Spokane Veterans Home
Inspection history, citations, penalties and survey trends for this long-term care facility in Spokane, Washington.
- Location
- 222 East Fifth, Spokane, Washington 99202
- CMS Provider Number
- 505509
- Inspections on file
- 36
- Latest survey
- February 20, 2026
- Citations (last 12 mo.)
- 1
Citation history
Health deficiencies cited at Spokane Veterans Home during CMS and state inspections, most recent first.
A resident with chronic back pain was prescribed Norco 10/325 mg, but multiple RNs signed out doses on the narcotic log and documented administration that was not supported by the resident’s recollection or by a subsequent urine drug screen, which was negative despite lab confirmation that the drug should have been detectable. A pouch containing Norco tablets was found on the floor near the nurse’s station, and review of the MAR and narcotic records showed missing documentation for at least one signed-out dose, leading to the determination that narcotic diversion had occurred and that the resident did not receive all prescribed pain medication.
The facility failed to maintain a homelike environment for three residents, with issues such as damaged walls and a protruding screw. Observations revealed that the walls in two residents' rooms had gouges and peeled paint, while another resident's room had a protruding screw. Staff interviews indicated a lack of awareness and no work orders for repairs, compromising the residents' safety and comfort.
The facility failed to involve residents or their representatives in care planning, as evidenced by two residents who did not participate in care conferences. One resident, cognitively intact with complex medical conditions, had not been involved in a team care plan meeting for over a year. Another resident with severe cognitive impairment had not participated in a care planning conference since August 2023. An audit revealed that 84 out of 97 residents had not participated in care planning conferences, contrary to facility policy.
The facility failed to store and handle food according to professional standards, with expired and undated food items found in storage areas. Sanitary practices were inadequate, as a staff member did not perform hand hygiene after wiping their nose, and the dishwasher did not consistently reach the required temperature. Additionally, incomplete cleaning schedules and lack of hair coverings for staff handling food were observed, posing risks of food-borne illnesses.
A facility failed to respect a resident's refusal of a bed position change alarm, despite the resident being cognitively intact and clearly expressing their wishes. The resident removed and damaged the alarm on multiple occasions, yet staff continued its use. Observations confirmed the alarm's presence, and staff interviews revealed uncertainty in handling such refusals.
A facility failed to document and follow up on a resident's advance directives, despite indications of the resident's impaired cognition and lack of knowledge about their healthcare Power of Attorney. The Social Services Director acknowledged the oversight, which placed the resident at risk of not having their end-of-life care preferences respected.
The facility failed to implement care plan interventions for a resident requiring aspiration precautions, leading to non-compliance with dietary and positioning orders. Additionally, another resident's care plan, which required care in pairs due to behavioral issues, was not followed, as care was provided by a single staff member. These deficiencies highlight a lack of adherence to established care plans.
The facility failed to address risks associated with SUD and falls for residents. A resident with a history of alcohol abuse was admitted without proper interventions in their care plan. Another resident consumed marijuana edibles brought by their spouse, leading to an elevated heart rate, but their care plan lacked documentation of alcohol abuse history. Additionally, residents at risk of falls were not properly monitored, with one resident's safety alarm failing to sound and another's care plan missing necessary interventions.
A resident with a history of stroke and moderate cognitive impairment was frequently incontinent of urine, yet the facility failed to implement a toileting program or other interventions to address the issue. Despite the resident's care plan indicating the need for assistance and a urinal at the bedside, these measures were not effectively executed, leading to continued incontinence and moisture-associated skin damage. Staff interviews revealed a lack of comprehensive assessment and intervention for the resident's incontinence.
A resident with diabetes did not receive two doses of Ozempic as ordered due to the medication being unavailable, and the provider was not notified timely. The facility failed to authorize an early refill for this specialty medication, leading to missed doses and potential health risks.
The facility failed to serve meals at palatable temperatures, affecting a resident with obesity, high blood pressure, and diabetes. The resident reported that meals in their room were sometimes cold, unlike those in the dining room. Kitchen logs showed missing temperature records for cold foods, and a lunch meal observation found food temperatures below acceptable levels. The Food Supervisor emphasized the importance of checking food temperatures for safety.
A facility failed to ensure accurate documentation of consents for psychotropic medications for a resident with Parkinson's, depression, and anxiety. Consents for medications like Quetiapine and Lorazepam were not documented as late entries, and some were not completed before resuming medication. Staff interviews confirmed the need for consents before administration and when medications are reordered, but this was not adhered to, resulting in a deficiency.
