Sullivan Park Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Spokane, Washington.
- Location
- 14820 East Fourth, Spokane, Washington 99216
- CMS Provider Number
- 505383
- Inspections on file
- 48
- Latest survey
- March 6, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Sullivan Park Care Center during CMS and state inspections, most recent first.
The facility did not complete annual performance reviews for four Nursing Assistants, leading to missing evaluations in their files. Despite claims of yearly evaluations, a change in facility ownership caused a paperwork gap. This oversight placed residents at risk of receiving care from inadequately trained staff.
The facility failed to provide adequate staffing to meet the needs of residents, particularly those with cognitive impairments and behavioral issues. Residents with severe cognitive impairments were observed wandering unsupervised, leading to safety risks and altercations. Additionally, care plans requiring specific staff interventions were not followed, and residents experienced long wait times for assistance. Staff interviews confirmed understaffing, particularly on the South unit, which housed many residents with cognitive and behavioral challenges.
The facility failed to provide appetizing and palatable food, as observed during a survey. Residents reported diminished food quality, with overcooked vegetables, tough meat, and flavorless desserts. The Resident Council noted issues with variety and weekend meals. A test tray sampling confirmed the food was lukewarm and bland. The Dietary Manager acknowledged these issues, admitting the need for additional seasoning. Residents with dietary needs were affected, risking decreased nutritional intake and diminished quality of life.
The facility failed to adhere to food safety standards, with issues in food storage, labeling, and temperature monitoring. Observations revealed unlabeled and expired food items, incomplete temperature logs, and improper preparation of thickened liquids. Additionally, the facility lacked a documented cleaning schedule, indicating inadequate sanitization practices.
The facility failed to obtain appropriate consents for psychoactive medications for three residents, preventing them or their representatives from participating in care decisions. One resident, who was alert and oriented, received medications without documented consent. Another resident had medication changes without new consents, and a third resident, who was severely cognitively impaired, incorrectly signed their own consent form. Staff acknowledged these oversights.
The facility failed to implement its abuse prevention policy, leading to unreported incidents involving residents. A resident reported an altercation with another resident, while another experienced delayed call light response. Incidents of missing money and resident-to-resident altercations were not logged or reported timely. Staff interviews revealed a lack of adherence to reporting guidelines, contributing to the deficiency.
The facility failed to follow infection control practices during wound care for two residents, neglecting hand hygiene and enhanced barrier precautions. Additionally, staff did not implement contact precautions or notify the Infection Preventionist of a potential gastrointestinal outbreak, risking the spread of infection. These lapses highlight significant deficiencies in the facility's infection control protocols.
The facility failed to provide trauma-informed care to six residents with PTSD, lacking proper screening and care plans to identify and manage trauma triggers. Staff were unaware of residents' trauma histories, and the Social Services Director admitted to deficiencies in the screening process. One resident alleged being hit by staff, triggering past trauma memories, highlighting the need for improved trauma screening and care planning.
The facility failed to educate staff on the COVID-19 vaccine and did not maintain proper documentation of vaccination status. An LPN reported not receiving education or signing consent for the vaccine. The Infection Prevention RN confirmed incomplete vaccination logs, and Human Resources lacked comprehensive documentation, risking exposure to COVID-19.
The facility failed to create baseline care plans within 48 hours of admission for two residents, omitting necessary goals and interventions for managing their specific medical conditions. One resident had cardiovascular issues and vision impairment, while another had lung diseases. The Resident Care Manager acknowledged the oversight.
The facility failed to develop and implement appropriate care plans for three residents, leading to deficiencies in their care. A resident with hearing loss was observed using only one hearing aid, contrary to their care plan, which also lacked alternative communication methods. Another resident, who required two staff for interactions due to a past incident, was often attended by a single staff member, violating their care plan. A third resident, needing glasses for daily activities, had no vision needs documented in their care plan, affecting their ability to engage in activities and perform tasks safely.
The facility failed to provide timely assistance with ADLs for two residents, impacting their quality of life. One resident did not receive showers as scheduled, while another was not regularly shaved, despite needing assistance. Staff shortages and reassignments contributed to these deficiencies.
The facility failed to prevent and manage pressure ulcers in three residents, leading to the development and worsening of pressure injuries. A resident developed a deep tissue injury due to inadequate documentation and communication regarding positioning devices and mattress settings. Another resident's Stage 4 pressure injury worsened due to lack of documentation on refusals and specific mattress settings. A third resident's pressure injury deteriorated, and additional heel blisters developed due to insufficient interventions and reliance on comfort-based mattress settings.
A facility failed to secure smoking materials and monitor the use of a heating pad, leading to potential safety risks. A resident used a heating pad without physician orders or care plan documentation, while another resident kept cigarettes and a lighter accessible, contrary to their care plan. Staff were aware but did not enforce safety protocols, increasing the risk of accidents and fire.
A facility failed to accommodate a resident's visual impairment needs, as the resident did not have corrective lenses despite having cataracts and impaired vision. The care plan required staff to ensure the availability of glasses, but after a new prescription was issued, there was no follow-up to obtain new glasses. Staff interviews revealed a lack of awareness and follow-up regarding the resident's need for glasses, and the facility lacked a clear process for handling new prescriptions.
The facility failed to ensure accurate completion and documentation of advanced directives for three residents. A resident had conflicting code status information between POLST forms and the EMR, another had no official POA paperwork despite being listed as having one, and a severely cognitively impaired resident inappropriately signed their own advanced directive documents. These discrepancies could lead to confusion during medical emergencies.
The facility failed to adequately supervise two cognitively impaired residents, leading to multiple resident-to-resident altercations. One resident, with moderate cognitive impairment, exhibited verbal aggression and wandering, while another, with severe cognitive impairment, engaged in aggressive behaviors despite having a wanderguard. Staff acknowledged the need for increased supervision, but the facility's actions were insufficient to prevent further incidents.
A resident with a history of stroke and difficulty swallowing was transferred to a hospital after vomiting blood, but the facility failed to document the events leading to the transfer. The medical records lacked entries detailing the resident's decline, interventions, and notifications, and the transfer form was incomplete. Staff interviews confirmed the absence of necessary documentation, posing a risk for incomplete information sharing.
The facility failed to implement a system to evaluate staff competencies, affecting 10 out of 12 sampled staff, including both in-house and agency personnel. The deficiency involved a lack of documented training in infection control, dementia care, and administration of TPN and IV care, despite the facility's complex resident needs. Interviews revealed systemic issues in training processes, with no structured system to verify staff skills and competencies.
The facility failed to track and dispose of controlled medications for discharged residents, as found in the North Hall medication room. Unopened bottles of Morphine and Lorazepam, along with expired Dronabinol capsules, were discovered without proper documentation in the narcotic book. Staff interviews revealed that these medications were not logged or counted as required, posing a risk for drug diversion.
The facility failed to administer medications as ordered for two residents. One resident with lupus missed multiple doses of Cellcept due to pharmacy delivery issues, leading to increased pain. Another resident with atrial fibrillation received amiodarone despite low blood pressure readings, as a new LPN was unaware of the hold parameters.
The facility failed to ensure that a dietary staff member, specifically the Dietary Manager/Registered Dietician, had the required Washington State Food Worker Card. This deficiency was identified during a review of dietary staff records, where it was found that the staff member did not possess the necessary qualification. The staff member acknowledged the absence of the card and its importance in demonstrating competency in dietary operations, posing a potential risk for unsafe food handling practices.
A facility failed to evaluate a resident for self-administration of medications, leading to a deficiency. The resident, with significant cognitive impairment and a history of refusing care, was left with medications unattended by a nurse without proper evaluation or documentation. The Director of Nursing confirmed that the facility's protocol requires observation unless self-administration is documented.
A facility failed to maintain a safe and homelike environment for a resident, with walls in disrepair and unsecured chemicals in a utility room. The resident's room had damaged walls and mismatched paint, while the utility room door was left ajar with a cleansing spray bottle inside. Staff acknowledged the issues, but repairs and securing of chemicals were delayed.
The facility failed to complete required PASRR Level 2 evaluations for two residents prior to admission and did not implement PASRR recommendations for another resident. A resident with serious mental illness indicators and another with delusional disorder were admitted without necessary evaluations. Additionally, a resident with borderline personality disorder did not receive timely behavioral health services as recommended. Another resident with a new depression diagnosis did not have a timely PASRR evaluation.
The facility failed to accurately complete PASRR Level I for three residents, leading to potential risks of inappropriate placement and unmet mental health care needs. One resident's PASRR omitted anxiety and depression diagnoses, another's incorrectly indicated schizophrenia, and a third's did not reflect mood or psychotic disorders despite a depression diagnosis and psychotropic medication use. The facility's policy required PASRRs to be reviewed for accuracy, but this was not effectively implemented.
The facility failed to update care plans for two residents with changing conditions. One resident, at high risk for falls, experienced multiple falls and a major injury without timely updates to their care plan. Another resident with Addison's disease did not have their care plan updated to include necessary interventions for adrenal crises, leading to concerns about staff's understanding of their condition.
The facility failed to implement the bowel management protocol for two residents, resulting in prolonged periods without bowel movements and lack of necessary medications. Additionally, the facility did not timely identify changes in a resident's skin condition, despite visible irritation and a history of psoriasis. Staff interviews revealed a lack of awareness and communication regarding these issues.
A resident with a PICC line for antibiotic therapy experienced deficiencies in care management, including missed dressing changes, omitted saline flushes, and failure to administer Cathflo Activase for an occluded line. The care plan lacked specific interventions for the PICC, and staff interviews revealed a lack of competency in managing such lines. The PICC was eventually removed, but the delay and non-compliance with protocols highlighted significant deficiencies.
The facility failed to maintain clean oxygen delivery equipment for two residents, risking respiratory complications. One resident's oxygen concentrator was unclean, and their oxygen level was set higher than prescribed. Another resident had unclean tubing with dried blood, and the concentrator filter was dusty. Staff interviews confirmed lapses in equipment maintenance and adherence to prescribed oxygen levels.
The facility failed to maintain the ADL abilities of two residents due to a lack of appropriate RNP referrals after therapy services. One resident, admitted for therapy after an arm fracture, did not receive restorative services due to issues with therapy referrals, leading to a gap in rehabilitation. Another resident, requiring partial ADL assistance, was not placed on an RNP after therapy completion, also due to referral issues. Both residents were at risk for physical decline and decreased quality of life.
A resident with schizoaffective disorder missed doses of clozapine due to delayed pharmacy delivery, leading to increased irritability and hallucinations. The facility's staff noted the behavioral changes and administered Seroquel for agitation. Despite this, the resident's condition worsened, resulting in a hospital evaluation. The facility was in the process of switching to a local pharmacy to improve medication delivery times.
A facility failed to promptly notify a resident's representatives and medical provider after an incident where two residents with dementia were found in the same bed. The delay in notification, approximately 13 hours, limited the effectiveness of a medical exam to rule out sexual assault. The Assistant Director of Nursing acknowledged that immediate notification should have been made.
The facility failed to properly investigate an alleged resident-to-resident abuse incident involving two residents with dementia. A resident was found in another's bed, undressed, and unable to provide a statement. The involved resident was not interviewed until the next day and was transferred to the hospital over 13 hours later, after being showered and having their clothing removed, compromising evidence preservation. The Assistant DON confirmed the need for a medical exam and acknowledged the lack of communication among staff.
A resident was transferred to a hospital for psychiatric evaluation after a physical altercation, but the facility failed to provide a written transfer/discharge notice to the resident, their representative, and the Ombudsman. Staff were unaware of the requirement for written notices, and verbal notifications were made instead.
