Sunnyside Healthcare Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Sunnyside, Washington.
- Location
- 721 Otis Avenue, Sunnyside, Washington 98944
- CMS Provider Number
- 505226
- Inspections on file
- 45
- Latest survey
- March 9, 2026
- Citations (last 12 mo.)
- 23
Citation history
Health deficiencies cited at Sunnyside Healthcare Center during CMS and state inspections, most recent first.
The facility failed to honor resident choice regarding shower times when it eliminated the shower aide role and reassigned showers to NAs, splitting them between day and evening shifts without consulting residents. A resident who was independent with ADLs but had moderately impaired cognition reported being moved to evening showers without being asked, despite preferring daytime showers. Another resident with post-stroke paralysis and moderately impaired cognition was routinely awakened early for showers, although their representative stated the resident preferred to sleep in and bathe in the afternoon; an NA confirmed this resident’s shower was always done first, before breakfast. A third resident with diabetes, paraplegia, and depression, who was cognitively intact and required substantial assistance, reported being informed of the staffing change but not given any choice between day or evening showers, despite assessments indicating that making choices about customary routines and activities was very important to all three residents.
The facility did not ensure residents were involved in decisions about their restorative and therapy services when frequencies and durations were reduced. One resident with diabetes and paraplegia, who had intact cognition and required assistance with ADLs, had an AROM program reduced from six to three sessions per week and reported not being informed of the change or the shortening of sessions. Another resident with post-stroke left-sided weakness, lung disease, and HTN had an AROM program similarly reduced, while the resident’s representative stated they had been told at a care conference that services were being provided daily and were not informed of any changes. These actions were inconsistent with the facility’s policy requiring resident participation in person-centered care planning, including changes to the type, amount, frequency, and duration of care.
A resident with rheumatoid arthritis and spinal compression fractures, who required extensive assistance with ADLs, had a standing q6h narcotic pain medication order but experienced multiple missed doses when the facility ran out of the medication. The resident reported significant pain and stated staff told them the pharmacy would not refill the narcotic until a new prescription was obtained and that no backup dose was available from the emergency supply. An LPN and the DON confirmed that the established refill process—requesting refills when seven doses remained and using emergency backup narcotics with a pharmacy authorization code if needed—was not followed, and confusion with the pharmacy order prevented timely access to the narcotic medication.
Three residents with various medical conditions, all cognitively intact and at least partially independent with eating, consistently received meals that were not hot, with food and plates arriving cold. Residents reported their concerns to dietary staff and filed grievances, but the issue persisted. Staff confirmed awareness of the problem and cited lack of equipment and funding as contributing factors, resulting in meals not being served at a safe and appetizing temperature.
A broken pipe under the kitchen floor led to restroom water backing up into the kitchen, resulting in unsanitary conditions. Staff used a shop vac to remove water from a soiled catch basin, with exhaust blowing onto open meal carts, and were unable to maintain proper dishwashing and sanitation. The Infection Preventionist was not involved in planning, and the kitchen was deemed unsanitary by staff.
A resident with multiple health conditions and moderate cognitive impairment was served meals on paper plates with a plastic spork for an extended period, reportedly due to a broken dishwasher. The resident expressed distress and a loss of dignity as a result. The DON was unaware of the use of disposable mealware and stated that decisions regarding meal service items were handled by the kitchen.
Two residents with physical impairments affecting their hands were unable to eat independently after the facility switched to plastic sporks and disposable dishware due to a kitchen issue. Both residents, who were cognitively intact and previously able to eat with metal or regular plastic utensils, reported difficulty and dissatisfaction with the sporks. Staff were aware of the complaints but had limited alternatives, and facility leadership was not fully informed about the ongoing use of disposable items.
The facility failed to maintain a sanitary environment by not consistently cleaning vents and changing filters in dining rooms, hallways, the kitchen, and the laundry room. Observations showed significant dust and dirt buildup, with some vents having spider webs and broken slats. Staff interviews revealed inadequate cleaning schedules, and records showed inconsistencies in maintenance documentation. The administrator acknowledged the need for more frequent monitoring and cleaning.