The facility failed to follow infection control practices during meal service, with staff not performing hand hygiene between handling meal trays and after touching contaminated surfaces. Additionally, Enhanced Barrier Precautions were not followed for a resident with an indwelling urinary catheter, as staff did not wear gowns during high-contact care activities. These lapses in protocol increased the risk of infection spread among residents.
A resident's representative reported concerns about respiratory equipment management, but the facility failed to document these as formal grievances or provide timely follow-up. Staff believed the issues were resolved informally, leading to a lack of documentation in the grievance logs.
A resident with dementia and a history of wandering eloped from the facility despite having a WanderGuard device. The alarm was triggered, but staff did not investigate further as the resident was not visible. The facility's policy lacked specific instructions for alarm response, and a malfunctioning door lock contributed to the incident.
A resident was transferred to the hospital due to a foot fracture, but the facility failed to notify the resident's representative, who had medical power of attorney. The resident, who was somewhat confused, returned to their former residence after hospitalization and was found with injuries from falls. Staff interviews revealed that the notification was delayed, and the facility had documentation of the power of attorney.
The facility failed to follow up with a physician's order to advance a catheter and obtain an order to increase the oxygen rate for a resident with benign prostatic hyperplasia and COPD. Despite instructions from the urology clinic and multiple instances of administering oxygen above the ordered amount, necessary follow-up actions were not taken, and the catheter was not advanced.
A resident with urinary retention and aspiration pneumonia was discharged without a recapitulation summary of their stay. The discharge packet included a referral to a wound care provider and a list of prescribed medications, but lacked the required summary. The Resident Care Manager confirmed the omission.
A facility failed to monitor a resident with cirrhosis, ascites, and general edema for fluid intake as per physician orders. Despite fluid restrictions, the resident had access to a water pitcher and ice chips, and staff did not consistently document fluid intake, leading to significant weight fluctuations and potential fluid retention issues.
A resident with end-stage renal disease, atrial fibrillation, and Parkinson's disease did not receive scheduled medications on dialysis days. The omission was documented by a Registered Nurse, who noted the resident was out of the facility and did not send the medications with the resident. The issue was not discussed with the provider, putting the resident at risk for adverse events.
The facility failed to secure controlled medications in permanently affixed containers within medication refrigerators. Controlled medications were found in open plastic baskets and on shelves inside the refrigerator doors, not separated from other medications. Staff interviews revealed a lack of awareness and compliance with the requirement to store narcotic medications securely.
The facility failed to ensure dietary staff had current Food Worker Cards, with one staff member working without a valid card and another with an expired card. The Dietary Manager confirmed the absence of a renewal process, risking unsafe food handling practices.
The facility failed to ensure sanitary food preparation and service as a staff member with a beard was observed not wearing a beard covering on two occasions. The staff member was unaware of the requirement and availability of beard covers. The Dietary Manager emphasized the importance of beard coverings to prevent food contamination.
The facility failed to ensure appropriate hand hygiene during meal service, wound care, and personal care, placing residents at risk for infections. Staff members did not follow hand hygiene protocols, as confirmed by interviews with the infection control nurse.
The facility failed to ensure that a resident with COPD, dementia, and a history of falls had their call light within reach, as observed multiple times over several days. The DON acknowledged the need for call lights to be accessible for resident safety.
The facility failed to ensure catheter care was provided in a dignified manner for a resident with a neurogenic bladder. The urine collection bag was observed multiple times without a privacy bag, and the catheter was emptied without ensuring privacy by pulling the curtain. Staff interviews confirmed that proper procedures were not followed.
The facility failed to ensure that the RD completed comprehensive nutritional assessments for two residents. One resident had a significant gap in nutritional monitoring, and another had an incomplete Admission Dietary Assessment and no comprehensive assessments since admission. Staff acknowledged the lapse in required assessments.