Two residents experienced harm due to inadequate pain management, resulting in hospital transfers. One resident with fractures did not receive prescribed morphine and tramadol due to prescription validity issues and pharmacy delays. Another resident, post-abdominal surgery, did not receive oxycodone due to staff disagreements over prescription validity. Both residents reported pain, but staff failed to provide timely relief, despite having medications in stock. Miscommunications and procedural gaps contributed to the deficiency.
A facility failed to provide sufficient nursing staff, resulting in delayed responses to call lights and unmet care needs for several residents. One resident waited over an hour for assistance with toileting, while another did not receive required bathing and meal supervision. Staff shortages, particularly on weekends, contributed to these delays, affecting residents' quality of life and safety.
Three residents in the facility did not receive their prescribed medications upon admission due to delays in pharmacy delivery and issues with the automated medication dispensing system. This included antibiotics, insulin, and other critical medications, leading to potential health risks. Staff interviews revealed confusion about medication order processing and access to necessary systems.
The facility failed to provide adequate assistance to residents during meals and bathing, leading to deficiencies in care. A resident with impairments did not receive necessary meal supervision, resulting in uneaten meals. Another resident struggled with meal setup and did not receive alternatives when needed. Additionally, residents experienced significant gaps in bathing assistance, contrary to their care plans, due to insufficient staffing.
A resident requiring negative pressure wound therapy was admitted without access to a wound vacuum machine, leading to inadequate care and discharge back to the hospital. Staff were untrained for weekend admissions, and necessary supplies were unavailable, resulting in a failure to provide proper wound care.
A resident with hemiplegia was improperly transferred using a mechanical sit-to-stand lift without proper assistance, contrary to their care plan which required a total body mechanical lift with two staff. The facility's care plan was not updated to reflect changes, leading to unsafe transfer practices.
Two residents experienced a lack of dignity and privacy in an LTC facility. One resident was taken to therapy in urine-soaked clothing, while another was left on a stretcher in a public area during admission. Staff acknowledged these actions were inappropriate.
A facility failed to report an allegation of medication misappropriation involving a nurse administering oxycodone from an unknown resident to another resident due to a pharmacy issue. The incident was documented by an LPN but not reported to the DON or logged in the facility's Incident Log. The DON was unaware of the allegation until informed by surveyors.
A resident with upper extremity mobility impairment did not receive meals with assistive devices correctly positioned, leading to food being pushed off the plate. The care plan lacked specific instructions for staff, and no staff monitored the resident during meals, risking decreased meal intake and loss of dignity.
A facility failed to maintain accurate medical records for a resident who was transferred to a hospital for pain control. The MAR showed no medications administered, despite an order for oxycodone. Progress notes indicated a nurse gave oxycodone, but documentation was inconsistent. Interviews revealed discrepancies in medication administration and documentation, contributing to the deficiency.
A staff member failed to wear the required PPE when entering the room of a COVID-19 positive resident, despite clear instructions and available PPE. This non-compliance with CDC guidelines occurred during an outbreak, risking further spread of the virus.
Failure to Conduct Annual Staff Performance Reviews
Penalty
Summary
The facility failed to complete annual staff performance reviews as required, affecting four out of six sampled staff members, specifically Nursing Assistants Staff I, BB, N, and UU. These staff members did not have documentation of performance evaluations in their personnel files, despite being employed for several years. Interviews with the Human Resources staff and the Director of Nursing revealed that while evaluations were reportedly completed yearly, a change in facility ownership led to a gap in paperwork, resulting in missing evaluations. The Administrator confirmed the expectation for yearly performance evaluations, which were not met, placing residents at risk of receiving care from inadequately trained or underqualified staff.
Inadequate Staffing Leads to Resident Safety Concerns
Penalty
Summary
The facility failed to ensure adequate staffing to meet the needs of residents, particularly those with cognitive impairments and behavioral issues. The report highlights several instances where residents with severe cognitive impairments, such as wandering and aggressive behaviors, were not adequately supervised. For example, Resident 63, who had severe cognitive impairment and a history of wandering and aggression, was observed wandering unsupervised on multiple occasions, leading to resident-to-resident altercations and potential safety risks. Similarly, Resident 89 and Resident 91, both with severe cognitive impairments and wandering behaviors, were involved in incidents of elopement and falls, indicating insufficient staff supervision and intervention. The report also details the facility's failure to adhere to care plans requiring specific staff interventions. Resident 62, who had a care plan requiring two staff members for all interactions due to previous allegations of abuse, was observed receiving care from a single staff member on multiple occasions. This non-compliance with the care plan highlights a lack of sufficient staffing to meet individualized resident needs and ensure their safety and well-being. Additionally, the report notes issues with call light response times, with residents experiencing excessively long waits for assistance. Resident 42 reported waiting over an hour for their call light to be answered after an incontinence episode, and similar delays were observed during the survey. Staff interviews revealed that the South unit, which housed many residents with cognitive impairments and behavioral issues, was understaffed, leading to difficulties in managing resident care and completing necessary tasks. The facility's reliance on minimum staffing levels and the use of agency staff further contributed to the inadequate staffing situation.
Facility Fails to Provide Palatable and Appetizing Food
Penalty
Summary
The facility failed to provide appetizing and palatable food for several residents, as observed during a survey. Residents reported that the food quality had diminished, with complaints about overcooked vegetables, tough meat, and desserts lacking flavor. Specific examples included Resident 35, who found the meat too tough to chew and the vegetables mushy, and Resident 211, who described their meal as overcooked and unappetizing. These issues were corroborated by observations of meals that appeared unappealing and were not consumed by the residents. The Resident Council also expressed dissatisfaction, stating that the food was only good a couple of days a week, with particular issues on weekends. The council noted a lack of variety and overcooked vegetables. During a test tray sampling by the survey team, the food was found to be lukewarm and bland, with the main entree lacking expected flavors. The Dietary Manager, Staff Z, acknowledged these issues, admitting that the lemon fish almondine lacked lemon flavor and required additional seasoning. Residents with specific dietary needs, such as those with malnutrition or diabetes, were affected by the poor food quality. Resident 46, who was on a therapeutic diet, expressed dissatisfaction with both the regular and alternate menu options. The facility's failure to provide appetizing and palatable food placed residents at risk for decreased nutritional intake and a diminished quality of life, as they often resorted to alternative food sources or skipped meals altogether.
Deficiencies in Food Safety and Preparation Standards
Penalty
Summary
The facility failed to adhere to professional standards for food safety, as evidenced by multiple observations of improper food storage and labeling. During a kitchen inspection, it was noted that a tossed salad in the reach-in refrigerator was unlabeled, and several opened bags of cereal in the dry storage room were past their expiration dates. Additionally, various items in the walk-in refrigerator and freezer were found to be opened and unlabeled, including precooked sausage patties, sliced turkey meat, and several gallons of condiments. The north nourishment refrigerator was overcrowded with resident food items that were opened and unlabeled, posing a risk for bacterial contamination. The facility also failed to monitor and record food temperatures as required. During a tray line service observation, the dietary staff did not check the temperatures of food items on the steam table, and a fruit parfait was found to be above the safe temperature for cold foods. Despite being prompted by the surveyor, the staff did not consistently check or record the temperatures of the food items, which is crucial for preventing foodborne illnesses. The kitchen temperature logs were incomplete, missing final cooking and holding temperatures for several dates. Furthermore, the facility did not ensure the accuracy of thickened liquids preparation, which is essential for residents with dysphagia. An observation revealed that a dietary aide incorrectly prepared thickened lemonade, using fewer pumps of thickener than required. The facility did not conduct regular IDDSI Flow Tests to verify the consistency of thickened liquids, and there was a lack of training for dietary staff on this matter. Additionally, the facility lacked a documented cleaning schedule, and the sanitizer bucket was not readily available in the kitchen, indicating inadequate cleaning and sanitization practices.
Failure to Obtain Informed Consent for Psychoactive Medications
Penalty
Summary
The facility failed to obtain appropriate consents prior to administering psychoactive medications to three residents, which prevented them or their representatives from participating in decisions regarding their care and treatment. For Resident 411, the facility's policy required informed consent before administering psychoactive medications, but the medical record lacked documentation of such consent. Despite being alert and oriented, Resident 411 was administered several psychoactive medications without a documented review of the risks and benefits. Staff acknowledged the oversight, noting that consent evaluations should have been completed upon admission. Resident 102, who was cognitively intact, had changes in their psychotropic medication regimen without obtaining new consents. Although initial consents were obtained for medications upon transfer from a hospital, subsequent changes, including the addition of escitalopram, were not consented to as required. Staff admitted that new consents should have been obtained with medication changes. For Resident 91, who was severely cognitively impaired, an informed consent form was incorrectly signed by the resident themselves, despite their inability to make decisions regarding their care. The Director of Nursing acknowledged this error.
Failure to Implement Abuse Prevention Policy
Penalty
Summary
The facility failed to implement its abuse prevention policy effectively, which included the identification of potential allegations, timely reporting to the State Survey Agency, thorough investigation of allegations, and monitoring residents for potential psychosocial harm. This deficiency was observed in six out of ten sampled residents, placing them at risk of potential abuse, neglect, and misappropriation of property. The facility's policy required all potential allegations to be identified, reported within required timeframes, investigated, and residents protected from potential harm during the investigation process. Resident 20, who was cognitively intact, reported an incident where another resident entered their room and yelled at them. The incident was not documented in the February 2025 incident log, and the State Survey Agency was not notified as required. Similarly, Resident 42 reported a delay in call light response, which was not initially reported to the administration or the State Survey Agency. Resident 62 alleged being hit in the head by a staff member, but the incident was reported over 24 hours later, and there was a delay in monitoring for potential psychosocial harm. Additionally, Resident 35 and Resident 311 reported missing money, but these incidents were not logged or investigated as potential allegations of misappropriation. Resident 63, who had severe cognitive impairment, was involved in multiple resident-to-resident altercations, but these incidents were not reported to the State Survey Agency within the required timeframe. Staff interviews revealed a lack of understanding and adherence to the facility's abuse prevention policy, contributing to the failure to report and investigate these incidents appropriately.
Infection Control Deficiencies in Wound Care and Outbreak Management
Penalty
Summary
The facility failed to adhere to proper infection control practices during wound care for two residents, Residents 101 and 105, who were being treated for pressure ulcers. Staff T, an LPN, did not perform hand hygiene at critical points during the dressing change for Resident 101, such as after removing soiled gloves and before donning new ones. This lapse in protocol occurred multiple times during the procedure, including when handling the resident's gastrostomy tube. Similarly, during wound care for Resident 105, the Infection Preventionist and other staff did not use enhanced barrier precautions, such as wearing gowns, despite the presence of an indwelling catheter and a moist wound that required dressing. The facility also failed to implement contact precautions and notify the Infection Preventionist of a potential gastrointestinal outbreak in one of the units. Residents 74 and 20 exhibited symptoms such as nausea, vomiting, and diarrhea, yet there were no contact precaution signs on their doors, and staff did not take necessary precautions to prevent the spread of infection. Staff M, a Registered Nurse, acknowledged the need for contact precautions but had not informed the Infection Preventionist, which is crucial for preventing the spread of germs. Additionally, the facility did not consistently follow enhanced barrier precautions for residents with wounds or indwelling medical devices. For instance, Resident 102, who had a stage 3 pressure ulcer, did not receive care with the required precautions, as staff only used enhanced barrier precautions when they anticipated contact with the resident's legs. Furthermore, there were multiple instances where staff failed to wear gowns or perform hand hygiene when entering rooms with contact precaution signage, indicating a broader issue with compliance and awareness of infection control protocols.
