Summitview Rehab And Health Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Yakima, Washington.
- Location
- 3801 Summitview Avenue, Yakima, Washington 98902
- CMS Provider Number
- 505409
- Inspections on file
- 36
- Latest survey
- March 24, 2026
- Citations (last 12 mo.)
- 1
Citation history
Health deficiencies cited at Summitview Rehab And Health Center during CMS and state inspections, most recent first.
A resident with severe cognitive impairment, a history of multiple falls related to toileting, and identified fall risk factors was assisted to the toilet by a NA, who then left the resident alone in the bathroom to respond to another alarm. The resident was later found on the bathroom floor with a bleeding forehead hematoma and was transferred to the hospital, where CT scans showed bilateral subdural hematomas. The resident’s care plan and bedside care plan included alarms and hourly rounding but did not direct staff to remain with or stand by the resident during toileting, despite staff and the resident’s representative describing the resident as impulsive, confused, and unsafe to stand alone.
Several residents reported receiving cold meals, especially when food was delivered to their rooms or served last. Test trays prepared by the Dietary Manager showed that multiple hot foods were below the required serving temperature, and some cold foods were above safe limits. The Dietary Manager confirmed that food temperatures did not meet facility standards.
Staff did not perform hand hygiene or change gloves between dirty and clean tasks during dining assistance and a urinary catheter procedure. For example, a nursing assistant assisted multiple residents with eating and handled personal items without hand hygiene, and a nurse technician failed to change gloves or sanitize hands while assisting with a catheter replacement and related care.
Two residents with cognitive impairments and significant care needs were not provided with their preferred type or frequency of bathing, despite documented preferences and assessments indicating the importance of choice. Staff interviews revealed that limited shower aide availability led to infrequent showers and substitution with bed baths, which did not align with facility policy supporting resident self-determination.
Three newly admitted residents did not have baseline care plans developed within 48 hours that included required elements such as resident-specific goals, physician and dietary orders, treatment plans, and social service needs. The care plans for residents with complex medical conditions, including stroke, sepsis, and respiratory failure, were incomplete, lacking necessary interventions and goals as required by facility policy and staff expectations.
Two residents did not have care plans that included necessary, person-centered interventions for their specific needs, such as arm/hand positioning and indwelling catheter care. Staff observations and interviews confirmed that care plans and Kardexes lacked updated instructions, despite ongoing care needs and changes in condition.
Three dependent residents with significant cognitive and physical impairments did not receive necessary assistance with bathing, nail care, and oral care. Observations showed residents with untrimmed, dirty nails, food particles in their mouths, and infrequent bathing, while staff interviews confirmed lapses in care due to staffing issues and lack of documentation.
Two residents with significant mobility limitations and contracture risk did not receive consistent positioning support or use of assistive devices as required. One resident with right-sided paralysis was repeatedly found with their affected arm and hand unsupported and positioned under their body, despite complaints of pain and visible swelling. Another resident with muscle weakness and lymphedema had no functioning arm support device for months, and staff relied on makeshift solutions that were not consistently applied. Care plans and staff instructions lacked clear interventions for proper positioning, and staff were unaware of the deficiencies.
Two residents did not have their food preferences documented or honored, resulting in dissatisfaction with meals, repeated serving of disliked foods, and missing condiments. Staff interviews confirmed that food preferences were not consistently discussed or followed up on, and condiments were not reliably provided.
Surveyors found that the nutritional refrigerator in the recreation room was not kept sanitary, with undated and expired foods present, a strong foul odor, and food items improperly stored and labeled. Staff interviews revealed confusion over who was responsible for cleaning and maintaining the refrigerator, and the Infection Preventionist Nurse was aware of the ongoing issues.
Two residents experienced injuries due to the facility's failure to implement necessary transfer assistance interventions. One resident, with multiple diagnoses, was transferred by a NA without the required two-person assistance, resulting in ankle fractures. Another resident, requiring two-person assistance, was transferred alone by a NA, leading to a fall. The facility's communication system for care plan changes was inadequate, contributing to these incidents.
The facility failed to notify the LHJ and State of a norovirus outbreak affecting 20 residents and 19 staff. The outbreak began with symptoms of nausea, vomiting, and diarrhea, but the Infection Preventionist was unaware of the requirement to report to the State. Interviews revealed a lack of awareness among staff about reporting obligations, contributing to the deficiency.