Narcotic Diversion and Failure to Administer Prescribed Pain Medication
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a prescribed narcotic medication (Norco 10/325 mg) was administered to the resident for whom it was ordered and not diverted for other use. A clear pouch containing two Norco tablets was found on the floor at the second-floor nurse’s station by the Administrator at 7:00 AM, and review of all residents’ medication orders showed that only one resident in the facility had an active prescription for this medication. Review of the narcotic logbook showed that a registered nurse had signed out doses of Norco for this resident during the night, including one dose at 11:30 PM and another at 5:00 AM. The Medication Administration Record documented that the 11:30 PM dose was given, but there was no documentation that the 5:00 AM dose was administered. When interviewed, the nurse stated the medication had been given and could not explain the pouch found on the floor. The resident, who had chronic back pain, reported not recalling receiving pain medication and not being awakened during the night for care or medication. Further review of records identified that two additional registered nurses had also signed out Norco for the same resident and documented administration over several days. A urine drug screen was ordered for the resident to check for the presence of narcotic medication, and the result was negative. The facility consulted with the laboratory and was informed that Norco would be detectable in urine within one to two days of administration. After additional consultation with the resident’s provider, it was determined that narcotic diversion had occurred. The facility’s investigation substantiated that the narcotic medication signed out for this resident had not been properly administered as ordered and had instead been diverted by nursing staff.
Failure to Maintain a Homelike Environment
Penalty
Summary
The facility failed to maintain a clean, comfortable, safe, and homelike environment for three residents, leading to a deficiency in the quality of care provided. Resident 35's room had a 2 feet by 2 feet section of peeled and scraped paint on the wall next to their bed, likely caused by the bed's upper rail scraping the wall. This damage was observed multiple times over several days, with a cloth band-aid stuck over one of the gouges. Resident 58's room had gouges in the wall next to their bed, with some gouges deep into the drywall, exposing the chalky white material beneath the dark gray paint. These gouges were also observed on multiple occasions. Neither resident could verbalize how long the damage had been present, and staff interviews revealed that no work orders had been submitted for these repairs. Resident 92's room had multiple gouges in the drywall and a protruding screw within reach, which the resident stated did not feel homelike. The screw was observed to be pushed into the wall but not flush, remaining a safety concern. Staff interviews indicated that maintenance staff were unaware of the need for repairs in these rooms, and no work orders had been submitted. The Maintenance Director acknowledged the importance of a homelike environment and recognized the safety concern posed by the protruding screw.
Failure to Involve Residents in Care Planning
Penalty
Summary
The facility failed to ensure that residents or their representatives were provided the opportunity to participate in care planning, as evidenced by the cases of two residents whose medical records were reviewed. Resident 29, who was cognitively intact and had complex medical conditions including heart failure and diabetes, reported that they had not participated in a team care plan meeting since January 2024. Instead, staff would bring a copy of the care plan and hang it in the closet without involving the resident in the process. The facility's records confirmed that the last care conference with Resident 29's participation was held over a year ago. Similarly, Resident 35, who had severe cognitive impairment and an appointed guardian, had not participated in a care planning conference since August 2023. An audit conducted by the Director of Nursing Services revealed that 84 out of 97 residents had not participated in care planning conferences. The facility's policy required that residents and their families be invited to participate in care planning conferences, but documentation showed that 47 out of 78 residents or their representatives were not offered this opportunity. The Social Services Director acknowledged the inconsistency in holding care planning conferences and stated that they were working on addressing the issue.
Deficiencies in Food Storage and Sanitary Practices
Penalty
Summary
The facility failed to adhere to professional standards for food service safety, as evidenced by the improper storage and handling of food items. During an inspection, it was observed that the dry storage area contained expired food items, including containers of grits and bottles of honey, as well as an opened box of spice mix cake without an open or expiration date. In the refrigerator, there was brown and wilted celery and mushrooms without a received or use-by date. The freezer contained multiple opened food items, such as blueberries, cinnamon rolls, and various other foods, all lacking open or expiration dates. Staff acknowledged the importance of dating opened food items and discarding expired products to prevent illness. Sanitary practices were also found lacking, as observed during a tray line operation where a staff member failed to perform hand hygiene after wiping their nose on their shirt and forearm. Additionally, the facility's dishwasher logs indicated that the final rinse temperature was below the required level on numerous occasions, which is necessary to kill germs. The kitchen cleaning schedules were incomplete, with missing documentation for daily cleaning. Furthermore, a staff member was observed handling food without wearing the required hair coverings, which is essential for maintaining sanitary conditions. These deficiencies collectively placed residents at risk for food-borne illnesses and unsanitary food service conditions.