Failure to Provide Trauma-Informed Care for Residents with PTSD
Penalty
Summary
The facility failed to provide trauma-informed and culturally competent care to six residents diagnosed with PTSD. The facility did not adequately screen, assess, or identify potential trauma triggers for these residents, nor did it develop and implement Trauma Informed Care Plans. This lack of action placed the residents at risk for re-traumatization and diminished quality of life. For instance, Resident 6, who had a history of PTSD and significant traumatic events, did not have a care plan in place, and staff were unaware of the resident's trauma history. Staff interviews revealed a lack of communication and awareness regarding the residents' trauma histories. Nursing assistants and LPNs on the 200 and 300 Halls were not informed about the residents' PTSD diagnoses or potential triggers. The Social Services Director admitted to being unaware of Resident 6's PTSD history and acknowledged that the facility's screening process did not trigger the development of Trauma Informed Care Plans for residents who answered 'Not sure' to significant life events. Additionally, Resident 62, who had anxiety and depression, was not properly screened for trauma. The resident alleged being hit by a staff member, which triggered memories of past trauma. The facility's trauma screening process was inadequate, as it did not directly ask residents if they had experienced trauma. Staff interviews confirmed a lack of awareness about Resident 62's trauma history, and the Social Services Director acknowledged the need for a more effective screening process to identify potential trauma triggers.
Inadequate COVID-19 Vaccine Education and Documentation
Penalty
Summary
The facility failed to ensure that staff were adequately educated about the risks and benefits of the COVID-19 vaccine and did not maintain proper documentation of staff vaccination status. Specifically, Staff P, an LPN who had been employed for about two weeks, reported that they were offered the COVID-19 vaccine during orientation but did not receive any education on it and had not signed any consent or declination form. This lack of education and documentation was confirmed during an interview with Staff D, the Infection Prevention RN, who acknowledged that a comprehensive log of staff COVID vaccinations was not yet completed. Further investigation revealed that Staff P's employment file, reviewed with Staff AA from Human Resources, only contained records of tuberculosis screening and respirator mask fit test results. Staff AA stated that health-related documents were kept in separate health folders and that a spreadsheet was maintained for any documents received, but it was not a comprehensive list of required documents. This deficiency in maintaining proper documentation and providing necessary education placed both staff and residents at risk of exposure to COVID-19.
Failure to Develop Baseline Care Plans for New Admissions
Penalty
Summary
The facility failed to develop a baseline care plan within 48 hours of admission for two residents, which documented resident-specific goals and treatment plans. Resident 6 was admitted with conditions including heart failure, high blood pressure, atrial fibrillation, and legal blindness. However, the baseline care plan lacked goals or interventions for managing these cardiovascular diagnoses and vision impairment. Similarly, Resident 411, who was admitted with chronic obstructive pulmonary disease and asthma, had a baseline care plan that did not include goals or interventions for managing these lung diseases. This oversight was acknowledged by Staff G, the Resident Care Manager, who confirmed that the baseline care plans did not identify the necessary nursing needs, interventions, or goals related to the residents' active or treated diagnoses.
Inadequate Care Planning for Residents
Penalty
Summary
The facility failed to develop and implement appropriate care plans for three residents, leading to deficiencies in their care. Resident 78, who had medically complex conditions and significant hearing loss, was observed using only one hearing aid, contrary to the care plan that indicated the use of hearing aids in both ears. The care plan also failed to include alternative communication methods such as sign language, lip reading, or written communication, which were necessary for effective interaction with the resident. Staff members were unaware of the resident's actual hearing aid usage and communication needs, resulting in inadequate care planning. Resident 62, diagnosed with anxiety and depression, reported an incident where they were allegedly hit by a staff member. As a result, their care plan was updated to require two staff members for all interactions. However, observations showed that staff frequently entered the resident's room alone, failing to adhere to the care plan. Staff interviews confirmed that the care plan's requirements were not consistently followed, leading to potential safety concerns for the resident. Resident 41, who had a history of stroke and heart failure, required glasses for daily activities and reading, which were important to them. Despite this, their care plan lacked documentation regarding their vision needs. Observations revealed that the resident often did not wear their glasses, and when they did, the glasses were sometimes incomplete or misplaced. Staff interviews acknowledged the oversight in the care plan, which failed to address the resident's vision needs, impacting their ability to engage in activities of interest and perform daily tasks safely.
Failure to Provide Timely ADL Assistance
Penalty
Summary
The facility failed to provide timely assistance with activities of daily living (ADLs) for two residents, leading to a decreased quality of life. Resident 52, who was cognitively intact and required substantial assistance for showering, did not receive showers according to their preference and schedule. Despite being at risk for skin breakdown due to incontinence, the resident's shower schedule was inconsistent, with significant gaps between shower dates. Interviews with staff revealed that shower aides were often reassigned to other duties, resulting in missed showers for residents scheduled during evening shifts. Resident 41, who had moderate cognitive impairment and required assistance with personal hygiene, was not shaved regularly, despite expressing a preference for being clean-shaven. Observations showed that the resident often had noticeable facial hair, indicating a lack of grooming. Staff interviews confirmed that shaving was supposed to occur on shower days and as needed, but this was not consistently done. The failure to provide regular shaving was acknowledged by staff, who recognized the importance of maintaining the resident's dignity.
Failure to Prevent and Manage Pressure Ulcers
Penalty
Summary
The facility failed to ensure proper communication and implementation of interventions for pressure ulcer prevention and care, leading to the development and worsening of pressure injuries in three residents. Resident 101, who was admitted without pressure ulcers, developed a deep tissue injury (DTI) due to inadequate documentation and communication regarding the use of positioning devices and specialty mattress settings. The staff did not document or address the resident's refusals to turn or reposition, which contributed to the development of the pressure ulcer. Resident 1, who had a history of malnutrition and multiple sclerosis, developed a Stage 4 pressure injury that was not present on admission. The facility failed to document the resident's refusals to adhere to skin integrity interventions and did not provide specific settings for the air mattress used. Despite being care planned for quarterly discussions on the risks and benefits of refusals, there was no documentation of these discussions, and the resident's pressure injury worsened. Resident 105, admitted with a Stage 1 pressure injury, experienced a deterioration to a DTI and developed additional heel blisters. The facility did not provide specific settings for the air mattress or implement timely interventions for the heel blisters. The resident's spouse reported that the wound worsened at the facility, and observations confirmed the presence of unstageable wounds and blisters. The staff's reliance on resident comfort to adjust air mattress settings, rather than specific medical orders, contributed to the inadequate care provided.
Failure to Secure Smoking Materials and Monitor Heating Pad Use
Penalty
Summary
The facility failed to ensure the safe use of a heating pad for a resident with medically complex conditions, intact cognition, and vision and hearing impairments. The resident's family brought in the heating pad, which the resident used without any physician orders or documentation in the care plan regarding its purpose or safe use. Staff were aware of the heating pad but did not take appropriate actions to ensure its safe use, such as monitoring the temperature or checking the resident's ability to manage it. The heating pad was observed in use multiple times without proper oversight, posing a risk of burns or thermal injury. Additionally, the facility did not secure smoking materials as care planned for a resident with a history of stroke, hemiplegia, and diabetes, who was able to make decisions regarding their care. The resident kept cigarettes and a lighter in a cup attached to their wheelchair, contrary to the care plan that required these items to be locked in the medication cart. The unsecured smoking materials were accessible to wandering residents, one of whom was observed taking items from other residents' rooms. Staff acknowledged the risk posed by the unsecured smoking materials, especially with a roommate on oxygen, but did not enforce the care plan. These deficiencies placed residents at risk for potentially avoidable accidents and increased the facility's risk of fire. Staff interviews revealed a lack of awareness and enforcement of safety protocols regarding the use of electrical appliances and the securing of smoking materials, highlighting a need for improved supervision and adherence to care plans.
Failure to Accommodate Resident's Visual Needs
Penalty
Summary
The facility failed to accommodate the visual impairment needs of a resident, identified as Resident 46, who had cataracts and impaired vision. Despite being cognitively intact and able to verbalize their needs, Resident 46 did not have corrective lenses as per their care plan. The care plan indicated that Resident 46's vision was within normal limits with glasses, and staff were instructed to arrange eye appointments and ensure the glasses were clean and available. However, after a vision exam in January 2025, where a new prescription was provided, there was no documentation of follow-up actions to obtain new glasses for the resident. Interviews with staff revealed a lack of awareness and follow-up regarding Resident 46's need for glasses. Staff members, including a Nursing Assistant, Registered Nurse, and Resident Care Manager, were either unaware of the resident's vision issues or the status of their glasses. The Director of Nursing acknowledged the importance of the resident having functional glasses, but there was no clear process in place for tracking or replacing glasses. The Administrator was also unsure of the facility's process for handling new prescriptions for glasses, indicating a systemic issue in addressing the resident's visual needs.
Inaccurate Advanced Directives and Documentation Errors
Penalty
Summary
The facility failed to ensure that advanced directive documents were completed accurately and that the correct information was entered into the medical records for three residents. Resident 102 had conflicting information regarding their code status, with discrepancies between the POLST forms and the electronic medical record (EMR). The POLST form in the binder indicated a Do Not Resuscitate (DNR) status, while the EMR and a provider order indicated full CPR. Staff interviews revealed that there was a lack of awareness about these discrepancies, which could lead to confusion during medical emergencies. Resident 63, who had severe cognitive impairment, was admitted with a diagnosis of progressive neurological conditions and dementia. The medical record indicated that Resident 63 had a Power of Attorney (POA), but there was no documentation of POA paperwork on file. Interviews with the identified POA and the resident's child confirmed that no official POA paperwork existed. Staff acknowledged the importance of having accurate resident representative information in the medical record, but this was not ensured in Resident 63's case. Resident 91, who was severely cognitively impaired due to stroke, aphasia, and dementia, had signed their own advanced directive documents, including the Admission Agreement and POLST form. This was inappropriate given their cognitive status, and staff acknowledged that the resident should not have signed the form. These failures in handling advanced directives created potential for confusion during medical emergencies and for resident decision-makers to be uninformed of a resident's care.
Inadequate Supervision of Cognitively Impaired Residents Leads to Altercations
Penalty
Summary
The facility failed to consistently supervise and monitor cognitively impaired residents, leading to resident-to-resident altercations. Resident 89, with moderate cognitive impairment, exhibited verbal aggression, hallucinations, and delusions. Despite having a care plan that instructed staff to monitor and redirect the resident, incidents of wandering into other residents' rooms and aggressive behavior were documented. An altercation occurred on February 5, 2025, when Resident 89 entered another resident's room, leading to a confrontation. The incident was not properly documented in the facility's incident log, indicating a lapse in reporting and monitoring. Resident 63, with severe cognitive impairment, also exhibited wandering and aggressive behaviors. The resident was involved in multiple altercations, including hitting a peer with a hairbrush and pulling another resident's hair. Despite being identified as a risk for wandering and having a wanderguard in place, Resident 63 continued to wander unsupervised, intruding on the privacy of other residents and engaging in aggressive behavior. The facility's care plan for Resident 63 included administering medications and providing supervision, but these measures were insufficient to prevent further incidents. Interviews with staff and residents revealed that both Resident 89 and Resident 63 frequently wandered and exhibited disruptive behaviors. Staff acknowledged the need for increased supervision and intervention, but the facility's actions were inadequate to ensure the safety of all residents. The lack of consistent monitoring and failure to document incidents properly contributed to the ongoing risk of resident-to-resident altercations and potential abuse.
Incomplete Medical Record Documentation for Hospital Transfer
Penalty
Summary
The facility failed to ensure complete and accurate documentation of medical records for a resident who was transferred to a hospital for urgent treatment. The resident, who had a history of stroke and difficulty swallowing, required substantial assistance with daily activities and was capable of making decisions about their care. On the day of the incident, the resident was observed to be absent from their room, and staff reported that the resident had vomited blood and was sent to the hospital. However, the medical records lacked documentation of the events leading to the resident's decline, any interventions attempted, notifications made to providers, or information provided to the hospital. The deficiency was identified when a review of the resident's records revealed no entries from the last physician visit until the hospital transfer, leaving a gap in the documentation of the resident's condition and care. The eINTERACT transfer form was incomplete, with the reason for transfer left blank. Staff interviews confirmed the absence of documentation regarding the resident's symptoms and the decision to transfer them to the hospital. This lack of documentation posed a risk for incomplete sharing of vital information with caregivers across different levels of care.