Two residents in an LTC facility received opioid pain medications without proper documentation of administration and effectiveness. One resident, receiving end-of-life care, had no record of morphine administration, while another recovering from surgery had incomplete documentation for oxycodone. The lack of documentation hindered the facility's ability to assess pain management effectiveness.
A visually impaired resident experienced psychosocial harm after being moved to a new room without proper orientation or consideration of their preferences. The resident, who had a history of anxiety and depression, struggled with the unfamiliar layout, leading to frustration and a decline in their usual activities. Staff noted the resident's increased sadness and frustration, and the resident's representative expressed dissatisfaction with the facility's handling of the room change.
A facility experienced a 12% medication error rate due to errors by an LPN, including incorrect dosing and failure to administer medications on time. One resident received an incorrect dose of Vitamin D, while another did not receive Colchicine or Zofran as prescribed. The DON noted that LNs should order refills timely and seek assistance if behind.
The facility failed to maintain a safe and sanitary kitchen environment, with ceiling damage and floor hazards posing risks of cross-contamination and foodborne illness. Staff acknowledged the issues but lacked a system for preventive maintenance.
A resident with blindness and anxiety was moved to a different room without prior written or verbal notification to them or their representative. The facility's policy requires notification and consent before room changes, but this was not documented or followed, as confirmed by interviews with staff and the resident's representative.
A resident reported rough handling by a night shift NA, but the facility failed to log or report the allegation to the State Agency. Despite the resident informing a day shift NA, and the issue being discussed with an LPN, the Social Service Director and DON were unaware of the incident, indicating a failure in the reporting process.
A resident reported rough handling by a night shift NA, describing the staff as rude. Despite informing a NA and an LPN, no investigation was initiated, and management was not informed. The facility's policy requiring investigation and staff removal was not followed.
A resident with severely impaired cognition signed a binding arbitration agreement without the involvement of their legal representative, contrary to facility policy. Staff interviews confirmed the resident's inability to understand the agreement, and the resident's representative, who held power of attorney, was not informed of the agreement.
The facility failed to implement infection control measures for Legionella, as evidenced by incomplete maintenance of water heaters and ice machines. Over ten months, required tasks were neglected, leading to mold-like biofilm growth in the ice machine. Staff interviews revealed a lack of awareness and involvement in the Water Management Plan, with the Maintenance Director and Assistant admitting to not following protocols. The Administrator and Infection Preventionist acknowledged the deficiencies.
Failure to Honor Resident Choice in Shower Scheduling
Penalty
Summary
The facility failed to honor residents' rights to self-determination and choice regarding shower times when it changed the shower schedule and eliminated the dedicated shower aide. The facility's Resident Rights policy from 02/2021 stated that residents had the right to a dignified existence and self-determination. Despite this, when the Director of Nursing Services and the Administrator implemented a change effective 03/01/2026, requiring NAs to perform showers on their own residents and splitting showers between day and evening shifts due to budget cuts and staffing changes, residents were not consulted or given a choice between day and evening showers. The Director of Nursing Services acknowledged that residents were not given a choice and stated they assumed residents would not want evening showers and that the workload needed to be split between shifts. The Administrator also stated residents should have been given a choice and was not aware that they had not been consulted. Resident 1, admitted with a right knee dislocation, anxiety, and a need for assistance with personal care, had a comprehensive assessment dated 01/06/2026 showing independence with ADLs, moderately impaired cognition, and that it was very important for them to make choices about customary routines and activities. Resident 1 reported they were not informed of the shower schedule change, were assigned to evening showers, and preferred daytime showers, stating they wished staff had asked their preference. Resident 2, admitted with left-sided weakness/paralysis after a stroke, lung disease, and high blood pressure, was dependent on one to two staff for ADLs, had moderately impaired cognition, and also had an assessment indicating it was very important to make choices about routines and activities. Resident 2’s representative reported staff woke the resident early for showers, which the resident disliked, and that the resident preferred to sleep in and shower in the afternoon; a NA confirmed they had always completed this resident’s shower first, before breakfast. Resident 3, admitted with diabetes, paraplegia, and depression, required substantial assistance for showers, was cognitively intact, and had an assessment indicating the importance of making choices about routines and activities. Resident 3 stated they were told the shower aide would no longer provide showers and that they were not given a choice of day or evening showers.