Failure to Honor Resident's Refusal of Safety Device
Penalty
Summary
The facility failed to honor and facilitate resident self-determination by not respecting the choices and refusals of Resident 94, who was cognitively intact and able to clearly verbalize their needs. Despite having an active order for the use of a wheelchair and bed position change alarms, Resident 94 expressed clear refusals of the bed alarm on multiple occasions. On 02/13/2025, Resident 94 removed the position change alarm from their bed and tore the wire, stating they did not want it on their bed. Again, on 02/21/2025, Resident 94 broke the bed alarm pad when it beeped, indicating their refusal of the device. However, staff continued to use the bed position change alarm despite these documented refusals. Observations on 03/17/2025 and 03/18/2025 confirmed the continued presence of the position change alarm on Resident 94's bed. Interviews with staff revealed a lack of clarity and adherence to the facility's process for handling resident refusals of safety devices. Staff P, a Nursing Assistant, acknowledged the use of alarms and stated they would notify the Resident Care Manager (RCM) if a resident refused an alarm. Staff W, an LPN, was unsure of the process for residents with dementia refusing alarms and would refer to the RCM. Staff F, the RCM, confirmed awareness of Resident 94's refusals and stated they would assess and remove alarms causing distress, yet the alarms remained in use.
Failure to Document and Follow Up on Advance Directives
Penalty
Summary
The facility failed to properly document and follow up on the advance directives for a resident with moderately impaired cognition. Upon admission, the resident, along with family and significant others, participated in the assessment and goal setting of care. However, during the admission process, questions regarding the resident's healthcare Power of Attorney (POA) and advance directives were left unanswered, with notes indicating the resident's lack of knowledge or memory about these matters. Despite these indications, there was no documented follow-up by the facility to ascertain the resident's wishes regarding advance directives. The deficiency was further highlighted by the lack of documentation in the progress notes and care plan regarding the resident's advance directives status. The Social Services Director acknowledged the oversight and confirmed that no follow-up had been conducted to determine the resident's advance directives status. This lapse in documentation and follow-up placed the resident at risk of not having their end-of-life care preferences respected, as the facility did not ensure the necessary information was obtained and recorded.
Failure to Implement Care Plans for Aspiration Precautions and Behavioral Interventions
Penalty
Summary
The facility failed to develop and implement care plan interventions for aspiration precautions for Resident 81, who had a history of aspiration pneumonia and required a mechanically altered therapeutic diet. Despite hospital discharge orders specifying aspiration precautions, such as maintaining an upright position during oral intake and elevating the head of the bed post-meal, these were not included in the care plan. Observations showed Resident 81 eating while nearly flat in bed, and staff interviews revealed a lack of awareness and compliance with the aspiration precautions, indicating a failure to communicate and implement necessary interventions. Additionally, the facility did not adhere to care plan interventions for Resident 91, who required care in pairs due to behavioral issues and accusations towards staff. Observations noted that care was provided by a single staff member, contrary to the care plan's instructions. Interviews with staff confirmed the necessity of two-person care to protect both the resident and staff from allegations, yet this was not consistently followed, highlighting a failure to implement the care plan as intended.
Failure to Address SUD and Fall Risks
Penalty
Summary
The facility failed to identify, evaluate, and analyze risks, and implement safety interventions for residents with substance use disorder (SUD) and those at risk of falls. Resident 95, who had a significant history of alcohol abuse, was admitted without proper documentation or interventions in their care plan to address potential risks associated with their SUD. Despite showing exit-seeking behaviors and being identified as a high risk to wander, the care plan lacked interventions related to their alcohol abuse history. Resident 2, who had a history of alcohol and marijuana use, consumed an edible marijuana product brought in by their spouse, resulting in an elevated heart rate. The facility held a care conference and educated the resident and their spouse about the prohibition of cannabis on the premises. However, the care plan did not document Resident 2's history of alcohol abuse, and there was no assessment for potential risks associated with their SUD. The facility also failed to ensure proper monitoring and intervention for residents at risk of falls. Resident 13, with a history of falls, had an incident where they slid out of bed, but the intervention to prevent this was not added to their care plan. Similarly, Resident 92, who had severe cognitive impairments and a history of falls, was found on the floor after their safety alarm failed to sound. The alarm's malfunction was not investigated, and the care plan did not address this critical safety issue.