Deficiency in Staff Competency Evaluation and Training
Penalty
Summary
The facility failed to develop and implement a system to evaluate staff competencies in skills and techniques necessary to provide care tailored to each resident's individualized needs. This deficiency was identified for 10 out of 12 sampled staff members, including both in-house and agency staff. The facility's assessment indicated an average daily census of 120 residents, many of whom were acutely ill with multiple co-morbidities, requiring specialized care such as total parental nutrition, respiratory care, intravenous medications, and wound care. Despite this, the facility did not ensure that staff had the necessary training and competency documentation, particularly in infection control and prevention, dementia care, and the administration of TPN and IV care. The report highlighted specific staff members who lacked documented training and competency in critical areas. For instance, several nursing assistants, including Staff N, UU, I, and BB, had no training or competency documentation on infection control and prevention. Staff RR, a Licensed Practical Nurse, lacked training in administering TPN, IV care, and infection control. Similarly, Staff LL, a Registered Nurse, had no documented training for caring for cognitively impaired residents or administering TPN and IV care. Agency staff also showed significant gaps in training, with some having only minimal or outdated training records. Interviews with facility personnel revealed systemic issues in the training and orientation processes for both in-house and agency staff. Staff AA, from Human Resources, acknowledged the absence of a process to train or orient agency staff and confirmed that the facility was working on developing such a process. The Staffing Coordinator, Staff NN, admitted that there was no process to verify agency staff skills and competencies. Staff C, responsible for staff development, was still in the process of developing a system to verify staff skills and competencies, despite having taken over the role several months prior. The Director of Nursing and the Administrator both expressed expectations that staff should have the appropriate skills and competencies, yet the facility lacked a structured system to ensure this was the case.
Failure to Track and Dispose of Controlled Medications for Discharged Residents
Penalty
Summary
The facility failed to ensure proper tracking and disposal of controlled medications for discharged residents, as observed in the North Hall medication room. During an inspection, it was found that controlled medications belonging to two discharged residents were still present in the locked narcotic box in the refrigerator. These medications included unopened bottles of liquid Morphine and Lorazepam, as well as expired Dronabinol capsules. The medications were not entered into the narcotic book, and the corresponding page numbers were missing, indicating a lack of proper documentation and tracking. Interviews with staff revealed that the medications should have been counted every shift and entered into the narcotic book upon receipt. However, the medications for the discharged residents were not logged, and the staff responsible for receiving and storing the medications did not follow the required procedures. The Director of Nursing admitted that the facility had not been checking the narcotic box for medications belonging to discharged residents, especially if they were not recorded in the medication book, which posed a risk for drug diversion.
Medication Administration Errors for Two Residents
Penalty
Summary
The facility failed to ensure medications were administered according to the provider's order for two residents. Resident 95, who had lupus and drug-induced suppression of the immune system, did not receive multiple doses of Cellcept, a medication to treat lupus, on several occasions in January and February 2025. The medication was unavailable due to issues with pharmacy delivery and prior authorization requirements. This omission was documented in the medication administration records and progress notes, and Resident 95 reported experiencing increased pain due to the missed doses. Resident 102, diagnosed with rapid atrial fibrillation and stroke, was prescribed amiodarone to control heart rate. The medication was to be held if the systolic blood pressure was below 110, but it was administered despite low blood pressure readings on multiple occasions in February 2025. Staff P, a newly employed LPN, was unaware of the hold parameters and did not notify the provider of the low readings. This oversight was attributed to frequent interruptions during medication administration.
Dietary Staff Lacked Required Food Worker Card
Penalty
Summary
The facility failed to ensure that all dietary staff had the required qualifications, specifically the current Washington State Food Worker Cards, for safe and effective food handling. This deficiency was identified for one of the fourteen dietary staff members, specifically the Dietary Manager/Registered Dietician, referred to as Staff Z. During a review of dietary staff records, it was found that Staff Z did not possess a valid Food Worker Card as required by state regulations. Staff Z acknowledged the absence of the card and confirmed the necessity of obtaining it to demonstrate competency and knowledge in dietary operations. This oversight posed a potential risk for unsafe food handling practices, which could lead to foodborne illnesses among residents.
Failure to Evaluate Resident for Self-Administration of Medications
Penalty
Summary
The facility failed to ensure a resident was evaluated for their ability to self-administer medications, which led to a deficiency. Resident 20, who had diagnoses including diabetes, heart failure, and aphasia, was observed during medication administration without an evaluation or provider order in their medical record to self-administer medications. The resident had a Brief Interview for Mental Status (BIMS) score of 00, indicating significant cognitive impairment, and their care plan noted episodes of refusing care. Despite this, a registered nurse left the resident's medications unattended on a table in front of them without observing the resident take the pills. The nurse, Staff M, acknowledged that they should have watched the resident take the medications, as there was no documentation authorizing the resident to self-administer. The Director of Nursing, Staff B, confirmed that the facility's expectation was for nurses to observe residents taking their medications unless there was specific documentation allowing self-administration. The lack of evaluation and documentation for Resident 20's ability to self-administer medications resulted in a failure to comply with the facility's medication administration protocols.
Facility Fails to Maintain Safe and Homelike Environment
Penalty
Summary
The facility failed to maintain a clean, comfortable, safe, and homelike environment for Resident 20, as observed through multiple instances of disrepair in the resident's room. The walls in Resident 20's room had multiple patches of drywall, black scrapes, gouges, and a hole near the floor. The bathroom had mismatched paint colors due to a raised paper towel dispenser. Resident 20 expressed dissatisfaction with the environment, stating it did not feel homelike. Staff L, the Maintenance Director, acknowledged the need for repairs and the importance of a homelike environment, but repairs were not completed in a timely manner. Additionally, the facility failed to secure chemicals properly in the soiled utility room on the 600 hall. The door to the utility room was observed ajar and not latched, with a large cleansing spray bottle inside. Staff WW and Staff K acknowledged the issue, noting the door had been ajar for at least a month, and the chemicals needed to be secured. Despite being aware of the problem, the facility delayed contacting fire door repair companies, resulting in prolonged exposure to unsecured chemicals. Staff L admitted uncertainty about the chemicals stored in the room and did not provide a solution for securing them until the door could be fixed.
Failure to Complete and Implement PASRR Evaluations
Penalty
Summary
The facility failed to ensure the completion of required Pre-Admission Screening and Resident Review (PASRR) Level 2 evaluations for two residents prior to their admission. Resident 6 was admitted with serious mental illness indicators, including depression, anxiety disorder, and post-traumatic stress disorder, but the facility did not complete the necessary PASRR Level 2 evaluation before admission. Similarly, Resident 102, who had diagnoses of delusional disorder and major depressive disorder, required a Level 2 evaluation due to their history of delusions and psychotic disorder, but the facility did not have this evaluation completed at the time of admission. Additionally, the facility failed to implement the PASRR Level 2 recommendations for Resident 52, who had borderline personality disorder and depression. Although a Level 2 evaluation was completed prior to admission, which recommended specialized behavioral health services, the facility did not ensure that Resident 52 received these services in a timely manner. The resident expressed suicidal ideation and was agreeable to a behavioral health consultation, but no progress notes from a behavioral health provider were available. Furthermore, Resident 91, who had diagnoses including stroke, aphasia, and dementia, was admitted without a timely Level 1 PASRR. A new diagnosis of depression and subsequent antidepressant medication order did not prompt a new Level 1 PASRR or a Level 2 referral. The Social Services Director acknowledged the oversight and the importance of completing PASRR evaluations to ensure appropriate state program evaluations.
Inaccurate PASRR Completion for Residents
Penalty
Summary
The facility failed to ensure accurate completion of Preadmission Screening and Resident Review Level I (PASRR) for three residents, which is crucial for identifying serious mental illness, intellectual or developmental disabilities, or related conditions. Resident 6 was admitted with diagnoses of anxiety disorder, depression, and PTSD, but the PASRR Level I only identified PTSD, omitting the other conditions. Resident 411's PASRR Level I did not mention PTSD and incorrectly indicated schizophrenia, which was not diagnosed in the medical record. Resident 63 was admitted with a diagnosis of depression and was on psychotropic medications, but the PASRR did not reflect any mood or psychotic disorders, and a Level II evaluation was not indicated. The facility's policy required PASRR Level I to be included in admission paperwork and reviewed for accuracy. However, the PASRRs for these residents were not accurately completed or reviewed, leading to potential risks of inappropriate placement and unmet mental health care needs. Staff Q, the Social Services Director, acknowledged the inaccuracies and the need for double-checking PASRRs upon admission. The facility's administrator expected social services to review and correct PASRRs as needed, but this was not effectively implemented, resulting in the deficiencies noted.
Failure to Update Care Plans for Residents with Changing Conditions
Penalty
Summary
The facility failed to update the care plan for Resident 44 after a significant change in their condition. Resident 44, who was severely cognitively impaired and at high risk for falls, fell and fractured their femur. Despite this major injury, the care plan was not updated until several months later. During this period, the resident experienced multiple additional falls, some resulting in injuries, yet the care plan remained unchanged for an extended time. Interviews with staff revealed that there was a lapse in documentation during a transition of facility ownership, which contributed to the delay in updating the care plan. Resident 35, who was diagnosed with Addison's disease, did not have their care plan updated to include disease-specific interventions. The resident experienced multiple adrenal crises, during which they required hydrocortisone injections. However, the care plan lacked documentation on how to manage these crises, and the nursing staff appeared to be inadequately informed about the necessary interventions. The resident expressed concerns about the staff's understanding of their condition, which was not addressed in the care plan. The deficiencies in updating and revising care plans for both residents put them at risk for unmet care needs and unintended health consequences. The facility's failure to promptly revise care plans in response to significant changes in residents' conditions highlights a gap in ensuring that care plans are reflective of current needs and interventions. This oversight was evident in both the management of fall risks for Resident 44 and the management of Addison's disease for Resident 35.
Failure to Implement Bowel Protocol and Identify Skin Changes
Penalty
Summary
The facility failed to implement the bowel management protocol for two residents, leading to prolonged periods without bowel movements. Resident 18, who required substantial assistance for daily activities, had multiple instances of three to five days without a bowel movement, yet did not receive the prescribed laxatives or suppositories as per the bowel protocol. Similarly, Resident 71 experienced three-day periods without bowel movements and also did not receive the necessary bowel medications. Interviews with staff confirmed that the bowel protocol was not followed, which should have included administering medications and notifying the provider. Additionally, the facility did not timely identify changes in the skin condition of Resident 15, who had a history of Alzheimer's Disease and required significant assistance with personal hygiene. Observations revealed red, irritated patches on the resident's scalp, with blood and flakes, which were not documented or addressed in the care plan. Despite the family member's intervention with personal psoriasis cream, there were no provider orders or documentation of the skin condition in the resident's records. Interviews with staff indicated a lack of awareness and communication regarding Resident 15's skin issues, which were not reported to the nurse as required. The failure to monitor and document the resident's skin condition and to follow the bowel management protocol placed residents at risk for complications and diminished quality of life.