Two residents suffered harm due to the facility's failure to prevent and manage pressure injuries. One resident developed a stage 4 MDRPI from an immobilization brace that was not assessed for eight days, despite complaints of pain. Another resident's pressure injury worsened due to inadequate implementation of wound care recommendations, including a lack of follow-up on critical treatments and incorrect transcription of orders. Staff interviews highlighted communication and procedural deficiencies in managing the residents' care.
A facility failed to address and document Advanced Directives (ADs) for a resident capable of making their own decisions. The resident was not asked about existing ADs or assisted in formulating one upon admission, contrary to facility policy. The social worker responsible for discussing ADs did not document these discussions during care conferences, leaving sections blank and risking the resident's end-of-life care preferences.
The facility failed to report allegations of abuse for two residents, placing them at risk for ongoing abuse. One resident reported an NT applied lymphedema wraps too tightly and responded rudely, while another resident reported rough handling by an NA. Both incidents were not logged or reported to the State Agency, contrary to facility policy and state requirements.
The facility failed to investigate abuse allegations involving two residents. One resident reported a NT for placing lymphedema wraps too tightly and responding rudely, while another resident alleged rough handling by a NA. Both incidents were not logged or properly investigated, and the DNS was unaware of one incident. Delayed reporting and lack of investigation led to deficiencies.
A resident with a history of stroke and obesity experienced significant health declines, including weight loss, pressure injury, and worsening eating abilities. The facility failed to complete a required significant change MDS assessment and care plan revisions, as acknowledged by the MDS Coordinator and DON.
The facility failed to update PASARR for two residents with mental health diagnoses. One resident's PASARR was incomplete, lacking validation for an exempted hospital discharge, while another resident's PASARR was not updated after a new diagnosis of Paranoid Schizophrenia. Staff responsible for PASARR reviews were unaware of requirements and missed updates due to communication lapses.
A facility failed to develop a baseline care plan (BCP) within 48 hours for a newly admitted resident with a leg fracture and foot wound. The resident, who was cognitively intact, did not receive a summary of initial goals and treatment plans due to a communication mix-up between staff.
A resident with limited ROM and significant contractures was not properly positioned in their tilt-in-space wheelchair, leading to discomfort and pain. Observations showed inadequate support for the resident's head and neck, and staff lacked formal training on correct positioning. The care plan required adjustments for eating and pressure relief, but these were not consistently implemented.
A resident with severe dementia and malnutrition had not received routine dental care for over a year, resulting in poor dental health, including darkened teeth and a broken tooth. The facility's contract with a dental service had lapsed, and efforts to renew it were ongoing, leading to a delay in providing necessary care.
A facility failed to provide routine dental services for a resident with significant health conditions, including stroke and paralysis, who was dependent on staff for oral care. Despite a care plan for teeth brushing after meals, observations showed poor oral hygiene, and the resident's representative noted a lack of dental referrals for years. The DNS confirmed the cessation of mobile dental services since 2020, with the last dental service recorded in 2021, leading to delayed treatment and potential risks for the resident.
The facility failed to implement proper infection control measures, including hand hygiene and sterile technique, during resident care. Staff did not perform hand hygiene between glove changes for residents with impaired cognition and unhealed wounds. Additionally, sterility was not maintained during a central line dressing change for a resident with an implanted port, and enhanced barrier precautions were not followed by a staff member during a high-contact care activity.
The facility failed to maintain a safe and sanitary environment, with damaged walls in resident rooms, uncleanable surfaces in utility rooms, and a water leak in the laundry room. The Director of Building Grounds admitted to not conducting routine audits, leading to oversight of these issues.
Failure to Provide Adequate Supervision During Toileting for High-Fall-Risk Resident
Penalty
Summary
The deficiency involves the facility’s failure to ensure an area was free from accident hazards and to provide adequate supervision to prevent accidents for a resident with a history of falls and severe cognitive impairment. The resident was admitted after a stroke and had severe cognitive impairment, requiring staff assistance for bed mobility, transfers, and toileting. A comprehensive assessment and care plan identified the resident as being at risk for falls due to intermittent confusion and medications that could affect balance and cause dizziness. Fall prevention interventions included sensor alarms and hourly rounding, but there were no directives or interventions in the care plan or bedside care plan requiring staff to stay with or stand by the resident while toileting. In the period leading up to the incident, the resident had five documented falls, several of which occurred when the resident was attempting to get to or use the bathroom. Progress notes showed falls outside the bathroom door, next to the bed, and on the floor mat, with the resident repeatedly stating they needed to use the bathroom. Staff interviews indicated that some staff recognized the resident as impulsive, confused, and unsafe to stand alone, and some reported that they would stay by the bathroom door with it cracked while the resident toileted. The resident’s representative also stated that the resident was confused and impulsive, needed someone to stay by the bathroom, and that staff knew this. On the date of the incident, a nursing assistant responded to the resident calling out to use the bathroom and found the resident standing by the bed beginning to lower their pants. The assistant helped the resident to sit on the toilet, where the resident said it would take a minute. The assistant then left the resident alone in the bathroom to respond to another alarm and assist another resident to and from the toilet. When the assistant returned about five minutes later, the resident was found on the bathroom floor, lying on their left side, with a hematoma on the right side of the forehead, an open area with bleeding, and approximately 90 cc of blood on the floor. The resident was transferred to the emergency department, where CT scans showed subdural hematomas on both sides of the brain. The administrator and DON later acknowledged that the resident’s care plan did not include a directive for staff to stand by during toileting.
