residents with wounds, highlighting the failure to implement this intervention.
Incomplete Discharge Summary for Resident
Penalty
Summary
The facility failed to complete a discharge summary for a resident, which included a recapitulation of the resident's stay, as required by regulations. This deficiency was identified for a resident who was cognitively intact and required assistance with activities of daily living. The resident was admitted for physical and occupational therapy following a urinary tract infection and sepsis. Upon discharge to another facility, the discharge summary completed by a Physician Assistant did not specify the destination or provide a detailed account of the care and services received during the resident's stay. The Director of Nursing confirmed that a recapitulation of stay/discharge summary is necessary when a resident is discharged.
Inconsistent Bathing and Grooming in LTC Facility
Penalty
Summary
The facility failed to consistently provide necessary bathing and grooming assistance to three residents, leading to deficiencies in personal hygiene and care. Resident 1, diagnosed with paraplegia and dependent on staff for activities of daily living, was observed with greasy hair and facial stubble, indicating a lack of regular bathing and shaving. Despite having a care plan that required bathing up to twice a week, records showed infrequent bathing, with significant gaps between documented bathing dates. Interviews with staff revealed challenges in completing bathing tasks due to time constraints and the absence of a dedicated bath team. Resident 43, who required moderate assistance for bathing, reported dissatisfaction with the frequency of their baths, which were supposed to occur twice weekly. Documentation showed that the resident was bathed only a few times over several months, far less than the scheduled frequency. Staff interviews confirmed the difficulty in adhering to the bathing schedule due to the time required for each resident and the competing demands of other care tasks. Resident 5, with diagnoses including obesity and candidiasis, also experienced irregular bathing despite a care plan specifying showers twice a week. The resident kept a personal record of their bathing schedule, which highlighted significant lapses between showers. Staff interviews acknowledged the issue, noting that missed showers were supposed to be made up by the next shift, but this was not consistently happening. The lack of regular bathing was recognized as a concern for maintaining skin health and preventing infections.
Inadequate Activity Program for Resident
Penalty
Summary
The facility failed to provide an ongoing program of activities that met the interests of a resident with moderate cognitive impairment, dementia, and depression. The resident expressed interest in activities such as books, music, animals, religion, spending time outdoors, and group activities. However, the resident's participation in activities was limited, with records showing involvement in arts and crafts twice, music once, an outside activity, and an entertainment activity once. Observations revealed the resident was often not engaged in activities, and staff interviews confirmed a lack of sufficient activities on the unit. Staffing issues contributed to the deficiency, as the Activity Director mentioned being short-staffed and having difficulty retaining an activities assistant. Staff members, including a Nursing Assistant and a Registered Nurse, acknowledged the lack of activities and the need for more hands-on and stimulating options for residents. The Director of Nursing also recognized the need for growth in the activities program and was in the process of initiating spiritual services. Despite the resident's expressed interests, the facility did not adequately provide activities that aligned with those interests, leading to the resident experiencing boredom and a diminished quality of life.
Inconsistent Pressure Ulcer Care for Resident
Penalty
Summary
The facility failed to consistently implement pressure-relieving interventions for a resident with a history of pressure ulcers, specifically on the left heel. The resident, who had a traumatic brain injury, hemiplegia, and a Stage 3 pressure ulcer on the left heel, was observed multiple times without the necessary protective boot or pillows to elevate the heels while in bed. Despite having a care plan that included the use of an air overlay mattress, repositioning every 2-3 hours, and floating heels, these interventions were not consistently applied, leading to the reopening of a wound on the resident's left heel. Observations and interviews revealed that while the resident wore a foam boot when in a wheelchair, staff often needed reminders to elevate the resident's heels or apply the boot when the resident was in bed. Staff acknowledged the inconsistency in following the care plan, noting that the resident sometimes kicked pillows away but did not remove the foam boot. The lack of consistent application of pressure-relieving measures contributed to the deterioration of the resident's heel condition, as evidenced by the presence of a wound covered with black eschar and subsequent observations of a dark red area with drainage.