Deficient Management of PICC Line in Resident
Penalty
Summary
The facility failed to maintain a resident's peripherally inserted central catheter (PICC) according to established standards, placing the resident at risk for complications. The resident, who was cognitively intact and had diagnoses including fractured ribs and empyema, was receiving antibiotics through a PICC line. However, the care plan did not include goals or interventions for managing the PICC line. Provider orders included regular saline flushes, dressing changes, and monitoring for complications, but these were not consistently followed. The resident's medication and treatment administration records showed that the last dose of antibiotics was administered on February 20, 2025, but the PICC dressing changes were missed on February 16 and March 2, 2025. Additionally, saline flushes were omitted from February 25 to March 1, 2025, and the ordered Cathflo Activase for an occluded PICC was not administered due to unavailability. There were no progress notes documenting attempts to restore the PICC's patency or assessing the continued need for the PICC line. Observations revealed that the PICC dressing was not changed as required, and the resident reported that the PICC line was no longer functional. Staff interviews indicated a lack of awareness and competency in managing PICC lines, with no documented competencies for nursing staff. The PICC line was eventually removed without difficulty, but the delay in addressing the occlusion and the lack of adherence to protocols highlighted deficiencies in the facility's management of the resident's PICC line.
Failure to Maintain Clean Oxygen Equipment
Penalty
Summary
The facility failed to maintain oxygen delivery equipment in a clean manner for two residents, leading to potential risks of respiratory complications and infection. Resident 74, diagnosed with chronic obstructive lung disease and respiratory failure, was observed using an oxygen concentrator that was unclean with thick dust debris. The resident's oxygen was set at 4 liters per minute, contrary to the physician's order of 3 liters per minute. Despite the facility's policy requiring weekly cleaning of concentrator filters, observations over several days showed the filter remained unclean until the resident cleaned it themselves. Staff interviews revealed a lack of adherence to the prescribed oxygen levels and maintenance schedule. Resident 35, with chronic respiratory failure, was also affected by the facility's failure to maintain clean oxygen equipment. The resident reported requesting a new nasal cannula due to visible blood and dirt, but the tubing was not changed promptly. Observations confirmed the presence of dried blood on the tubing, which was dated several months prior, and the concentrator filter was unclean with dust debris. Staff interviews confirmed there was no documentation of the tubing and cannula being changed, highlighting a lapse in infection control practices.
Failure to Provide Restorative Nursing Program Referrals
Penalty
Summary
The facility failed to ensure that two residents maintained their abilities in activities of daily living (ADLs) due to a lack of appropriate restorative nursing program (RNP) referrals following the completion of therapy services. Resident 1, admitted for therapy services after an arm fracture, was discharged from physical therapy without meeting most of their therapy goals and was supposed to be referred to an RNP. However, due to a problem with receiving therapy referrals after a change in the facility's electronic medical record system, Resident 1 did not receive the necessary restorative services, leading to a gap in their rehabilitation process. Similarly, Resident 3, who required partial assistance with ADLs and was receiving therapy services, was not placed on an RNP after completing occupational and physical therapy. Despite meeting some therapy goals, Resident 3 was not referred to an RNP due to the same issue with therapy referrals. This oversight resulted in a failure to maintain the resident's functional abilities as intended. Both residents were at risk for physical decline and decreased quality of life due to these deficiencies.
Medication Management Failure Leads to Resident's Behavioral Crisis
Penalty
Summary
The facility failed to ensure that pharmacy services were provided to meet the needs of a resident diagnosed with schizoaffective disorder, bipolar type. The resident missed doses of clozapine on two consecutive days, 11/11/2024 and 11/12/2024, due to the medication not being available. This lapse in medication administration was attributed to a delay in delivery from the pharmacy, which was not realized until just before the scheduled administration time on 11/11/2024, a holiday. The medication was reordered but did not arrive until 11/13/2024, missing the cutoff time for next-day delivery. The resident exhibited increased irritability, distressing hallucinations, and aggressive behavior, including kicking a staff member, following the missed doses. The facility's staff, including a Physician Assistant and a Licensed Practical Nurse, noted these behavioral changes and communicated with the medical provider. A one-time dose of Seroquel was administered to manage the resident's agitation. Despite this intervention, the resident continued to display erratic behavior, including tearfulness, aggression, and talking to themselves, leading to a family-requested hospital evaluation on 11/15/2024. The Director of Nursing and the facility Administrator acknowledged the issue with the pharmacy's delivery times and were in the process of switching to a local pharmacy to ensure timely medication delivery. However, this transition was not completed until after the incident. The hospital records indicated that the resident's worsening condition was likely due to a combination of missed medications and a suspected neurocognitive disorder related to alcohol abuse.
Delayed Notification of Incident Involving Residents with Dementia
Penalty
Summary
The facility failed to ensure timely notification of an incident involving Resident 8, who was found in another resident's bed. Both residents had dementia, and the incident occurred at 9:40 PM. Resident 8 reported that the other resident brought them into the room, encouraged them into bed, attempted to remove their clothes, and laid down next to them. The facility's investigation report indicated that notifications to Resident 8's representatives and medical provider were made, but it lacked specific details on the timing of these notifications. A representative for Resident 8 stated they were not informed of the incident until the following morning, approximately 13 hours later. This delay in notification resulted in Resident 8 receiving care that limited the outcome of a subsequent medical exam to rule out sexual assault. Staff B, the Assistant Director of Nursing, acknowledged that the nurse responsible at the time should have immediately notified the resident's representative, medical provider, and local law enforcement.
Failure to Investigate Resident-to-Resident Abuse
Penalty
Summary
The facility failed to thoroughly investigate an allegation of resident-to-resident abuse involving two residents with dementia. Resident 8 was found in Resident 1's bed, with Resident 1 undressed and unable to provide a statement due to cognitive deficits. Despite the potential for sexual assault, Resident 8 was not interviewed until the following morning and was transferred to the hospital for examination over 13 hours after the incident. During this time, Resident 8 was showered and their clothing was removed, which compromised the preservation of potential evidence. The Assistant Director of Nursing confirmed that a medical exam was recommended due to the potential for sexual assault and acknowledged that Resident 8 should have been transferred to the hospital in their original clothing and without a prior shower. The incident was not properly communicated among facility staff, leading to the shower aide being unaware of the need to preserve evidence. This lack of communication and failure to follow proper procedures placed Resident 8 at risk of unidentified abuse.
Failure to Provide Written Transfer/Discharge Notice
Penalty
Summary
The facility failed to provide a written transfer or discharge notice to a resident, their representative, and the State Long-Term Care Ombudsman, as required by their policy. This deficiency was identified for one of the five sampled residents, who was involved in a physical altercation and subsequently transferred to a hospital for psychiatric evaluation. The facility's policy, adopted on 08/01/2024, mandates that a written notice be given to the resident and their representative, and a copy sent to the Ombudsman, especially in cases of emergency transfers. However, a review of the resident's electronic health record showed no documentation of such a notice being provided. Interviews with facility staff revealed that while verbal notifications were made to the resident's representative and medical provider, there was a lack of awareness regarding the requirement for written notices. Staff C, responsible for notifying the Ombudsman, admitted to not being aware of any forms required for such notifications and did not believe the Ombudsman had been informed of the transfer. The Assistant Director of Nursing also confirmed the absence of written notices, and the Administrator incorrectly believed that safety-related discharges exempted the facility from providing a 30-day notice.
Failure in Pain Management Leads to Hospital Transfers
Penalty
Summary
The facility failed to provide necessary pain management for two residents, resulting in harm and hospital transfers. Resident 3, who had fractures from a fall, was admitted with orders for morphine and tramadol for pain management. However, these medications were not administered due to issues with the prescription's validity and delays in pharmacy processing. Despite the resident's repeated requests for pain relief, staff offered only a muscle relaxer, which was insufficient. The resident eventually called emergency services for hospital transfer due to uncontrolled pain. Resident 4, who had undergone multiple abdominal surgeries, was admitted with orders for oxycodone and acetaminophen for pain management. The facility failed to enter the acetaminophen order and did not administer the oxycodone due to staff disagreements over the prescription's validity. The resident reported pain multiple times, but staff delayed addressing it, leading to a decision to send the resident back to the hospital. Observations revealed that the facility had the necessary medications in stock, but access was restricted due to pharmacy authorization issues. Interviews with staff highlighted procedural gaps and miscommunications regarding medication orders and access. Staff were unsure about weekend pharmacy submission times, and there was reluctance from the facility's medical providers to authorize prescriptions without seeing the residents. Additionally, there were misunderstandings about the availability of medications in the automated dispensing system, contributing to the failure to manage the residents' pain effectively.
Staffing Shortages Lead to Delayed Resident Care
Penalty
Summary
The facility failed to ensure sufficient nursing staff were available to respond to call lights timely and meet the care needs of several residents. Observations and interviews revealed that Resident 13 experienced significant delays in receiving assistance for transferring and toileting, waiting over an hour despite having activated the call light. The resident expressed frustration and discomfort due to gastrointestinal symptoms while waiting for help. Staff interviews confirmed that staffing shortages, particularly on weekends, contributed to these delays, with only two nursing assistants available for a hall where multiple residents required assistance from two staff members. Resident 8's care plan required supervision and verbal cues during meals and assistance from two staff for bathing. However, records indicated that the resident did not receive showers twice weekly as required, and observations showed a lack of supervision during meals. Staff interviews highlighted concerns about insufficient staffing to monitor residents closely, especially those needing extensive care. Similar issues were noted for Resident 3, who reported feeling unsafe due to delayed staff responses to call lights, and Resident 4, who also experienced long wait times for assistance, sometimes resorting to calling the facility for help. Resident 5, who was dependent on staff for activities of daily living, did not receive documented bathing assistance for 19 days since admission. Staff attributed this to staffing shortages, with shower aides unavailable and nursing assistants responsible for showers. Resident 12, requiring assistance with meal setup due to mobility impairments, was observed eating less than 25% of their meal without supervision or cues. Staff interviews confirmed the need for more staff to manage residents with complex medical needs requiring close supervision and assistance.
Failure to Administer Medications as Ordered
Penalty
Summary
The facility failed to ensure that significant medications were administered as ordered for three residents, leading to potential risks for their health conditions. Resident 3 was admitted with orders for multiple medications, including an oral antibiotic and medications for neurological disorders and pain. However, none of these medications were administered due to a delay in processing the orders and receiving them from the pharmacy. The resident was informed that medications would not be available until the following Monday, which was not acceptable given the resident's immediate needs. Resident 4 also experienced a failure in medication administration upon admission. The resident had orders for an oral antibiotic and regular insulin, crucial for managing a peritoneal abscess and diabetes. Despite these needs, no medications were administered, and the facility did not receive the necessary records from the hospital. The delay in medication delivery was attributed to the pharmacy's slow response, and the resident's dependency on insulin made this delay particularly concerning. Resident 5 was admitted with orders for multiple antibiotics and medications for blood pressure and thyroid management. However, no medications were administered on the day of admission, and only insulin was given the following day. The delay in medication delivery extended to the third day of the resident's stay, with no documentation of the missed doses or communication with the medical provider. This lack of timely medication administration was due to delays in pharmacy delivery and issues with accessing the automated medication dispensing system.
Deficiencies in Meal Assistance and Bathing Care
Penalty
Summary
The facility failed to provide necessary assistance to residents during meal times and bathing, leading to deficiencies in care. Resident 8, who had impairments in both upper and lower extremities, was observed not receiving the required supervision and verbal cues during meals, as outlined in their care plan. On multiple occasions, Resident 8 was left without assistance, resulting in uneaten meals and inadequate dietary intake. Additionally, the resident did not receive the prescribed twice-weekly bathing assistance, with records showing a significant gap in bathing documentation. Resident 12, with mobility impairments in one arm, also did not receive the necessary meal setup assistance. Staff failed to provide supervision and verbal cues, and the resident struggled to cut their meal, leading to inadequate food consumption. The resident expressed concerns about their nutritional intake, particularly protein, due to a wound, but no staff were available to offer assistance or alternatives. This lack of support during meals was consistent with observations of staff being unable to monitor residents adequately. Residents 1 and 5 also experienced deficiencies in bathing assistance. Resident 1, who was severely cognitively impaired, had significant gaps between showers, contrary to their care plan. The documentation did not reflect the resident's care needs or refusals accurately. Resident 5, with paralysis in both legs, did not receive any documented showers or bed baths for 19 days since admission, despite having skin impairments. Staff attributed these failures to insufficient staffing, impacting the facility's ability to meet residents' care needs effectively.