Failure to Involve Residents in Changes to Restorative Care Plans
Penalty
Summary
The facility failed to ensure residents were provided the opportunity to participate in decisions about their care and treatment, specifically related to restorative nursing and therapy services. Facility policy dated 03/2022 stated that residents had the right to participate in the development and implementation of their comprehensive person-centered care plan, including determining the type, amount, frequency, and duration of care, receiving the services in the care plan, and seeing and signing the care plan after significant changes. For one resident with diabetes, paraplegia, and depression, whose comprehensive assessment showed intact cognition and a need for partial to maximum assistance with ADLs, the medical record documented a restorative nursing AROM program at a frequency of six times per week. The care plan, initiated on 10/30/2025, was later modified on 03/05/2026 to reduce the AROM frequency to three times per week. During interview, this resident reported frustration about the change in therapy services, stating they were not informed of the reduction from six to three days per week and that session length had been cut from 30 minutes to 20 minutes. A second resident, with left-sided weakness/paralysis after a stroke, lung disease, and hypertension, was assessed as dependent on one to two staff for ADLs and having moderately impaired cognition. This resident’s care plan showed an AROM program initiated at six times per week, which was also reduced to three times per week on 03/05/2026. In an interview, the resident’s representative stated that at a recent care conference they were told the resident was receiving restorative nursing services every day, but they did not know if that was occurring and were not informed of any changes in services. These findings showed that changes in restorative/AROM frequency and duration were made without informing or involving the residents or their representative as required by the facility’s person-centered care planning policy.
Failure to Ensure Continuous Availability of Ordered Narcotic Pain Medication
Penalty
Summary
The facility failed to provide pharmaceutical services to ensure accurate acquiring, receiving, dispensing, and administering of drugs for one resident. The resident had rheumatoid arthritis and a history of spinal compression fractures, required maximum assistance for activities of daily living, and had intact cognition. A physician’s order dated 10/01/2025 directed that a narcotic pain medication be administered every six hours for rheumatoid arthritis. Review of the January 2026 MAR showed multiple missed doses of this narcotic pain medication on 01/27/2026 and 01/28/2026, as well as the midnight dose on 01/29/2026. During observation and interview, the resident reported that the facility did not have their narcotic pain medication available, resulting in six missed doses, and described pain throughout their body, including hands, back, feet, and elbows. The resident stated staff told them the medication had run out and the pharmacy would not refill it until a new prescription was written, and that there was no backup supply available from the emergency supply. Staff interviews confirmed that the facility’s processes for refilling and administering medications were not followed. An LPN explained that the standard process was to request refills when the medication card reached the blue section, indicating seven doses remaining, and that if a medication ran out before the refill arrived, a dose could be obtained from the emergency backup supply using a pharmacy authorization code. For this resident, the LPN stated there was a problem receiving the narcotic from the pharmacy, and although the provider was contacted and a new prescription sent, staff were unable to obtain an authorization code from the pharmacy due to confusion with the order, resulting in the resident going without the narcotic pain medication until the pharmacy resolved the issue. The DON stated that narcotic refills were to be requested at least seven days before the resident ran out and acknowledged that the process for refilling and administering medications was not followed. The Administrator stated that licensed nurses were responsible for communicating with the provider and pharmacy to ensure residents had needed medications and to request refills before medications were depleted.
Failure to Serve Meals at Safe and Appetizing Temperatures
Penalty
Summary
The facility failed to serve meals at a preferred temperature for three residents reviewed for food temperatures. Observations and interviews revealed that residents consistently received meals that were not hot, with food and plates often arriving cold. One resident, who was independent with ADLs and cognitively intact, reported repeated experiences of cold food, voiced concerns to the Dietary Manager, and filed a grievance, but noted that nothing was done. Another resident, dependent on staff for ADLs but independent with eating, also reported consistently cold meals, lack of plate warmers or covers, and stated that grievances had not led to any changes. A third resident, with similar dependencies and cognitive status, expressed a preference for hotter meals and reported informing staff about the issue. Staff interviews confirmed awareness of the ongoing complaints regarding cold food. The Dietary Manager acknowledged the purchase of thermal pellets intended to keep food warm but indicated that the necessary warming device had not been approved for purchase, and the kitchen lacked insulated carts. The Administrator was also aware of the issue and stated that additional parts were needed for the plate warmers, but there were insufficient funds to purchase them. Despite food leaving the kitchen at the appropriate temperature, the facility was unable to ensure that meals arrived to residents at a safe and appetizing temperature.