Failure to Serve Food at Safe and Appetizing Temperatures
Penalty
Summary
The facility failed to provide food at proper temperatures and in a palatable, appetizing manner for four of seven residents reviewed for nutrition. Multiple residents reported receiving cold food, particularly when meals were served in their rooms or when they were among the last to be served. One resident stated they were served cold eggs daily and were unable to eat them, while others reported that food was sometimes cold and that meal service was too long, resulting in cold food on hallway trays. These concerns were communicated to staff by the residents. During an observation, the Dietary Manager served two test trays at the request of the survey team and measured the temperatures of various food items. The recorded temperatures for several hot food items were below the facility's stated normal range, and some cold items were above the recommended temperature for safe serving. The Dietary Manager acknowledged that the food temperatures did not meet the required standards as outlined in the facility's food safety policy.
Failure to Perform Hand Hygiene and Glove Changes During Resident Care and Dining
Penalty
Summary
Staff failed to maintain proper infection prevention and control practices during both dining and personal care activities. During dining observations, a nursing assistant assisted a resident with eating and then handled another resident's napkin and face without performing hand hygiene. The same staff member then continued to assist the first resident with their drink, again without hand hygiene. Another nurse technician was observed rubbing a resident's shoulder, then feeding two different residents consecutively without performing hand hygiene between residents. During a personal care procedure involving a urinary retention catheter replacement, a nurse technician did not change gloves or perform hand hygiene after cleaning a resident's groin and before assisting with securing a leg strap for the catheter. The staff member continued to hold the resident's hand and perform additional tasks with the same contaminated gloves. The infection preventionist nurse acknowledged the lack of hand hygiene during an interview.
Failure to Honor Resident Bathing Preferences and Frequency
Penalty
Summary
The facility failed to honor and facilitate resident choices regarding bathing preferences and frequency for two residents reviewed. One resident, with Alzheimer's disease, pressure ulcer, and chronic pain, was assessed as having a strong preference for tub baths over showers. Despite this documented preference, the resident was provided showers on multiple occasions, contrary to their wishes. Another resident, with a history of stroke, diabetes, and dementia, expressed that they had to wait over a week for a shower and felt embarrassed having to request one. Records confirmed an eight-day gap between showers for this resident, despite their assessment indicating the importance of choosing their bathing schedule. Interviews with nursing assistants revealed that staffing limitations often resulted in reduced availability of showers or baths, with residents typically receiving only one bathing opportunity per week. When additional bathing was requested, residents were often offered a bed bath instead due to scheduling constraints. The facility's policy states that residents have the right to self-determination and should be supported in exercising their choices, but these practices did not align with the policy or the residents' documented preferences.
Failure to Develop Timely and Complete Baseline Care Plans Upon Admission
Penalty
Summary
The facility failed to develop baseline care plans within 48 hours of admission for three residents, as required by policy. For each of these residents, the baseline care plans lacked essential elements such as resident-specific goals, physician orders, dietary orders, treatment plans, and social service needs. Specifically, one resident with a history of stroke, diabetes, and dementia required substantial assistance with activities of daily living and had moderately impaired cognition, but their baseline care plan did not address their specific care needs. Another resident admitted with lumbar osteomyelitis, sepsis, and urine retention, who had a PICC line and urinary catheter, did not have a baseline care plan that included focus areas, goals, or interventions related to their medical and social service needs. A third resident with respiratory failure, embolism, alcohol withdrawal, chronic pain, and edema, who required supervision for ADLs, also had a baseline care plan lacking in resident-specific goals and interventions. Interviews with facility staff confirmed that the baseline care plans were expected to be completed within 48 hours of admission and should include admission diagnoses, immediate goals, medications, therapy types, specialty orders, and discharge plans. However, the review of records and staff interviews revealed that these requirements were not met for the three residents reviewed, resulting in incomplete baseline care plans that did not address their immediate health and safety needs as outlined in facility policy.