Failure to Provide Necessary Wound Care Supplies and Training
Penalty
Summary
The facility failed to ensure necessary wound care supplies were available and that staff were knowledgeable in their use for a resident who required negative pressure wound therapy following multiple abdominal surgeries. The resident was discharged from the hospital with two surgical drains and was to receive continuous wound vacuum therapy. However, upon admission to the facility, the resident did not have access to a wound vacuum machine, and the facility lacked the proper supplies for the resident's care. Despite being notified of the resident's pending admission two days prior, the facility was unprepared, leading to the resident's discharge back to the hospital the same day due to inadequate wound care and pain management. Interviews revealed that staff were not trained to handle weekend admissions, and hospital records were not accessible to direct care staff. Staff H, who was responsible for the resident's care, was unable to obtain guidance or necessary supplies and was instructed to apply a wet-to-dry dressing instead. Staff I, who was not assigned to the resident, attempted to assist but was unable to locate a wound vacuum machine. The Director of Nursing advised Staff H to contact the medical provider for a new dressing order, but the resident was discharged before this could be resolved. The lack of coordination and communication among staff contributed to the failure to provide the necessary care for the resident.
Improper Transfer Method Used for Resident with Hemiplegia
Penalty
Summary
The facility failed to ensure the safe transfer of a resident with hemiplegia, who was dependent on staff for transfers. The resident was assessed to require a total body mechanical lift with the assistance of two staff members. However, an unidentified staff member improperly transferred the resident using a mechanical sit-to-stand lift without additional staff assistance. The resident was not strapped into the lift correctly, causing pain and improper weight distribution during the transfer. This incident was observed and confirmed by a collateral contact, who noted that the resident's right arm and leg were not positioned correctly, leading to discomfort and potential risk of injury. Further investigation revealed that the facility's care plan for the resident was not updated to reflect the recent changes in the resident's transfer status. The care plan still listed the total body mechanical lift as the only method for transfers, despite therapy staff recommending a non-mechanical stand aid due to the resident's condition. Staff members were unable to access the updated care plan due to a system change, leading to confusion and improper transfer methods being used. The resident care manager confirmed that the care plan was not updated in the printed version available to staff, resulting in the use of an unsafe transfer method for the resident.
Failure to Maintain Resident Dignity and Privacy
Penalty
Summary
The facility failed to provide personal privacy and maintain the dignity of two residents, leading to a deficiency in care. Resident 8 was observed in a state of neglect when visitors found them soaked in urine on two occasions. On a subsequent observation, a physical therapist entered Resident 8's room and discovered the resident lying in a large puddle of fluid with a strong odor of urine. Despite this, the therapist assisted the resident into a wheelchair and took them to the therapy gym, exposing the resident's soiled condition to others. Nursing assistants later returned the resident to their room to change their clothing, acknowledging that the resident should not have been taken out in urine-soaked clothing. The facility's administrator and director of nursing confirmed that Resident 8 should have received personal care before being removed from their room. Resident 5 experienced a lack of privacy and dignity upon their arrival at the facility. The resident was brought in on a stretcher wearing a hospital gown and was left in the main gathering area of the hall while their room was being prepared. During this time, healthcare staff discussed the resident's admission in front of other residents and visitors. Resident 5 later expressed that waiting in the main room on a stretcher was not dignified. These incidents highlight the facility's failure to ensure personal privacy and dignity for its residents, as required by regulations.
Failure to Report Medication Misappropriation Allegation
Penalty
Summary
The facility failed to report an allegation of potential misappropriation of medication immediately to administration and the State Agency, as required. This involved a situation where a Registered Nurse allegedly misappropriated oxycodone from an unknown resident and administered it to Resident 4 due to the unavailability of Resident 4's prescribed medication from the pharmacy. The incident was documented by a Licensed Practical Nurse in Resident 4's progress notes, but there was no indication that the Director of Nursing was informed of the misappropriation allegation. Additionally, the facility's Incident Log for the relevant period did not contain any entries related to this incident. The Director of Nursing was aware of Resident 4's pain issues, which led to a hospital return, but was not previously notified of the misappropriation allegation until the surveyor's interview.
Failure to Provide Correctly Positioned Assistive Devices During Meals
Penalty
Summary
The facility failed to provide meals with assistive devices in the correct position for use for a resident with an impairment in mobility to their upper extremity, who was dependent upon staff for eating assistance. The resident's care plan, initiated prior to the observation, lacked specific instructions for staff on how to maintain or encourage independence with eating and did not mention the assistive devices the resident utilized. During an observation, the resident was seated at a table with a plate guard incorrectly positioned, which led to food being pushed off the plate onto the resident's lap instead of onto their utensils. No staff members stayed to monitor the resident during the meal. Interviews with staff revealed that the care plan did not include directions on the correct use of the plate guard, and staff were expected to know resident-specific dietary information from a printed care plan at the nurse's station. Despite this, the plate guard was not correctly positioned during multiple observations, and the resident continued to struggle with feeding themselves. This oversight placed the resident at risk for decreased meal intake, loss of dignity, and a diminished quality of life.
Incomplete Medical Records for Pain Management
Penalty
Summary
The facility failed to maintain complete and accurate medical records for one resident, identified as Resident 4, who was reviewed for accurate and complete medical records. On 07/07/2024, Resident 4's Medication Administration Record (MAR) showed no medications were administered, despite an order for oxycodone 5 mg to be given every four hours as needed for pain. Additionally, there was no order for acetaminophen on the MAR. However, progress notes indicated that a Registered Nurse, Staff I, administered a pill in a cup to Resident 4, which was stated to be oxycodone 10 mg, prior to the resident's transfer to the hospital for pain control. Interviews revealed discrepancies in the administration and documentation of medication. Collateral Contact 4 reported that Staff I administered pain medication from a kiosk with supervisor permission shortly before Resident 4's hospital transfer. Staff H, the nurse responsible for Resident 4, confirmed that Staff I administered oxycodone but refused to document it. Staff I later denied administering any medication to Resident 4. The Director of Nursing, Staff B, stated that during an investigation, Staff I claimed to have administered acetaminophen to Resident 4. These inconsistencies in documentation and communication contributed to the deficiency in maintaining accurate medical records.
Failure to Adhere to PPE Protocols During COVID-19 Outbreak
Penalty
Summary
The facility failed to ensure that a staff member, identified as Staff L, adhered to the Centers for Disease Control (CDC) guidelines for wearing personal protective equipment (PPE) during a COVID-19 outbreak. Specifically, Staff L, a Nursing Assistant, was observed entering the room of a resident who had tested positive for COVID-19 without donning the required PPE, which included an N95 respirator, gown, gloves, and eye protection. This observation was made despite the presence of a PPE cart and instructional signage near the resident's room, indicating the necessary procedures for applying and removing PPE. The deficiency was further corroborated by an interview with Staff C, the Resident Care Manager, who confirmed that staff were expected to follow PPE protocols when entering rooms of COVID-19 positive residents. Additionally, a collateral contact reported that staff members were not wearing PPE as required during the outbreak. The facility's failure to enforce proper PPE usage placed both residents and staff at risk for the spread of COVID-19, as evidenced by the ongoing outbreak affecting multiple residents in the facility.
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A resident with cerebral palsy and a court-appointed guardian experienced multiple episodes of nausea, vomiting, loose stools, abdominal discomfort, fatigue, and later refusal of meals and medications, leading to changes in the care plan including close monitoring, lab testing, and IV fluid administration. Despite a facility policy recognizing court-appointed guardians as resident representatives with decision-making authority, staff did not document any notification to the guardian during these changes in condition or treatment decisions. The guardian reported not being contacted when the resident stopped eating or developed stomach issues and felt the facility did not respect the guardianship, while the DON acknowledged there were multiple missed opportunities to notify the guardian of the resident’s change from baseline.
A resident with depression, anxiety, moderate cognitive impairment, and urinary incontinence, care-planned for q2h checks and assistance with toileting, was found by a visitor to be soaking wet, unusually agitated, and reporting they had been told to wait to be changed and referred to with a derogatory remark. The visitor filed a written grievance alleging abuse/neglect related to delayed incontinence care and removal of the resident’s tablet as a consequence. Although an incident report noted that the matter was reported to the state and that the resident was not soaking wet, a CNA who actually changed the resident later reported the resident’s brief, pants, wheelchair, and socks were soaked and that the resident was acting timid and repeatedly saying they had to sit for five minutes, but this CNA was never interviewed. The DON acknowledged not investigating the resident’s behavior or interviewing this CNA, and the grievance official acknowledged the facility did not fully investigate or communicate findings and resolution to the complainant, resulting in a failure to follow the facility’s grievance policy.
A resident with dementia, respiratory failure, and heart failure developed new shortness of breath with an O2 sat of 90%, and a physician ordered transfer to the ED for tx and eval. An RN completed an SBAR, notified the MD and family, and reported to the oncoming nurse that the resident needed ED transfer and that paramedics should be contacted, then left the facility. Instead of calling 911 for this emergent respiratory distress, staff arranged non-emergent transport through a contracted ambulance service, resulting in the resident remaining at the facility for several hours without pickup until the dispatcher later instructed staff to call 911. The DON stated that 911 is expected to be used for emergent conditions and the contracted service only for non-emergent transport.
A resident with anoxic brain injury, dysarthria, and documented lack of decisional capacity alleged physical abuse and expressed fear of their identified representative, yet social services only reported the allegation to the state and did not complete an incident report, revise the care plan, or implement protective interventions. The same representative continued to be treated as the resident’s decision-maker and visited frequently, with staff noting suspicious odors of foreign substances and concerns about possible illicit substance use. Psychiatry later documented concern that the representative was providing illicit substances, and the resident was subsequently hospitalized for altered mental status and overdose, after which the representative was banned. Key staff, including the DON, unit manager, and administrator/abuse coordinator, were unaware of the initial abuse allegation, and social services did not timely explore or clarify legal decision-making authority or alternative representation for the resident.
A resident with severe cognitive impairment, osteoarthritis, and spinal spondylosis, care planned for 2-person Hoyer transfers, was being moved by two CNAs using a mechanical lift when one corner loop of the sling became disengaged, causing the resident to fall about four feet, strike the floor and the lift, and sustain head abrasion, multiple rib fractures, and lumbar vertebral fractures. Facility policy required staff to verify secure sling attachment, examine hooks, clips, fasteners, and strap stability, and ensure the sling bar was sound before lifting, but during this transfer the sling loop detached despite staff believing it was properly fastened and hearing it click into place; post-incident assessment showed the loop had come loose, the sling appeared in good condition, and a CNA later reported thinking one of the round metal disks on the lift might have been slightly loose, while maintenance logs documented no prior concerns with the lifts or slings.
The facility failed to revise and individualize care plans to reflect current needs and preferences for multiple residents, including one cognitively intact resident with hemiplegia, hemiparesis, and mononeuropathy who had bilateral shoulder surgery and could not tolerate BP measurements on the upper arms but preferred forearm readings. Despite repeatedly informing staff, this preference was not documented in the care plan or Kardex, and direct care staff and the RN/UM were unaware of it. Another cognitively intact resident with hemiplegia, contractures, and weakness reported they were supposed to get out of bed for two hours daily, but some NACs did not know this, even though the MAR/TAR contained an order to document times up and back to bed. The surveyors concluded that care plans were not accurately revised for several residents, placing them at risk for unidentified and unmet care needs and diminished quality of life.