Unsanitary Kitchen Conditions Due to Plumbing Failure
Penalty
Summary
The facility failed to maintain a clean and sanitary environment in the Main Kitchen, as required for food preparation and storage safety. A broken pipe under the kitchen floor caused water from restrooms to back up into the kitchen through the drains, resulting in unsanitary conditions. Observations revealed a soiled catch basin with dark brown residue, folded blankets placed over drains, and a shop vac being used to remove water from the catch basin. The shop vac's exhaust was directed onto open meal delivery carts, and staff reported that the kitchen and dishwasher area were not sanitary and should not be used. The dishwasher was out of service due to drainage issues, and staff had to switch to alternative dishwashing methods, which were insufficient to keep up with meal demands. Staff interviews confirmed that the drain problem began several days prior, with backflow of water that smelled and appeared contaminated. The restrooms adjacent to the kitchen were locked and out of service, and the dishwasher could not be used without the shop vac. The Infection Preventionist was not involved in planning for cross-contamination prevention and was unaware of the extent of the issue. The Dietary Manager and other staff described the backflow as brown and gunky, and the Director of Nursing Services stated the kitchen was not sanitary. The facility's policy required maintaining a clean and sanitary food service area, which was not met due to the ongoing plumbing failure and inadequate interim measures.
Failure to Provide Dignified Dining Experience Due to Use of Disposable Mealware
Penalty
Summary
The facility failed to provide a dignified dining experience for a resident who was reviewed for dignity. The resident, who had diagnoses including heart failure, arthritis, and weakness, required substantial assistance with activities of daily living and supervision for eating, and had moderately impaired cognition but was able to express their needs. During an observation and interview, the resident was found sitting in their room, visibly upset and crying, with a Styrofoam cup of ice water and a meal served on a paper plate with a plastic spork. The resident reported feeling that their dignity was taken away due to being served meals on disposable items for an extended period, attributing this to a broken dishwasher as communicated by staff. The Director of Nursing Services (DON) was interviewed and stated they were not aware that paper products were being used for meal service and indicated that maintaining resident dignity involved staff training and the grievance process. The DON also stated they were not involved in the decision to switch to paper items, as it was considered a kitchen issue. The facility's policy on resident rights emphasized the importance of treating residents with respect, kindness, and dignity, in accordance with federal and state laws.
Failure to Provide Appropriate Eating Utensils and Dishware for Residents with Physical Limitations
Penalty
Summary
The facility failed to ensure that two residents maintained their ability to eat independently by not providing appropriate eating utensils and dishware. One resident with rheumatoid arthritis and deformed fingers reported difficulty using the provided plastic spork and Styrofoam containers, stating that these made it hard to access and eat food. This resident preferred metal silverware and found the spork unusable due to their arthritis, despite informing staff of the issue. Another resident with Parkinson's disease and neuropathy also reported being unable to use the plastic spork, stating they could feed themselves with a metal fork or, to some extent, a plastic fork, but not with the spork. Both residents were cognitively intact and had previously been able to eat independently or with minimal assistance. The use of plastic sporks and disposable dishware began after a kitchen pipe broke, rendering the dishwasher unusable. The dietary manager confirmed that regular plastic utensils ran out, leading to the exclusive use of sporks. Nursing staff were aware of resident complaints and would substitute a regular plastic fork if available, but supplies were limited. The director of nursing was not aware of the switch to disposable items, and the administrator believed the use of paper/plastic products was only for a single meal, not an ongoing practice. This lack of coordination and communication resulted in residents not receiving the necessary goods and services to maintain their ability to eat independently.