Failure in Dialysis Communication and Coordination
Penalty
Summary
The facility failed to maintain consistent and ongoing communication and collaboration with the dialysis facility for a resident who required dialysis services. Resident 65, who had kidney disease and diabetes, was admitted to the facility and required dialysis treatment. An agreement between the facility and the dialysis center stipulated that care for residents receiving dialysis should be coordinated to ensure continuity of care and the resident's well-being. However, the facility did not adhere to this agreement, as evidenced by the absence of dialysis communication forms on multiple occasions in July 2024. These forms were meant to be sent with the resident to the dialysis clinic and returned with them to ensure any necessary changes to the resident's care could be processed. Interviews with facility staff revealed that the communication forms were not consistently returned with the resident, and there was a lack of follow-up when forms were missing. Staff E, a Registered Nurse, acknowledged that the forms did not always return with the resident and emphasized the importance of contacting the clinic if the forms were not returned. Staff B, the Director of Nursing, confirmed that the facility used these forms for communication with the dialysis clinic and that they should have been sent and received consistently. The failure to maintain this communication placed the resident at risk for unmet care needs and medical complications.
Failure to Ensure Timely Physician Visits for Residents
Penalty
Summary
The facility failed to ensure that residents were seen by a physician within the required timeframes, affecting two of the eight sampled residents. Resident 59, who had kidney disease and chronic urinary tract infections, expressed concerns about not having seen a physician despite requesting to do so. The last documented physician visit for Resident 59 was on 06/12/2024, with a significant gap since the previous visit on 09/18/2023. The facility's records indicated that a physician's assistant had seen the resident multiple times, but there was no documentation of a physician visit within the required three-month interval. Resident 5, who had generalized anxiety disorder and insomnia, was also affected by the facility's failure to adhere to the required physician visit schedule. The resident preferred being seen by a physician assistant and reported issues with medication changes made by a physician. The review of records showed that Resident 5 had not been seen by a physician within the required 90-day interval between 10/18/2023 and 01/31/2024. Interviews with staff revealed confusion about the required frequency of physician visits, with discrepancies in understanding whether visits should occur every 60 or 90 days.
Failure to Conduct Annual Performance Reviews for Nursing Assistants
Penalty
Summary
The facility failed to complete a yearly performance review for three sampled nursing assistants, identified as AA, BB, and CC, as required by regulations. Staff AA was hired on May 3, 2022, and there was no documentation of an annual performance evaluation. Staff BB and CC were hired on July 1, 2023, and July 13, 2023, respectively, and similarly lacked documentation of their annual performance evaluations. This oversight was confirmed through an email correspondence with the Director of Nursing, who acknowledged that no annual performance reviews had been completed for these staff members. This failure placed residents at risk of receiving care from inadequately trained staff.
Failure to Provide Behavioral Health Services
Penalty
Summary
The facility failed to provide necessary behavioral health services for two residents, leading to a deficiency in care. Resident 7, who was admitted with severe mental health conditions including psychosis and schizoaffective bipolar disorder, was not provided with adequate behavioral health services. Despite a PASARR level II assessment indicating the need for specialized services, the resident's care plan lacked specific goals or interventions for their behavioral health needs. The resident was only seen once by a Psychiatric Nurse Practitioner, and there were no further documented behavioral health visits, leaving the resident without the necessary support for their mental health conditions. Resident 36, diagnosed with major depressive disorder and borderline personality disorder, also did not receive appropriate behavioral health services. The resident's care plan was incomplete, lacking specific interventions for their depression and anxiety. Despite a provider's order for psychiatric evaluation and treatment, there was no documentation of mental health services being provided by Social Services. The resident expressed a need for increased antidepressant dosage and counseling, but these needs were not addressed, and no appointments were made for counseling. Interviews with staff revealed a lack of awareness and follow-through regarding the residents' behavioral health needs. The Director of Nursing acknowledged that PASARR level II recommendations were not implemented due to a change in social workers and the absence of a dedicated behavioral health provider. The facility's current provider group was unable to offer comprehensive behavioral health services, resulting in unmet needs for the residents.
Medication Error Rate Exceeds Acceptable Threshold
Penalty
Summary
The facility failed to maintain a medication error rate of less than five percent, as evidenced by five medication errors identified for one resident during 40 medication opportunities, resulting in an error rate of 12.5 percent. During an observation, a Licensed Practical Nurse (LPN) administered medications to a resident, including Mesalamine and Azelastine nasal spray, but failed to administer Acetylcysteine, Spiriva Respimat, and Ipratropium-Albuterol. The incorrect doses of Azelastine and Mesalamine, along with the omission of the other medications, constituted medication errors. The LPN acknowledged administering the incorrect dose of Azelastine and Mesalamine and omitting the other medications. The LPN stated that the resident preferred two sprays of Azelastine and was unaware of the incorrect Mesalamine dose at the time of administration. The LPN also mentioned that the omitted medications were out of stock and had been ordered from the pharmacy the previous week but had not yet been delivered.