Surveyors found that two residents with hemiplegia, hemiparesis, weakness, and contractures did not receive restorative nursing services, including ROM exercises and splint/brace or orthotic assistance, after therapy discharge. Although PT and OT discharge summaries documented established restorative ROM and transfer programs, recommended PROM to affected extremities, and recommended splint/brace use and assistance with orthotic wear, these recommendations were not entered as restorative referrals in the EHR. As a result, the residents’ care plans and records showed no restorative programs, and both residents reported that therapy and restorative exercises had stopped, while the DON, rehab director, and MDS coordinator confirmed they were unaware of and had not implemented the recommended restorative services.
A resident with cancer, cognitive impairment, and declining strength experienced multiple unwitnessed falls, most occurring while attempting to toilet or move toward the bathroom, culminating in a fractured ankle requiring ED treatment. Although assessments identified fall and incontinence risks and the facility’s policy required individualized interventions, the comprehensive care plan lacked a toileting plan and did not include several interventions that were discussed in incident investigations, such as consistent wheelchair placement and frequent rounding for bathroom assistance. Staff reported relying on verbal reminders and education to use the call light, despite acknowledging the resident’s impulsivity and failure to call for help, and the resident’s bed remained furthest from the bathroom while repeated bathroom-related falls occurred without the trend being recognized or addressed in the care plan.
A resident with a history of acute urinary retention and acute kidney injury had a Foley catheter deemed permanent by the hospital, with instructions that it not be removed in the SNF. At a later urology visit, the catheter was removed, and the resident returned with no new orders documented. Facility staff did not document bladder assessments, post-void residuals, or urine output, and CNA documentation showed the resident did not void that evening. Over the next day, the resident had vomiting, poor intake, altered level of consciousness, tachycardia, hypotension, and no documented wet briefs. A bladder scan eventually showed more than 2000–2500 mL of retained urine, and a new catheter drained a large volume. The resident and a roommate reported moaning, crying out in pain, and repeatedly alerting staff that the resident was not urinating and that the catheter was not draining, while nurses documented catheter care when no catheter was in place and later had to flush and replace the catheter due to continued complaints.
Surveyors found that nurses and nurse aides did not consistently administer medications according to professional standards and facility policy. Multiple residents reported that agency nurses were slow with medications, did not fully follow instructions, and often gave routine meds late. Observations showed an LPN administering expired Humalog/Lispro insulin well past the scheduled time, an LPN giving several scheduled meds (including Tizanidine) late and all at once, and an RN attempting to give sliding-scale insulin nearly two hours late, which a resident refused after already eating. Another resident received Methocarbamol two hours late after questioning the RN, and a resident on scheduled Tramadol had doses given without timely documentation, with a discrepancy between the narcotic count and pills remaining. These events demonstrated failures in timely administration, use of non-expired medications, and immediate, accurate MAR and narcotic documentation.
Failure to Notify Court-Appointed Guardian of Resident’s Clinical Changes
Penalty
Summary
The deficiency involves the facility’s failure to notify a resident’s court-appointed guardian of significant clinical changes and care decisions, contrary to its own policy and state requirements. The facility’s policy on Resident Representatives, revised 02/2021, states that a resident representative includes a court-appointed guardian or conservator and that the facility treats the representative’s decisions as those of the resident to the extent delegated or required by the court. Resident 1, admitted with cerebral palsy, had a Superior Court guardianship letter dated 02/07/2025 indicating a guardian of person and conservator of the estate with full authority, identifying Collateral Contact 1 (CC1) as the guardian. Despite this, multiple clinical events and changes in condition were documented without any corresponding documentation that CC1 was notified. Progress notes and provider notes show that Resident 1 experienced an episode of nausea and vomiting, frequent loose stools, abdominal discomfort, bloating, worsening fatigue, generalized weakness, and later refusal of meals and medications over at least a 24-hour period, with observations that the resident appeared frailer, more fatigued, and had no energy or interest to talk. The provider developed care plans including close monitoring for deterioration, sending stool to the lab, and later initiating IV fluids for rehydration, with a plan to call family/POA for discussion. However, there was no documentation that the guardian was notified at any of these points, including when IV fluids were started. CC1 reported that they were not contacted when the resident stopped eating or developed stomach issues, and expressed that the facility did not respect their guardianship and that involvement in care planning took too long. The DON confirmed on record review that there were many opportunities to notify the guardian when the resident’s condition changed from baseline and that there was no evidence staff did so.
Failure to Thoroughly Investigate and Resolve Resident Grievance Regarding Incontinence Care and Staff Conduct
Penalty
Summary
The deficiency involves the facility’s failure to thoroughly investigate and resolve a grievance alleging neglect and disrespect toward a resident, as required by its grievance policy. The resident had depression, anxiety, moderate cognitive impairment, occasional urinary incontinence, and required moderate assistance with toileting, with a care plan directing staff to check the resident every two hours, ask about toileting needs, and ensure they were clean and dry. A collateral contact reported arriving to visit the resident and finding them soaking wet and agitated, with behavior that was not typical for the resident. The collateral contact documented in a written grievance that the resident’s tablet was off, the resident appeared upset, and the resident reported being told they had to wait five minutes to be changed and that staff would change their “nasty *ss” in five minutes, leading the collateral contact to believe the resident had been given a consequence of no tablet and sitting in wet clothes, which they characterized as abuse/neglect and requested immediate removal of the responsible staff and a report filed. The facility documented receipt of the grievance and created an incident report indicating the matter was reported to the state agency, and that the unit manager interviewed the collateral contact and the resident, with the resident described as confused and denying being soaking wet. The incident report stated that a different nursing assistant was assigned to assist with the brief change and that the unit manager believed the resident was not soaking wet, and that the resident and collateral contact were satisfied when they left the room. However, a CNA who actually changed the resident reported that the resident’s brief was soaked through their pants onto the wheelchair and their socks were soaked, and that the resident was timid, repeatedly saying they had to sit for five minutes, and not acting like themselves; this CNA stated they were never interviewed or asked about the grievance or the resident’s condition. The DON acknowledged not interviewing this CNA or investigating the resident’s behavior and why they were upset, and the unit manager did not recall whether the collateral contact was present during follow-up and did not believe they followed up with the collateral contact regarding the grievance. The administrator, identified as the Grievance Official, stated the facility should have thoroughly investigated the grievance and discussed findings and resolution with the collateral contact, indicating the grievance process was not fully carried out in accordance with policy and WAC 388-97-0460.
Failure to Obtain Timely Emergency Transport for Resident in Respiratory Distress
Penalty
Summary
The deficiency involves the facility’s failure to obtain timely emergency medical services for a resident experiencing new-onset respiratory distress. The resident had dementia, respiratory failure, and heart failure, with severe cognitive impairment and a need for substantial assistance with activities of daily living. On the day the resident was sent to the hospital, a collateral contact observed the resident having difficulty breathing, appearing unable to get enough air, and looking as if they were sleeping or unconscious, and reported this to staff with a request to contact the doctor. An SBAR Communication Form documented that the resident was experiencing shortness of breath that had not occurred before, with an oxygen saturation of 90%. The physician was notified and ordered the resident sent to the emergency department for treatment and evaluation, and the collateral contact was notified shortly thereafter. Progress notes later documented that, despite the order for emergency department transfer, the resident was still awaiting pickup by Olympic transportation several hours later, with no estimated time of arrival. At approximately 3:30 AM, the dispatcher informed the facility that they could not provide transportation and instructed that 911 be called; only then was 911 contacted and the resident transported to the hospital via ambulance for respiratory distress. The RN caring for the resident stated they completed the SBAR, notified the physician and family, and at the end of their shift reported to the oncoming nurse that the resident needed to be sent to the emergency department for respiratory distress and that paramedics should be contacted, then left assuming 911 would be called. The DON stated that staff are expected to contact 911 for emergent conditions such as shortness of breath or respiratory distress, and that Olympic Ambulance is used only for non-emergent transport.
Failure to Provide Social Service Advocacy After Abuse Allegation and Questionable Representative
Penalty
Summary
The deficiency involves the facility’s failure to provide appropriate medically-related social services and advocacy for a resident following an allegation of abuse and concerns about the resident’s representative. The resident had an anoxic brain injury, dysarthria, moderate cognitive impairment, and was dependent on staff for activities of daily living. A hospital palliative care note documented that the resident lacked decisional capacity, had no DPOA, that the legal next of kin (CC4) did not want to be part of care decisions, and that care decisions were being deferred to another contact (CC5). CC5 accompanied the resident on admission, signed admission forms, and was listed as the primary contact in the medical record profile. On a date in February, during communication therapy, the resident reported that CC5 had done something to them, pounded their hands on their chest, recalled being hit in the back of the head by an unknown person, and stated they were sometimes afraid of CC5. A social services staff member reported this allegation to the state agency but did not complete a facility incident report, did not initiate care plan changes or interventions, and took no further action. CC5 continued to be treated as the resident’s representative, and progress notes documented CC5 at the bedside on multiple dates, including an entry noting the room smelled like foreign substances and that CC5 was seen waking the resident and then asking the nurse to administer pain medications. A psychiatry note later documented concern that CC5 was providing the resident with illicit substances and stated it would be prudent for the resident to identify a POA. Subsequently, the resident was found unresponsive, transported to the hospital, and later readmitted after altered mental status and overdose, with a provider note stating that CC5 posed a significant danger to the resident and was banned from visiting. After readmission, staff attempted to contact CC4 for consent to treat but initially reached someone who stated they were not CC4. The social service director acknowledged that, beyond reporting the initial allegation, no additional interventions were implemented, that CC5 continued to be used as the resident’s representative after the allegation, and that they had not explored legal authority for decision making following the abuse allegation or concerns about substances. The social service assistant reported they did not speak with the resident about the hospital stay or CC5 and did not complete an incident report or care plan changes after the allegation. The unit manager and DON were unaware of the initial abuse allegation, and the administrator, who served as abuse coordinator, also stated they were unaware of the allegation and that an investigation should have been initiated and a representative for the resident investigated at a minimum.
Injury from Mechanical Lift Sling Detachment During Transfer
Penalty
Summary
The facility failed to ensure a safe mechanical lift transfer when a resident was being moved with a Hoyer lift and sling, resulting in a fall and injury. Facility policy for using a mechanical lifting machine required staff to securely attach sling straps to the sling bar according to manufacturer’s instructions, double-check the security of the sling attachment before lifting, examine all hooks, clips, or fasteners, check strap stability, and ensure the sling bar was securely attached and sound. Despite these requirements, during a transfer for dinner, two CNAs placed the sling under the resident, attached the loops at each corner of the sling to the lift, and raised the resident off the bed into the space between the bed and wheelchair when the bottom left corner of the sling became disengaged from the lift. The resident involved had multiple diagnoses including osteoarthritis, cervical and thoracic spondylosis, and Alzheimer’s disease, with the Minimum Data Set documenting severely impaired cognitive skills for daily decision-making. The resident’s care plan required the assistance of two staff during Hoyer lift transfers. During the transfer, the resident fell approximately four feet, landing on her buttocks, bouncing, and then falling backward and striking her head on the leg of the Hoyer lift. Hospital records documented that the resident sustained an abrasion to the back of the head, fractures of the 6th, 7th, 8th, and 10th ribs, and fractures of the 1st and 2nd lumbar vertebra. Staff interviews and observations showed that staff believed the sling loops had been securely fastened and reported hearing the loops click into place before lifting. One CNA stated that they had barely lifted the resident off the bed when the bottom left loop became disconnected and the resident fell. Another CNA reported being shocked and unable to figure out what had happened. A nurse who assessed the resident and then examined the equipment after the fall noted that one of the loops of the sling had become disengaged but stated the sling appeared to be in good condition. During a later demonstration, a CNA indicated she thought one of the round metal disks on the lift might have been a little loose. Maintenance logs for Hoyer slings and lifts for the preceding months documented no concerns with the slings or lifts, and the DON acknowledged expecting a citation due to the resident’s injury from the fall.