Facility Fails to Maintain Sanitary Environment Due to Inadequate Vent Cleaning
Penalty
Summary
The facility failed to maintain a sanitary and homelike environment by not consistently cleaning the heating and air exchange vents and changing the filters in various areas, including four dining rooms, three hallways, the kitchen, and the laundry room. Observations revealed significant dust and dirt buildup on vents, with some vents having visible spider webs and broken slats. The presence of built-up dust and dirt was noted in the Garden, Private, Transition Care Unit, and [NAME] dining rooms, as well as in Hallways 100, 200, and 300, and the kitchen's dry storage and dishwashing areas. In the laundry room, thick dust and lint were observed on the vents, exhaust pipes, and water piping, indicating a lack of regular cleaning. Interviews with staff revealed that the responsibility for cleaning vents was divided between housekeeping and maintenance, with maintenance being responsible for higher areas. However, the maintenance director admitted to cleaning vents only every six months and lacked a schedule for changing filters, relying instead on visual assessment. The facility's records showed inconsistencies in the documentation of cleaning and maintenance activities, with some entries lacking completion details. The administrator acknowledged that daily walkthroughs should have been conducted to identify areas needing more frequent cleaning. The maintenance director recognized the need to restructure the cleaning process to ensure more frequent monitoring and cleaning of vents and filters.
Failure to Document Opioid Administration and Effectiveness
Penalty
Summary
The facility failed to provide goods and services that met professional standards of care for two residents who were administered opioid pain medications. For Resident 3, who had severe cognitive impairment and was receiving end-of-life care, there was no documentation of morphine sulfate administration on the medication administration record (MAR) or in the nursing progress notes on the day it was given. Staff D, the LPN responsible, recalled administering the medication but did not document it, leaving no record of the resident's symptoms or the medication's effectiveness. Resident 7, who was recovering from surgery and experiencing moderate pain, also experienced a lack of proper documentation. The resident received oxycodone for pain, but Staff E, the LPN, failed to document the assessment of pain or the effectiveness of the medication in the MAR and progress notes for one of the doses. This lack of documentation made it difficult to assess the frequency and effectiveness of the pain management provided to the resident. The Assistant Director of Nursing expressed concern over the lack of documentation, as it hindered the ability to review and determine the effectiveness of pain management. The Director of Nursing acknowledged the issue and indicated that steps were being taken to address the problem, although specific corrective actions were not detailed in the report.
Failure to Accommodate Visually Impaired Resident's Needs
Penalty
Summary
The facility failed to accommodate the needs and preferences of a visually impaired resident, Resident 6, leading to psychosocial harm. Resident 6, who was legally blind and had a history of anxiety, depression, and end-stage renal disease, was moved to a new room without proper orientation or consideration of their preferences. The resident's care plan indicated a preference for room arrangements that promoted independence, such as having the bed on the right side, but the new room setup did not reflect these preferences. The resident expressed discomfort with the new environment, which was not addressed in the care plan. Resident 6 had previously expressed dissatisfaction with a roommate due to cleanliness and odor issues, leading to a request for a room change. Despite the request, the move to a new room was not handled with the necessary support, as therapy staff were not involved, and the resident was not oriented to the new environment. This lack of orientation and the unfamiliar room setup caused Resident 6 to experience difficulty navigating the space, leading to frustration and a decline in their usual activities and mood. Observations and interviews revealed that Resident 6 struggled with the new room's layout, including the bathroom and closet, which were not conducive to their needs. The resident's inability to find their way around the room independently led to a decrease in their social interactions and activities, such as walking to the dining room and listening to music. Staff noted the resident's increased frustration and sadness, and the resident's representative expressed dissatisfaction with the facility's handling of the room change, highlighting the lack of communication and support for Resident 6 during the transition.