Failure to Develop and Implement Comprehensive Care Plans with Appropriate Interventions
Penalty
Summary
The facility failed to develop and implement comprehensive care plans with appropriate, person-centered interventions for two residents, resulting in a deficiency. For one resident with muscle weakness, right shoulder pain, osteoporosis, and dementia, the care plan did not include specific interventions for right arm and hand positioning, despite the resident being dependent on staff for care and having severely impaired cognition. Observations showed the resident's right hand was consistently red, swollen, and hanging down, and staff interviews revealed that an arm trough had been broken and removed months prior, with no alternative interventions clearly documented in the care plan or Kardex. Staff acknowledged that the care plan did not reflect the use of a pillow, teddy bear, or other positioning devices for the resident's right arm and hand. For another resident with heart disease, osteomyelitis, and urinary retention, the care plan did not address the presence or care of an indwelling urinary retention catheter, even though the resident was observed with the catheter in place and staff confirmed its use and related care needs. The Kardex also lacked any tasks or instructions for catheter care. Staff interviews confirmed that the care plan and Kardex should have included this information but did not. The facility's policy required ongoing assessment and timely revision of care plans as residents' conditions changed, but this was not followed for either resident. The lack of updated and comprehensive care plans with measurable interventions placed both residents at risk for inadequate or unsafe care, as staff did not have clear guidance on how to address their specific needs.
Failure to Provide Adequate ADL Assistance: Bathing, Nail, and Oral Care
Penalty
Summary
The facility failed to provide adequate assistance with activities of daily living (ADLs), specifically bathing, nail care, and oral care, for three dependent residents. Observations and interviews revealed that these residents, all of whom were dependent on staff for personal hygiene due to conditions such as multiple sclerosis, stroke, and dementia, were not receiving necessary care. For example, one resident was observed multiple times with food particles in their teeth, long and dirty fingernails, and untrimmed toenails. Staff interviews confirmed that nail care was not being completed due to staffing changes, and oral care was not consistently provided after meals. Another resident, also dependent on staff for all ADLs, was observed with long, dirty fingernails and visible scratch marks on their skin from itching. This resident reported feeling itchy and expressed a preference for bathing, but records showed infrequent showers and refusals of bed baths. Staff acknowledged that oral care and bathing had not been completed as required, and documentation for nail care was lacking for an extended period. A third resident with severe cognitive impairment and dependence on staff for personal hygiene was found with long, dry, and dirty fingernails and toenails, as well as food stuck in their dentures. The resident's representative reported that the resident often appeared disheveled and that denture care was not performed regularly. Staff interviews indicated that while personal care tasks were assigned, there was no documentation for completion of nail care or other hygiene-related tasks, and staffing shortages had impacted the ability to provide these services.
Failure to Provide Proper Positioning and ROM Support for Residents with Limited Mobility
Penalty
Summary
The facility failed to provide appropriate care and services to maintain or improve range of motion (ROM) and prevent further decline in two residents with limited mobility and contracture risk. One resident, who had a history of stroke with right-sided paralysis and cognitive impairment, was observed multiple times lying on their affected right side with their paralyzed arm and hand positioned underneath their body without support. The resident complained of pain, and their right arm and hand appeared red and swollen. Although a soft hand brace had been prescribed, it was removed due to a laceration, and no alternative support or positioning device was provided. The care plan and bedside care documentation did not include interventions for right arm or hand positioning, and staff were unaware of the lack of proper positioning. Another resident with muscle weakness, lymphedema, right shoulder pain, osteoporosis, and severe cognitive impairment was observed sitting in a wheelchair with their right arm and hand unsupported, red, and swollen. The resident's arm positioning device had been broken and removed months prior, and staff used a teddy bear or were supposed to use a pillow for support, but these interventions were inconsistently applied. The care assignment documentation for nursing assistants did not include instructions for right arm or hand positioning, and staff acknowledged that no interventions were in place for this need. In both cases, the lack of consistent use of assistive devices and absence of clear care plan interventions for positioning and support led to residents being left without necessary measures to prevent further decline in ROM and contracture. Staff interviews confirmed gaps in awareness and implementation of required positioning supports, and documentation failed to reflect the residents' needs for proper positioning and use of assistive devices.