Failure to Revise Care Plans to Reflect Resident Needs and Preferences
Penalty
Summary
The deficiency involves the facility’s failure to revise and individualize comprehensive care plans to reflect residents’ current needs and preferences, as required by its own care planning policy. For one resident with hemiplegia, hemiparesis following cerebrovascular disease, and mononeuropathy of the upper limb, the admission MDS showed intact cognition and upper extremity impairment. This resident reported having bilateral shoulder surgery and an inability to tolerate blood pressure measurements on the upper arms due to pain, and stated a preference for BP measurements on the forearms. The resident reported having informed multiple nursing staff of this preference, but staff continued to place the cuff on the upper arms. Review of the resident’s care plan and Kardex showed no interventions or instructions regarding forearm BP cuff placement. A NAC confirmed they were unaware of the preference until the resident told them directly and that this instruction was not documented in the Kardex. The RN/Unit Manager, who stated they were responsible for revising and reviewing care plans when there were changes, also confirmed they were not aware of the resident’s preference and that it should have been updated in the care plan. Another resident, readmitted with hemiplegia and hemiparesis following a nontraumatic subarachnoid hemorrhage, contracture of the left hand, and weakness, was cognitively intact and required maximum assistance for bed mobility per a quarterly MDS. This resident stated they were supposed to get out of bed for two hours every day, but some NACs were not aware of this care requirement. Review of the resident’s March 2026 MAR/TAR showed an order to document the time the resident got up and the time they returned to bed daily. The report states that, overall, the facility failed to revise care plans accurately to reflect residents’ needs for three of four residents reviewed for care plan revision, placing them at risk for unidentified and unmet care needs and a diminished quality of life.
Failure to Implement Restorative Nursing and Splint/Brace Programs After Therapy Discharge
Penalty
Summary
The deficiency involves the facility’s failure to provide restorative nursing services, including range of motion (ROM) exercises and splint/brace assistance, to maintain or prevent decline in mobility and contractures for two residents with significant motor impairments. The facility’s undated Restorative Nursing Services policy stated that residents would receive restorative care as needed to achieve and maintain optimal functioning and that residents may initiate a restorative program upon discharge from rehabilitative care. Despite this, surveyors found that residents with documented hemiplegia, hemiparesis, weakness, and contractures were not placed on restorative programs and had no restorative interventions documented in their electronic health records (EHRs). Resident 1 was admitted with hemiplegia and hemiparesis following cerebrovascular disease, a left lower leg fracture, and weakness, and the admission MDS showed intact cognition, moderate assistance needs for bed mobility and transfers, and one-sided upper and lower extremity impairment. During observation, the resident was seen lying in bed with a bent inward left forearm and hand and reported no longer receiving therapy or nursing-assisted exercises. The care plan initiated in January showed no restorative services, and the care plan history and EHR contained no restorative nursing interventions. However, the PT discharge summary from February documented that restorative ROM and transfer programs had been established and trained, including PROM to the left upper and lower extremities and stand-by assist with transfers, and the OT discharge summary recommended a splint/brace to prevent contracture. The OT stated that the splint/brace was not tried due to lack of time before insurance was discontinued, and both the Director of Rehab and the MDS coordinator confirmed there was no restorative referral in the EHR and they were unaware of the recommendations. Resident 2 was readmitted with hemiplegia and hemiparesis following a nontraumatic subarachnoid hemorrhage, a left-hand contracture, and weakness, and the quarterly MDS showed intact cognition, maximum assistance needs for bed mobility, total assistance for transfers, bilateral upper and lower extremity impairment, and no therapy or restorative programs. The resident reported that therapy had been discontinued months earlier and that no restorative staff were assisting with exercises. The care plan and EHR showed no restorative services. OT evaluation documented left upper extremity ROM impairment, a left-hand contracture, and prior use of a left orthotic to manage flexion tone, and the OT discharge summary recommended restorative care and assistance with donning/doffing the orthotic. The PT discharge summary recommended restorative programs if Medicaid Part B services did not continue. The Director of Rehab confirmed therapy was discontinued and that restorative nursing programs were recommended, but both the Director of Rehab and the MDS coordinator stated there were no restorative referrals in the EHR after readmission, and the MDS coordinator confirmed the resident had no restorative programs since readmission.
Failure to Implement Effective Fall and Toileting Interventions for High-Risk Resident
Penalty
Summary
The deficiency involves the facility’s failure to provide adequate supervision, identify fall trends, and implement progressive, resident-centered interventions for a resident with multiple falls and declining strength. The facility’s own Falls and Fall Risk Management policy required staff to identify interventions related to residents’ specific risks and causes to prevent falls and minimize complications. The resident’s Care Area Assessment identified cancer-related risks for pain, falls, and ADL decline, and stated that falls and urinary incontinence would be addressed in the care plan with an objective of improvement and risk minimization. However, the comprehensive care plan did not include a urinary or ADL care plan and contained no toileting plan, despite the resident’s identified risks and prior fall history. Over a series of falls, the resident repeatedly fell while attempting to toilet or move toward the bathroom, yet the facility did not recognize or address this pattern in its investigations or care planning. The resident had multiple unwitnessed falls: next to the bed while getting up to use the restroom, in the bathroom while standing to use the toilet, and near or in the bathroom on several occasions. Incident investigations and post-fall assessments documented environmental factors such as clutter, items on the floor, water on the floor, and issues with footwear, as well as the resident’s increasing weakness, impulsivity, poor safety awareness, and poor insight into limitations. Interventions documented in investigations and risk reviews included encouraging use of the front-wheeled walker, keeping the wheelchair and walker accessible, ensuring proper footwear and non-skid socks, and providing resident education on safe transfers, ambulation, and assistive device use. However, several of these planned interventions, including placement of the wheelchair and frequent rounding/toileting assistance, were not added to or reflected in the care plan as stated. Staff interviews further showed that the resident frequently fell while trying to go to the bathroom and that staff relied on verbal education and reminders to use the call light, even though the resident often did not use it. Staff acknowledged the resident’s impulsivity and tendency to get up independently despite instructions, and one staff member stated that nursing assistants were verbally instructed to offer bathroom assistance, but this intervention was not documented in the care plan. The resident’s bed remained the one furthest from the bathroom throughout the stay, and none of the facility’s investigations identified the trend of bathroom-related falls or addressed toileting options in the care plan. Ultimately, the resident sustained a left ankle fracture after another bathroom-related fall, requiring transfer to the emergency department for evaluation and treatment, and later records documented additional fractures and a decline in condition. The surveyors concluded that the facility’s failures placed residents at risk of repeated falls and injuries.
Failure to Monitor Urinary Retention After Foley Removal Leading to Prolonged Pain
Penalty
Summary
The deficiency involves the facility’s failure to adequately assess and monitor a resident for complications associated with an indwelling urinary catheter and urinary retention, particularly after catheter removal. The resident had a history of acute kidney injury due to urinary retention, which improved after Foley catheter placement in the hospital. Hospital discharge documentation indicated the catheter was placed for acute urinary retention, was deemed permanent, and included instructions that, given the resident’s significant retention and acute renal failure, staff at the skilled nursing facility should not attempt Foley removal. The facility’s catheter care plan directed staff to empty the catheter as needed and record output in milliliters, but review of the last 30 days of documentation showed continence was not rated due to the indwelling catheter and there was no documented urinary output in milliliters on the treatment administration records. The resident had a scheduled urology appointment at which the urinary catheter was discontinued. Upon return from this appointment, nursing documentation initially indicated no new orders, and an alert note later stated the catheter was discontinued and staff were monitoring for retention or pain. However, there was no documented bladder assessment or urinary output following catheter removal. Nursing assistant documentation showed that the resident did not void on the evening shift that same day. Despite the catheter having been removed, the treatment administration record showed staff continued to document provision of catheter care on subsequent shifts when no catheter was in place. Over the next day, the resident experienced vomiting, decreased oral intake, and an altered level of consciousness, with vital signs showing tachycardia and low blood pressure, and staff documented decreased urine output. A bladder scan performed later revealed more than 2000–2500 milliliters of urine in the bladder, and an indwelling catheter was reinserted, initially draining a large volume of urine. The provider note indicated the resident had not eaten since the prior night, was unable to hold down fluids, and staff were unsure whether the resident had urinated in incontinence briefs, with no wet briefs reported since the resident’s return from the hospital after catheter removal. The provider expressed concern that the documented early-morning wet brief might not be accurate given the large bladder volume on scan and stated this should require further investigation. Subsequent notes described the resident moaning and complaining of pain, with limited urine output in the catheter bag and staff flushing and then replacing the catheter due to continued complaints. Interviews with the resident, the roommate, and staff indicated the resident was crying out and moaning in pain, the roommate repeatedly alerted staff that the resident was not urinating and that the catheter was not draining, and staff had to seek assistance to replace the catheter. Facility leadership and clinical staff later acknowledged that typical practice after catheter removal would include contacting the provider, placing the resident on alert, performing post-void residuals with bladder scans, and documenting monitoring, which was not done in this case.
Medication Administration Delays, Documentation Errors, and Use of Expired Insulin
Penalty
Summary
The deficiency involves the facility’s failure to ensure sufficient nursing staff with appropriate competencies and skill sets to administer medications according to professional standards of practice, facility policy, and prescriber orders. The facility’s medication administration policy required medications to be given as prescribed, in accordance with manufacturers’ specifications and good nursing principles, with no expired medications used, and doses administered within 60 minutes of the scheduled time and documented immediately after administration. Multiple residents reported that agency nurses often gave medications late, did not read full instructions, or were slow in bringing medications, and that routinely scheduled medications were not consistently provided without residents having to ask. Surveyors observed several specific medication administration failures. For a resident with diabetes, an LPN drew up and administered Humalog/Lispro insulin from a multi-dose vial that had been opened and dated “02/16” with no year, making it expired per policy, and administered the dose nearly 1 hour and 45 minutes after it was due. Another resident with care plan instructions to receive medications as ordered had multiple scheduled medications (Gabapentin, Oxybutynin, Baclofen, and Tizanidine) that were ordered at specific times throughout the day; the LPN was observed administering all four together and acknowledged that at least one (Tizanidine) was late, while the resident reported that receiving them together at that time was typical and not at their request. For another diabetic resident, an RN checked blood sugar and prepared sliding scale Humalog/Lispro insulin almost two hours after the scheduled time; the resident refused the insulin, stating they had already finished lunch. Additional deficiencies were identified with other residents’ pain and scheduled medications. One resident with a pain care plan and an order for Methocarbamol four times daily at set times approached the cart requesting Methocarbamol and Tylenol; the RN initially stated the Methocarbamol had already been given, but then administered it two hours after it was due when the resident pointed out the scheduled timing. For another resident with a risk for pain care plan and Tramadol ordered three times daily at specific times, an LPN retrieved a PRN pain medication while the electronic record showed no 8:00 AM medications documented; the LPN stated they had given them but had not yet documented. Later, an RN prepared the 2:00 PM Tramadol dose, and review of the narcotic count showed a discrepancy between the number of pills documented and the number remaining in the card. The RN stated they had given the 8:00 AM Tramadol but had not signed it out, then signed out both the 8:00 AM and 2:00 PM doses at that time. Residents interviewed consistently reported that medications were sometimes or frequently late, that agency nurses did not always follow instructions, and that they often had to request medications that were routinely scheduled.
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