Failure to Address Resident's Incontinence
Penalty
Summary
The facility failed to provide appropriate treatments and services to restore bladder continence for a resident, identified as Resident 69, who was frequently incontinent of urine. The facility's policy required comprehensive assessment and interventions for residents with incontinence, but Resident 69 was not placed on any toileting program despite being frequently incontinent. The resident, who had a history of stroke and moderate cognitive impairment, required assistance for transfers and toileting but was not receiving scheduled toileting, prompted voiding, or bladder training. Observations and interviews revealed that Resident 69 experienced urinary incontinence multiple times a day and was not on a toileting program. Staff interviews indicated that the resident was considered continent if staff responded promptly, but incontinence occurred when staff did not arrive in time. The resident's care plan included interventions for incontinence, but these were not effectively implemented, as evidenced by the resident's continued incontinence and the absence of a urinal at the bedside, contrary to the care plan. The facility's failure to assess and address the resident's incontinence comprehensively was further highlighted by the lack of referrals to therapy or other disciplines for the mixed incontinence identified earlier. Staff acknowledged the need for a toileting schedule and confirmed that no interventions had been attempted to improve the resident's bladder continence. The resident also suffered from moisture-associated skin damage due to prolonged exposure to moisture from incontinence.
Failure to Administer Ozempic as Ordered
Penalty
Summary
The facility failed to ensure that a resident received their prescribed doses of Ozempic, a medication used to control blood sugar levels, as ordered. This deficiency involved Resident 36, who had diagnoses of diabetes and stroke and was cognitively intact. The resident was supposed to receive an Ozempic injection once weekly on Saturday mornings. However, the March 2025 Medication Administration Record (MAR) indicated that the resident did not receive the doses on two occasions, March 8 and March 15, 2025, due to the medication being unavailable. The facility did not notify the provider of the missed dose on March 8, 2025, until March 15, 2025. Interviews with facility staff revealed that the medication was not refilled in time due to a lack of authorization for an early refill, as Ozempic is a specialty medication requiring approval for early refills. The pharmacist confirmed that the medication was not due for a refill when ordered by the facility, and no authorization form for an early refill was documented. The Resident Care Manager (RCM) and Licensed Practical Nurse (LPN) acknowledged the failure to notify the provider timely and the lack of appropriate follow-up when the medication was unavailable. This oversight placed the resident at risk of complications from high blood sugar levels.
Failure to Serve Meals at Palatable Temperatures
Penalty
Summary
The facility failed to ensure that meals were served at palatable temperatures, which affected at least one resident and a meal test tray. Resident 12, who had diagnoses including obesity, high blood pressure, and diabetes, reported that meals served in their room were sometimes cold, whereas meals in the dining room were hot. During an interview, Resident 12 expressed that their breakfast, which included cold cereal, an English muffin, sausage patty, hard-boiled egg, and hashbrowns, could have been hotter. The kitchen food temperature logs for March 2025 showed that while temperatures for hot foods were documented, the temperatures for cold foods were not recorded, as indicated by a line through the box for cold items. An observation and sampling of a lunch meal revealed that the temperatures of the food items were below acceptable parameters, with buttered noodles at 119 F, oriental style mixed vegetables at 100 F, and cubed seasoned potatoes at 125 F. Staff S, the Food Supervisor, acknowledged the importance of checking both hot and cold food temperatures to ensure food safety.
Failure to Accurately Document Consents for Psychotropic Medications
Penalty
Summary
The facility failed to ensure that consents for psychotropic medications were completed accurately for a resident reviewed for unnecessary medications. Specifically, the consents for medications such as Quetiapine, Prazosin, Trazodone, and Lorazepam were not documented as late entries, and two consents were not completed before the medication was resumed. This failure was identified during a review of the resident's medical records, which showed discrepancies in the dates of consent documentation and the actual administration of the medications. The resident involved had diagnoses of Parkinson's Disease, depression, and anxiety, and was alert and able to communicate their needs. The Medication Administration Record indicated that the resident was taking several psychotropic medications that required documented consents. However, the consents were either signed late or not redone when the medications were resumed after being discontinued. Interviews with facility staff confirmed that consents should be obtained before administering the first dose and redone if the medication is reordered, but this process was not followed, leading to the deficiency.