Medication Management and Security Deficiencies
Penalty
Summary
The facility failed to ensure proper management of medications and medical supplies, as observed during a recertification survey. In one of the medication rooms inspected, expired medications were not disposed of, and multi-dose vials were not dated when opened. Specifically, a multi-dose vial of tuberculin serum was found without an opening date, and several expired items, including needles, Heparin flushes, sodium bicarbonate tablets, and B-complex multi-vitamins, were present. Additionally, there were no current logs for refrigerator temperatures for August 2024, and previous months' logs had multiple omissions. Staff O, an LPN, acknowledged the lack of dating on the multi-dose vials and disposed of the expired medications but was unsure about who was responsible for maintaining the medication room and logging refrigerator temperatures. Furthermore, the surveyors found unsecured insulin needles in a closed nursing station on a unit that had been shut down since May 2024. The needles were stored in unlocked cabinets, posing a risk of needlestick injuries. Although there were no residents in the vicinity at the time of the initial observation, residents from an assisted living facility were later seen walking past the unsecured area. Staff B, the Director of Nursing, was unaware of the unsecured needles and emphasized the importance of securing them to prevent resident access. The maintenance staff was notified, and the unsecured needles were subsequently removed.
Dietary Staff Lacked Valid Food Worker Card
Penalty
Summary
The facility failed to ensure that dietary staff had the required qualifications, specifically a current Washington State Food Worker Card, for one of the twelve dietary staff reviewed. Staff EE, who was hired on June 21, 2024, did not possess the necessary state-approved food worker card. Instead, Staff EE had a certificate from Food Handler Solutions, dated July 4, 2024, which was not recognized as valid in Washington State. This certificate was intended only for personal development and preparation for state-provided training. Staff EE worked in the kitchen from August 1st to 4th and August 7th to 11th, without the appropriate credentials. During an interview, the Human Resources Manager, Staff P, admitted to verifying food handler's cards by obtaining the receipt and confirmation number but was unaware that the Food Handler Solutions Certificate was not valid in Washington State. Consequently, Staff EE was not allowed to continue working until obtaining the appropriate credential through the Washington State Department of Health.
Failure to Perform Hand Hygiene During Meal Service
Penalty
Summary
The facility failed to ensure proper hand hygiene was performed by a nursing assistant, identified as Staff JJ, during meal service, which was observed during one of four meals. On multiple occasions, Staff JJ was seen delivering meal trays to residents without performing hand hygiene between tasks. Specifically, Staff JJ was observed pushing a resident in a wheelchair into the dining room and then delivering a meal tray to another resident, cutting a sandwich, and refilling a coffee cup without washing hands. This pattern continued as Staff JJ handled meal trays for additional residents, unwrapping food items, pouring water, and placing utensils without performing hand hygiene. Further observations revealed that Staff JJ delivered a meal tray to a resident in their room, assisted the resident to sit up, and then proceeded to another room with a meal tray without washing hands. Additionally, Staff JJ was seen assisting a resident with eating by spooning food into their mouth without prior hand hygiene. In an interview, Staff JJ acknowledged the need for hand hygiene between passing meal trays but admitted to forgetting due to being busy. The infection preventionist confirmed that hand hygiene should be performed when entering or exiting a resident's room and between handling meal trays.
Deficiencies in Medication Management for Three Residents
Penalty
Summary
The facility failed to provide necessary pharmacy services to meet the needs of three residents, leading to deficiencies in medication management. Resident 1, diagnosed with anemia, was not administered Procrit injections as ordered due to the facility's failure to complete necessary pharmacy forms, resulting in the resident's family having to arrange for the medication to be administered externally. The facility's Director of Nursing (DNS) claimed that the medication was not refused due to cost, but there was no follow-up with the pharmacy once the resident's representative took over the medication administration. Resident 2, who has diabetes, did not receive their prescribed long-acting insulin, glargine, from the time of admission. The medication was not available in the facility, and there was no documentation of follow-up with the pharmacy or notification to the provider about the unavailability of the medication. The DNS was unaware of the missing medication and acknowledged that the pharmacy should have sent it with the other admission medications. Resident 3, diagnosed with Multiple Sclerosis, did not receive their prescribed tizanidine and L-Lysine due to a lack of communication and follow-up between the facility and the pharmacy. The DNS was not aware of the discontinuation of these medications and noted that the orders were discontinued by nursing staff who were not present. The facility's central supply did not stock L-Lysine, and it was not requested from the pharmacy, leading to the resident not receiving the supplement as ordered.