Failure to Honor Resident Food Preferences and Provide Requested Condiments
Penalty
Summary
The facility failed to honor food preferences for two residents, resulting in dissatisfaction with their dining experience. For one resident with a history of stroke, diabetes, and dementia, the Nutrition Food Preference form was left incomplete, with no documentation of likes, dislikes, or cultural preferences. The resident reported that meals were consistently salty, not served hot, and that they had not been asked about their food preferences. Staff interviews confirmed that food preferences were not always documented due to time constraints, and cultural preferences were not addressed. Another resident with chronic obstructive pulmonary disease, malnutrition, and arthritis also had an incomplete Nutrition Food Preference form. This resident reported a lack of variety in meals, repeated requests for specific foods like bananas, and missing condiments such as salt, pepper, and sugar. The resident stated they continued to receive foods they disliked, such as oatmeal, despite informing staff. Interviews with dietary staff revealed that food preferences were not routinely discussed or followed up on, and condiments were not consistently provided with meals.
Failure to Maintain Sanitary Conditions and Proper Food Labeling in Nutritional Refrigerator
Penalty
Summary
The facility failed to maintain the nutritional refrigerator in the resident recreation room in a sanitary condition and did not ensure that undated or expired foods were discarded. Observations revealed a large container of ice cream and three chocolate ice cream bars in the freezer without any dates indicating when they were opened or their expiration. The refrigerator emitted a strong foul, sour odor, and its shelves were cluttered with trays of food stacked on top of each other, as well as undated items such as Jello cups, a birthday cake, a paper bag, and two zip lock bags with fruit, some of which were labeled with resident names but lacked dates. Interviews with facility staff indicated confusion and lack of clarity regarding responsibility for cleaning the nutritional refrigerator. The Dietary Manager stated that kitchen staff did not clean the refrigerator and that this was the responsibility of nursing staff. The clerk responsible for monitoring daily temperatures was not informed that cleaning was part of their duties, and the housekeeper was also unsure about who was responsible. The Infection Preventionist Nurse acknowledged awareness of the refrigerator's poor condition, including the presence of undated and unnamed food items.
Failure to Implement Transfer Assistance Leads to Resident Injuries
Penalty
Summary
The facility failed to implement necessary interventions to prevent injuries during resident transfers, as evidenced by incidents involving two residents. Resident 1, who had multiple diagnoses including heart failure, orthostatic hypotension, and dementia, was dependent on staff for activities of daily living, including transfers. Despite the care plan indicating the need for two-person assistance, Staff C, a Nursing Assistant, attempted a one-person pivot transfer, resulting in Resident 1 experiencing pain and ankle fractures. Staff C was unaware of the care plan requirement for two-person assistance, which was documented in the resident's Bedside Care Plan and confirmed by a physical therapy note. Similarly, Resident 4, who was cognitively intact and required two-person assistance for transfers, was transferred by Staff E, another Nursing Assistant, without the required assistance, leading to a fall. Staff E was not familiar with Resident 4's transfer care plan and did not follow it, resulting in the resident ending up on the floor. The facility's system for communicating changes in care plans to staff was inadequate, as there was no mechanism to inform Nursing Assistants who were not present on the day of the change. This lack of communication and adherence to care plans contributed to the incidents involving both residents.
Failure to Report Norovirus Outbreak
Penalty
Summary
The facility failed to notify the local health jurisdiction (LHJ) and the State of a communicable disease outbreak within the required time frames, affecting 20 residents and 19 staff members. The outbreak, identified as norovirus, began on 11/18/2024, with the last symptom onset on 12/09/2024. Despite being in communication with the LHJ, the facility did not report the outbreak to the State, as the Infection Preventionist (IP) was unaware of this requirement. This oversight was confirmed during an interview with Staff C, the IP, who stated that they had not reported to the State because they were not aware it was required. The outbreak involved multiple residents with varying symptoms, including nausea, vomiting, and diarrhea. Resident 1, who had a history of ulcerative colitis and dementia, experienced symptoms that were initially thought to be related to their chronic condition. Other residents, such as Resident 2 and Resident 3, also exhibited symptoms consistent with norovirus, with some residents requiring therapy services during their illness. The facility's outbreak line list documented the symptoms and duration for each affected resident, highlighting the widespread impact of the outbreak. Interviews with facility staff, including the Director of Nursing (DON), revealed a lack of awareness regarding the requirement to notify the State of an infectious disease outbreak. Staff B, the DON, acknowledged that they were not clear on when they would have known there was an outbreak, given Resident 1's ongoing GI issues. The facility's failure to report the outbreak in a timely manner was a repeat citation from a previous Statement of Deficiencies dated 06/12/2024, indicating ongoing issues with compliance in this area.