Infection Control Deficiencies During Meal Service and EBP
Penalty
Summary
The facility failed to adhere to proper infection control practices during meal service, as observed in multiple instances where staff did not perform hand hygiene when indicated. Staff G, a Nursing Assistant, was seen sanitizing their hands, handling meal trays, and picking up cups from the floor without performing hand hygiene before passing the tray to a resident. Similarly, Staff J, another Nursing Assistant, did not perform hand hygiene between handling different meal trays and after touching the trash can lid. Staff K also failed to perform hand hygiene between delivering meal trays to different rooms. Interviews with staff members, including Staff J, Staff H, and the Infection Preventionist, confirmed that hand hygiene was expected to be performed between passing meal trays and after touching potentially contaminated surfaces to prevent the spread of infection. The facility also failed to implement Enhanced Barrier Precautions (EBP) for Resident 91, who had an indwelling urinary catheter and was at risk of infection. The resident's care plan required the use of gowns and gloves during high-contact care activities. However, during an observation, Staff L, a Nursing Assistant, assisted Resident 91 with transferring without wearing a gown, as required by the EBP policy. Staff L acknowledged the oversight and recognized the importance of wearing a gown to protect both the resident and themselves from germs. These deficiencies in infection control practices, including the failure to perform hand hygiene and adhere to EBP, placed residents at risk for the spread of infections and illnesses. The facility's policies on hand hygiene and EBP were not followed, as evidenced by the observations and staff interviews, highlighting a lapse in adherence to established infection prevention protocols.
Failure to Document and Follow Up on Resident Grievances
Penalty
Summary
The facility failed to provide timely follow-up for grievances reported by a resident's representative, which affected the quality of life for the resident. The policy in place allowed residents to voice grievances either formally or informally, with the expectation of a timely review and response. However, the facility did not document or follow up on the grievances reported by the representative of a resident concerning the management of respiratory equipment. Despite the representative voicing concerns to various staff members, including licensed nurses, nurse managers, and social services, there was no record of these grievances in the facility's logs during the resident's stay. Interviews with staff revealed that the concerns were acknowledged and additional staff training was implemented, but the grievances were not documented as formal grievances. Staff members, including the Resident Care Manager and Social Services, believed the issues were resolved informally and did not require formal documentation. The Administrator and Director of Nursing indicated that only issues requiring permanent fixes were documented as grievances, which led to the oversight in this case. This lack of documentation and formal follow-up was a deviation from the facility's grievance policy.
Failure to Prevent Resident Elopement Due to Inadequate Response to WanderGuard Alarm
Penalty
Summary
The facility failed to implement adequate standards of care to prevent the elopement of a resident with dementia, who was severely cognitively impaired and required supervision while walking. The resident, who had a history of wandering, was equipped with a WanderGuard device intended to trigger an alarm when near exit doors. Despite this precaution, the resident managed to leave the facility unattended, and was later found by local law enforcement at a nearby intersection, confused but uninjured. The facility's investigation revealed that the resident exited through the front door, and although a nursing assistant responded to the alarm, they did not investigate further as the resident was no longer visible. The facility's policy on WanderGuards required routine testing of the devices and monthly checks of door monitors by maintenance staff. However, the policy lacked specific instructions for staff on how to respond when an alarm sounded, particularly if no resident was found at the door. On the day following the incident, it was discovered that the front door's magnetic lock was malfunctioning, which was subsequently repaired. The Director of Nursing confirmed that staff responded to the alarm shortly after the resident exited, but the door was expected to lock automatically when the WanderGuard alarm was triggered, which did not occur.
Failure to Notify Resident's Representative of Hospital Transfer
Penalty
Summary
The facility failed to notify the representative of Resident 4, who had medical power of attorney, about a significant change in the resident's condition. On the evening of June 20, 2024, Resident 4 was transferred to the hospital due to a foot fracture. However, there was no documentation indicating that the resident's representative was informed of this transfer. The resident returned to their former residence after hospitalization, where they were found by their representative with injuries from falls that occurred while the resident was alone. Interviews with facility staff revealed that Resident 4 was somewhat confused prior to the hospital transfer, exhibiting behaviors such as running over their own foot and hallucinating. Staff B, who received the physician's order for the hospital transfer, stated they left a message for staff to notify the resident's representative the next morning, as the decision to call representatives at night depended on the situation. Staff A, the Director of Nursing, confirmed that the facility had documentation of the resident's power of attorney and that staff were expected to notify representatives of hospital transfers, which did not occur in this case.