Failure in Medication Management for a Resident
Penalty
Summary
The facility failed to adhere to professional standards of practice in medication management for a resident, leading to the discontinuation of prescribed medications without proper authorization. Specifically, the resident was not provided with the prescribed muscle relaxant tizanidine from July 3 to July 7, and the order was discontinued on July 8. Similarly, the over-the-counter supplement L-Lysine was not administered from July 3 to July 8, with the order discontinued on July 9. There was no documentation in the resident's July 2024 Medication Administration Record (MAR) or progress notes regarding these medications, and a provider note dated July 8 did not list any medication changes. Interviews with facility staff revealed a lack of awareness and documentation regarding the discontinuation of these medications. The Director of Nursing (Staff A) was unaware of the circumstances and confirmed that the orders were discontinued by nursing staff without electronic signatures from an authorized health care practitioner. Medical Records staff (Staff E) confirmed that all current provider orders were scanned into the electronic records, and no unscanned orders existed for the resident. A signed provider order dated July 11 did not include the tizanidine and L-Lysine, indicating a lapse in following proper procedures for medication management.
Incomplete Medical Records for Resident Receiving Procrit
Penalty
Summary
The facility failed to maintain complete and accurate medical records for a resident, specifically regarding the administration of Procrit, an injectable medication for anemia treatment. The resident's Medication Administration Record (MAR) for July 2024 indicated an order for Procrit to be administered once daily every 14 days, starting on July 11, 2024. However, the MAR showed that the resident was not receiving the medication. A progress note from July 9, 2024, mentioned that the resident's family would provide the Procrit, but there were no subsequent notes confirming that the medication was administered, either at the facility or during external provider visits. Interviews with facility staff revealed that the resident received Procrit at their nephrologist's office, but there was no documentation in the resident's electronic medical record regarding the transport to the external provider or the treatment received. The Director of Nursing confirmed the lack of records from the nephrologist's office and stated that staff would have to manually enter such information into the resident's record. The Medical Records staff also confirmed that they had not been instructed to follow up or add any records to reflect the care and services provided during the resident's external visits.
Failure to Provide Appropriate Diet Texture
Penalty
Summary
The facility failed to provide a resident with the appropriate diet texture, leading to a choking hazard. The resident, who had a history of dementia, stroke, and aspiration, was on a mechanically altered diet as per physician orders. Despite the resident's diet being downgraded to L3: Advanced texture, which excludes hard, crunchy, and sticky foods, they were served a meal that included tater tots, a food not suitable for their dietary needs. This resulted in the resident coughing and gagging, requiring staff intervention to clear their airway. The incident occurred because the dietary staff did not adhere to the diet spread sheet, which clearly outlined the necessary substitutions for residents on an L3 diet. The cook and nursing assistant involved were not fully aware of the resident's dietary restrictions, leading to the inappropriate meal being served. The dietary manager or cook in charge was responsible for posting the diet spread sheet daily, but inconsistencies in the spreadsheet's accuracy led to staff not consistently checking it. This oversight placed the resident at risk for decreased nutritional intake and serious injury.
Failure to Provide Effective CPR and Ensure Staff Certification
Penalty
Summary
The facility failed to ensure staff provided CPR in accordance with national standards for effective CPR to a resident with a Full Code status. The resident was found on the floor by a nursing assistant and was still breathing at that time. However, the resident stopped breathing and no longer had a pulse by the time additional staff arrived. Instead of performing CPR on the firm surface of the floor, the staff moved the resident to the bed, which is a soft surface, and began CPR without a backboard. This action was against the American Heart Association (AHA) guidelines, which recommend performing CPR on a firm surface. The facility's emergency cart, which contained a backboard, was not utilized during the incident. Staff B, who was involved in the incident, did not provide a clear reason for moving the resident to the bed before starting CPR. Additionally, Staff C, who assisted, was under the impression that the resident was already deceased and was being moved for post-mortem care. The facility also failed to ensure that two staff members, Staff B and Staff D, had current CPR certification credentials. Staff B's employee file did not contain a CPR card, and although Staff B verbally reported having a current CPR card, it was not provided to the facility. Similarly, Staff D's employee file did not contain a CPR card, and there was no documentation to confirm attendance at a CPR class provided by the facility. The Director of Nursing acknowledged these deficiencies and noted that the facility had identified concerns related to the provision of effective CPR during their investigation.
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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