Failure to Prevent and Manage Pressure Injuries
Penalty
Summary
The facility failed to provide timely treatment and care to prevent pressure injuries for two residents, leading to significant harm. Resident 49 developed a stage 4 medical device-related pressure injury (MDRPI) on their right lower leg due to an immobilization brace that was not assessed or adjusted for eight days. Despite the resident's complaints of increasing pain, the staff did not remove the brace or assess the skin underneath until the wound care provider intervened. The delay in clarifying orders and assessing the resident's skin resulted in an infected stage 4 MDRPI, causing extreme pain and requiring urgent follow-up. Resident 18 experienced a worsening of a pressure injury on their right buttock, which became infected and required antibiotic treatment. The facility failed to implement the wound care provider's recommendations, such as using a wound vac, obtaining necessary lab tests, and consulting an infectious disease specialist. The resident's pressure injury was not managed effectively, with incorrect transcription of treatment orders and a lack of follow-up on critical recommendations. The resident's condition deteriorated over several months, with the wound becoming more severe and exposing muscle and bone. Interviews with staff revealed a lack of communication and coordination in managing the residents' care. Staff were unsure about the correct procedures for assessing and treating pressure injuries, and there were delays in obtaining necessary clarifications from providers. The Director of Nursing Services acknowledged that the correct processes were not followed, and the facility's failure to act on the wound care provider's recommendations contributed to the residents' harm.
Failure to Address and Document Advanced Directives
Penalty
Summary
The facility failed to properly address and document Advanced Directives (ADs) for a resident, identified as Resident 10, who was cognitively intact and capable of making their own decisions. Upon admission, the facility did not inquire about any existing ADs or assist the resident in formulating one, as required by their policy. This oversight was confirmed during an interview with Resident 10, who expressed a need for an AD but stated they had not been approached or assisted by the facility in this regard since their admission. Further investigation revealed that the facility's social worker, Staff Z, was responsible for discussing ADs with residents upon admission and during quarterly Interdisciplinary Team (IDT) care conferences. However, a review of the IDT care conference documents for Resident 10 showed that ADs were neither discussed nor documented, as evidenced by blank sections on the forms where AD-related information should have been recorded. This lack of documentation and discussion placed the resident at risk of not having their end-of-life care preferences and decisions followed.
Failure to Report Allegations of Abuse
Penalty
Summary
The facility failed to report allegations of abuse and/or neglect to the State Agency for two residents, which placed them at risk for unidentified and ongoing abuse or neglect. Resident 27, who was admitted with a right femur fracture and had intact cognition, reported an allegation of abuse involving a Nursing Technician (NT) who applied lymphedema wraps too tightly and responded rudely when the resident expressed discomfort. The Director of Nursing Services (DNS) initially did not consider the incident as abuse based on verbal statements but later acknowledged it should have been reported after receiving a written statement. The facility's reporting log did not include this allegation. Resident 13, admitted with an infection of the lower spine region and also cognitively intact, reported rough handling by a Nursing Assistant (NA) during care. The resident informed a nurse, who then removed the NA from the room. However, the DNS was not informed of this allegation, and it was not logged in the facility's reporting log. Both incidents highlight a failure to follow the facility's policy and state requirements for reporting abuse allegations.
Failure to Investigate Abuse Allegations
Penalty
Summary
The facility failed to conduct a thorough investigation into allegations of abuse involving two residents. Resident 27 reported to the Director of Nursing Services (DNS) that a Nursing Technician (NT) placed their lymphedema wraps too tightly and responded rudely when the resident expressed discomfort. Despite the resident's report, the incident was not logged, and the DNS did not initially consider it an allegation of abuse. Written statements from involved staff were delayed, and the allegation was reported to the state agency seven days after the incident. Resident 13 alleged that a Nursing Assistant (NA) forcefully grabbed their hands off a side rail, which was reported to a Licensed Practical Nurse (LPN) and subsequently to a charge nurse. However, the allegation was not logged, and the DNS was unaware of the incident. No investigation was conducted, and the NA continued to work, although they were not allowed to care for Resident 13. The facility's failure to follow proper procedures for investigating and reporting abuse allegations resulted in deficiencies in handling these incidents.