Failure to Follow Physician's Orders for Catheter Advancement and Oxygen Rate Adjustment
Penalty
Summary
The facility failed to follow up with a physician's order to advance a catheter and obtain an order to increase the oxygen rate for a resident. The resident had diagnoses including benign prostatic hyperplasia and chronic obstructive pulmonary disease (COPD) and required supplemental oxygen. On 08/01/2022, the urology clinic informed the facility that the resident's urinary catheter needed to be advanced into the bladder. Staff B, a Registered Nurse, received the instruction and left a message for the facility provider to obtain the order, but no further follow-up was documented, and the catheter was not advanced. Additionally, the resident's Medication Administration Records (MAR) for July and August 2022 showed multiple instances where oxygen was administered above the ordered amount. Staff interviews revealed that the facility's protocol required nurses to notify the provider for any changes in oxygen rate and to continue calling the provider if no response was obtained. However, the necessary follow-up actions were not taken, and the Director of Nursing confirmed that the provider had not returned the call, and no further follow-up was done regarding the catheter advancement or the oxygen rate adjustment.
Failure to Complete Discharge Summary
Penalty
Summary
The facility failed to complete a discharge summary that included a recapitulation of the resident's stay for a resident who was reviewed for community discharge. The resident, who had diagnoses including urinary retention and aspiration pneumonia, was admitted for physical and occupational therapy following deconditioning related to these diagnoses. The resident, who had moderate cognitive impairments and needed moderate to substantial assistance with activities of daily living, was discharged to home. A review of the discharge packet revealed that while the resident was discharged with a referral to a wound care provider and a list of prescribed medications, a recapitulation summary was not documented in the resident's record. This was confirmed in an interview with the Resident Care Manager, who acknowledged that the recapitulation discharge summary had not been completed.
Failure to Monitor Fluid Intake for Resident with Fluid Balance Concerns
Penalty
Summary
The facility failed to ensure that residents with fluid balance concerns were properly monitored, specifically for a resident with cirrhosis of the liver, ascites, and general edema. Despite physician orders to restrict the resident's fluid intake to 2000mls daily and to document extra fluids received each shift, the facility did not consistently record the resident's fluid intake. Observations revealed that the resident had access to a water pitcher and ice chips, contrary to the care plan, and staff did not accurately track the resident's fluid consumption. The resident's weight showed significant fluctuations, indicating potential fluid retention issues. Interviews with staff revealed a lack of consistent documentation and monitoring of the resident's fluid intake. Staff members were unclear about their responsibilities in tracking the resident's fluids, and there was a misunderstanding about whether ice chips counted towards the fluid restriction. The resident was aware of their fluid restriction but admitted to drinking extra water due to thirst. The facility's failure to adhere to the fluid restriction guidelines and properly monitor the resident's fluid intake placed the resident at risk for adverse health events related to fluid overload.
Failure to Administer Scheduled Medications on Dialysis Days
Penalty
Summary
The facility failed to ensure a resident received their scheduled medications on the mornings they had dialysis. Resident 15, who had diagnoses including end-stage renal disease (ESRD) dependent on dialysis, atrial fibrillation (AFIB), and Parkinson's disease, did not receive their medications on dialysis days. The medications omitted included a multivitamin, pantoprazole, apixaban, tamsulosin, carbidopa/levodopa, entacapone, Renvela, cholecalciferol, and Lispro insulin. The omission was documented by Staff P, a Registered Nurse, who noted that the resident was out of the facility at the time the medications were to be given and did not send the medications with the resident to their dialysis appointments. Staff P also stated that certain medications could not be given upon the resident's return from dialysis as it was too close to the next scheduled dose. This issue was not discussed with the provider to determine an appropriate course of action. During an interview, Staff G, the Resident Care Manager, reviewed the February and March medication administration records (MARs) for Resident 15 and acknowledged the need to discuss the omitted medications with the provider. The failure to administer the medications as scheduled on dialysis days put the resident at risk for worsening of their chronic health conditions or unintended adverse events. The deficiency was identified through observation, interview, and record review, highlighting a significant lapse in medication administration protocol for residents undergoing dialysis.
Failure to Secure Controlled Medications in Permanently Affixed Containers
Penalty
Summary
The facility failed to ensure controlled medications stored in the medication refrigerators were secured in a permanently affixed container. During an inspection of the second-floor medication room, it was observed that controlled medications such as Ativan and Marinol were stored in an open plastic basket on a shelf in the refrigerator, which had a padlock on the door. Similarly, in the first-floor medication room, controlled medications were found on a narrow shelf inside the refrigerator door, not separated from other medications. Staff P, RN, stated that there was no need to keep narcotics in a separate, locked box as both the medication room door and the refrigerator door were locked, and only the nurse had a key. Staff interviews revealed a lack of awareness and compliance with the requirement to store narcotic medications in a permanently affixed, secured box within the refrigerator. Staff I, LPN, was unaware of the need for such separation and security measures. Staff N, RCM, acknowledged the requirement and mentioned that the DON was looking into obtaining the necessary lockboxes. The DON confirmed awareness of the requirement and stated efforts were being made to acquire the lockboxes.
Failure to Maintain Valid Food Worker Cards for Dietary Staff
Penalty
Summary
The facility failed to ensure that dietary staff had the required qualifications, specifically current Food Worker Cards, for two of nine sampled dietary staff members. Staff L was found to be working without a valid Washington State Food Workers card, and Staff M had an expired card. The Dietary Manager, Staff K, confirmed that there was no process in place to ensure food handler cards were renewed prior to expiration. This lapse in protocol had the potential to result in unsafe food handling practices, posing a risk to all residents for developing foodborne illnesses.
Failure to Ensure Sanitary Food Preparation and Service
Penalty
Summary
The facility failed to ensure food was prepared and served in a sanitary manner during two meal preparations observed. A staff member with a beard was not wearing a beard covering while preparing and serving food. This was observed on two separate occasions. During an interview, the staff member stated that in the five years they had worked at the facility, it had never been an issue, and they usually kept their beard shorter. They also mentioned not knowing if beard covers were available. The Dietary Manager confirmed the importance of beard coverings to prevent food contamination, especially for the vulnerable population served by the facility.
Inadequate Hand Hygiene During Care Activities
Penalty
Summary
The facility failed to ensure appropriate hand hygiene during meal service, wound care, and personal care, placing residents at risk for infections. During a lunch observation, a nursing assistant donned gloves, pushed a resident to the table, and handled food items without performing hand hygiene. Another staff member touched a resident's coat and passed a tray without sanitizing their hands. Interviews with the staff confirmed that hand hygiene protocols were not followed as required. In wound care, a registered nurse handled dressings, a pen light, and a resident's wound without changing gloves or performing hand hygiene. Similarly, during personal care, a nursing assistant did not change gloves or sanitize hands after performing peri-care and before applying protective cream and handling other items. The infection control nurse confirmed that hand hygiene should have been performed between these tasks to prevent the spread of infection.
Failure to Ensure Call Light Accessibility
Penalty
Summary
The facility failed to ensure that equipment to allow residents to call for staff assistance was provided for one of the sampled residents. Resident 44, who had diagnoses including chronic obstructive pulmonary disease (COPD), dementia, and a history of falls, was observed multiple times with their call light not within reach. This was despite the care plan indicating that the call light should be within reach and the resident should be encouraged to use it. Observations on several occasions over multiple days showed the call light under the bed and not accessible to the resident. The Director of Nursing acknowledged that call lights needed to be placed within the reach of residents for their safety.
Failure to Provide Dignified Catheter Care
Penalty
Summary
The facility failed to ensure catheter care was provided in a dignified manner for a resident with a neurogenic bladder who utilized a urinary catheter. The urine collection bag was observed multiple times without a privacy bag, and the catheter was emptied without ensuring privacy by pulling the curtain. These observations were made on several occasions, and staff interviews confirmed that the proper procedures for maintaining the resident's dignity were not followed.
Failure to Complete Comprehensive Nutritional Assessments
Penalty
Summary
The facility failed to ensure that the Registered Dietician (RD) completed comprehensive nutritional assessments as required for two residents. Resident 4, who had diagnoses including depression, diabetes, and stroke, was identified as being at nutritional risk. Despite this, the last annual comprehensive nutritional assessment was completed on 11/16/2022, and the last quarterly assessment was done on 04/26/2023. No further comprehensive assessments were documented after 04/26/2023, leaving a significant gap in the resident's nutritional monitoring and care planning. Resident 83, diagnosed with Parkinson's disease and dysphagia, was admitted on 10/25/2023. The Admission Dietary Assessment dated 01/04/2024 was not comprehensive, lacking evaluations of the resident's weights, oral intake, or estimated caloric and nutritional needs. No comprehensive RD assessments were documented since the resident's admission. Interviews with staff revealed that the facility had been using contracted/interim dieticians after the previous RD retired in May 2023, and acknowledged that nutritional assessments were not completed as required.
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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