Failure to Complete Significant Change Assessment
Penalty
Summary
The facility failed to complete a significant change in status assessment for a resident who experienced a decline in multiple health areas, including skin integrity, weight loss, and swallowing and eating abilities. The resident, who was admitted with right-sided weakness due to a stroke and obesity, showed significant weight loss of 22.66% over six months, developed an unstageable pressure injury, and had worsening eating and swallowing abilities. Despite these changes, the facility did not complete the required Minimum Data Set (MDS) assessment and care plan revisions within the 14-day timeframe as outlined in the Resident Assessment Instrument (RAI) manual. Observations and interviews revealed that the resident had become non-verbal and was unable to feed themselves, requiring assistance from staff. The Minimum Data Set Coordinator acknowledged the need for a significant change MDS but did not complete it, hoping for the resident's improvement. The Director of Nursing Services admitted that the facility's process of discussing residents' health declines in morning meetings failed to identify the resident's overall decline, resulting in the oversight of the necessary assessment and care plan updates.
Failure to Update PASARR for Residents with Mental Health Diagnoses
Penalty
Summary
The facility failed to properly review and validate the Preadmission Screening and Resident Reviews (PASARR) for two residents, leading to deficiencies in their care. Resident 26 was admitted with a diagnosis of schizophrenia, and their PASARR document was incomplete, lacking the necessary validation signature for an exempted hospital discharge. Observations showed the resident experiencing confusion and delusions, yet the PASARR was not appropriately filled out or signed. Staff responsible for reviewing and updating PASARRs were unaware of the exempted hospital discharge requirements and failed to correct the document prior to the resident's admission. Resident 36 was admitted with diagnoses including delusional disorder and developmental disorder, and later received a new diagnosis of Paranoid Schizophrenia. However, the PASARR was not updated to reflect this significant change. Staff Z, responsible for reviewing PASARRs, was not informed of the new diagnosis, which was expected to be communicated during daily morning meetings. The Director of Nursing Services acknowledged that the correct process for updating the PASARR was not followed, as charge nurses did not bring the new diagnosis to the morning meetings.
Failure to Develop Baseline Care Plan for New Admission
Penalty
Summary
The facility failed to develop a baseline care plan (BCP) within 48 hours of admission for a newly admitted resident, identified as Resident 49. This BCP was supposed to include resident-specific initial goals and treatment plans. Additionally, the facility did not provide a summary of the required information from the BCP to the resident. This oversight was discovered during a review of the medical record, which showed that Resident 49 was admitted with a fracture of the right lower leg bone, managed with a compression bandage and immobilization brace, and an open non-pressure related left foot wound. The comprehensive assessment indicated that the resident was cognitively intact and capable of communicating their needs. During an interview, the Director of Nursing Services, identified as Staff B, acknowledged that Resident 49 did not have a completed BCP. The failure to complete the BCP was attributed to a communication mix-up between the admissions nurse and the Resident Care Manager, resulting in the task being overlooked. This deficiency placed the resident at risk of not having their initial care needs adequately addressed and communicated.
Failure to Maintain Proper Wheelchair Positioning for Resident
Penalty
Summary
The facility failed to provide necessary services to maintain the positioning and range of motion (ROM) for a resident with limited mobility, identified as Resident 20. The resident, who was admitted with conditions including gastric reflux disease, a stroke with left-sided hemiparesis, and significant contractures, was dependent on staff for daily functions. Observations revealed that the resident was not properly positioned in their tilt-in-space wheelchair, leading to discomfort and pain. The wheelchair was tilted in a manner that caused pressure on the resident's buttocks, and the headrest did not adequately support the resident's head and neck, resulting in the resident's head hanging to the side. Interviews with staff indicated a lack of formal training on how to position the resident correctly in the wheelchair, particularly after meals. The care plan required staff to adjust the wheelchair for eating and to relieve skin pressure, but this was not consistently done. The resident experienced pain when seated in the wheelchair for extended periods, and there were signs of previous skin complications. The hospice assessment confirmed the resident's complaints of pain, and staff acknowledged the need for better positioning to prevent pressure and ensure proper alignment.
Failure to Provide Routine Dental Care
Penalty
Summary
The facility failed to provide prompt routine dental services for a resident, identified as Resident 29, who was admitted with diagnoses including a stroke, severe dementia, and moderate protein calorie malnutrition. The comprehensive assessment indicated that the resident had severe cognitive impairment and required maximal assistance with oral hygiene and eating. Despite these needs, the resident had not been seen by a dentist or had their teeth cleaned in over a year, as confirmed by the resident's representative and the Director of Nursing Services. The last dental visit was recorded in September 2022, where the resident was diagnosed with gingivitis and noted to have a chipped front tooth. Observations and interviews revealed that the resident's teeth were dark gray/black in color, with a broken front bottom tooth. Although the resident did not report pain and could eat without complications, the condition of their teeth indicated a lack of routine dental care. Staff interviews confirmed the resident's refusal to allow teeth brushing, accepting only oral swabs for hygiene. The facility's contract with a third-party dental service had lapsed, and efforts to renew it were ongoing, contributing to the delay in providing necessary dental care.
Failure to Provide Routine Dental Services
Penalty
Summary
The facility failed to provide routine dental services for Resident 20, who was admitted with a stroke, left-sided paralysis, and significant contractures. The resident was dependent on staff for all personal care needs, including oral care. Despite the care plan indicating that the resident's teeth should be brushed after meals, observations revealed that the resident's teeth were not clean, with a white substance around the bottom teeth and a brownish crusty film on the upper and lower back teeth. The resident's representative reported that it had been years since the facility referred the resident for routine dental checkups. The Director of Nursing Services (DNS) stated that the facility had not used their mobile dental services since 2020, and it was the responsibility of Resident Care Managers to set up routine dental appointments. The last recorded dental service for Resident 20 was in June 2021, where a mobile dental service noted generalized tooth wear due to bruxism but no signs of infection. The lack of routine dental care resulted in a delay in treatment, placing the resident at risk for dental pain and unmet dental needs.
Infection Control Deficiencies in Hand Hygiene and Sterile Technique
Penalty
Summary
The facility failed to implement proper infection prevention and control measures, specifically in hand hygiene and glove changes, during resident care and wound treatment. Staff members BB, CC, and DD did not perform hand hygiene after removing soiled gloves and before applying new ones, despite being aware of the correct procedures. This lapse occurred during the care of Resident 18, who had severely impaired cognition and an unhealed wound, and Resident 14, who had moderately impaired cognition and required assistance with daily activities. Staff members admitted to not following the normal process, which included using gloves stored in their pockets and wearing two pairs of gloves to avoid hand hygiene. In another instance, the facility failed to maintain sterility during a central venous catheter dressing change for Resident 8, who had a right chest implanted port and was receiving intravenous medication. Staff W, an RN, did not maintain sterility while handling the Huber needle and used non-sterile gloves to disinfect the port site. This breach in sterile technique was acknowledged by Staff W, who realized the mistake after reviewing the process with the surveyor. The Director of Nursing Services confirmed that the procedure was not performed correctly, necessitating a repeat of the dressing change. Additionally, the facility did not adhere to enhanced barrier precautions (EBP) for a high-contact resident care activity involving a central line dressing change. Staff C, a Resident Care Manager, entered Resident 8's EBP room without donning the required gown, only wearing gloves. Staff C acknowledged the oversight, and the Infection Preventionist confirmed that the correct process was not followed. These failures increased the risk of cross-contamination and transmission of infectious diseases among residents.
Environmental Deficiencies in Resident and Utility Areas
Penalty
Summary
The facility failed to maintain a safe, functional, and sanitary environment in several areas, including three resident rooms, a soiled utility room, a clean utility room, and a laundry room. Observations revealed significant damage to the walls in the resident rooms, with deep gouges and missing paint, which were not addressed in a timely manner. The facility's Administrator expected repairs to be completed within 48 hours, but there was a lack of communication and follow-up to ensure this was done. The Director of Building and Grounds admitted to not conducting routine audits in these areas, which contributed to the oversight. In the clean utility room, there was an unpainted, uncleanable plywood surface with jagged edges around electrical outlets, and water-stained light covers. The soiled utility room had multiple holes in the drywall, unpainted surfaces with stains, and unfinished wood with rusty hooks, indicating a lack of maintenance and sanitation. The Director of Building Grounds acknowledged these issues and the need for routine audits to prevent such oversights. The laundry room had an active water leak from a hot water hose, causing water to spread under the laminate flooring and damage the sheetrock wall. The flooring was missing in sections, and the wall showed signs of previous water damage. The Director of Building Grounds was aware of the recurring leak and recognized the need for repairs to the flooring and wall. These deficiencies increased the risk of infections due to non-cleanable surfaces and compromised the safety and security of the environment for residents and staff.
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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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