Medication Administration Errors and Delays
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, as evidenced by a 12% error rate observed during a medication pass. Staff O, a Licensed Practical Nurse, made three errors out of 25 opportunities for error. One error involved administering an incorrect dose of Vitamin D to Resident 16, who had intact cognition and was diagnosed with diabetes and vitamin D deficiency. Staff O dispensed only one tablet of Vitamin D instead of the required two tablets, resulting in an incorrect dose being administered. Another error involved Resident 32, who had moderately impaired cognition and was diagnosed with diabetes and gout. Staff O failed to administer Colchicine due to an empty medication card and did not reorder the medication in time. Additionally, Resident 32 did not receive Zofran before breakfast, as required, because Staff O was delayed in the medication pass after assisting with a difficult resident. This led to Resident 32 refusing the medication due to an upset stomach. The Director of Nursing Services acknowledged that LNs should order refills when the medication card reaches the highlighted blue column and should seek help if they fall behind in their duties.
Facility Fails to Maintain Safe and Sanitary Kitchen Environment
Penalty
Summary
The facility failed to maintain a safe, functional, and sanitary environment in the kitchen area, which posed risks of cross-contamination and foodborne illness to residents. During an observation, it was noted that the ceiling above the dishwasher hood had missing plaster and drywall, with chunks falling onto the hood. Dust balls with fuzzy black spots were also observed hanging from the ceiling over the freezers and refrigerators. Staff H, the Dietary Manager, confirmed that a water leak had caused the ceiling damage, which had been reported to maintenance and the administrator but remained unaddressed. Additionally, the kitchen floor had several areas of concern, including an open floor area in front of the sinks with exposed underflooring, which posed a tripping hazard. There were multiple seam separations in the linoleum flooring, missing flooring pieces, and accumulations of black substances in various areas. Staff F, the Maintenance Director, acknowledged responsibility for cleaning and repairing these areas but admitted that there was no operational system for preventive maintenance or scheduled repairs. The administrator also recognized the need for a kitchen project to address these issues.
Failure to Notify Resident of Room Change
Penalty
Summary
The facility failed to provide written notification of a room change to Resident 6 or their representative, as required by their policy. Resident 6, who was admitted with diagnoses including blindness and anxiety, was transferred to a different room without prior written or verbal notification to the resident or their representative. The medical record review showed no documentation of notification or the reason for the room change from 11/15/2024 to 11/19/2024. Interviews with the Resident Representative and facility staff revealed that the notification process was not followed. The Resident Representative confirmed they did not receive any notification before the room change. Staff P, the Social Service Director, stated that they usually notify and obtain consent prior to a room change, but acknowledged that the resident and/or representative had not signed the notice of room change. Staff B, the Director of Nursing Services, also confirmed that the process involves obtaining consent and making appropriate notifications before a room change.
Failure to Report Alleged Abuse
Penalty
Summary
The facility failed to report allegations of potential abuse and/or neglect to the State Agency for one resident, which placed residents at risk for unidentified abuse or neglect. The facility's policy required reporting allegations of abuse to the appropriate authority, but this was not followed in the case of a resident who reported rough handling by a night shift nursing assistant (NA). The resident, who was cognitively intact and able to communicate their needs, reported that the NA was rough during perineal care and had a mean demeanor. The resident informed a day shift NA about the incident, but no grievance or allegation was logged or reported to the State Agency. Interviews with staff revealed that the day shift NA informed an LPN about the resident's allegations, and they both discussed the incident with the resident. However, the Social Service Director and the Director of Nursing Services were unaware of the allegations, indicating a breakdown in communication and reporting processes. The Director of Nursing Services acknowledged that the concerns should have been reported to both the DNS and the State Agency, but the correct process was not followed.
Failure to Investigate Allegation of Abuse
Penalty
Summary
The facility failed to conduct a thorough investigation into an allegation of abuse involving a resident, identified as Resident 69, who was cognitively intact and able to communicate their needs. The resident reported an incident of rough handling by a night shift nursing assistant (NA), describing the staff member as rude and likening their behavior to that of a linebacker. Despite the resident's report to Staff II, a nursing assistant, and Staff JJ, an LPN, no formal grievance or investigation was initiated as required by the facility's policy. Staff II and Staff JJ both acknowledged being informed of the resident's concerns and identified the night shift NA involved as Staff KK. However, they failed to report the incident to management, which resulted in no investigation being conducted. The Director of Nursing Services and the Social Service Director confirmed they were not informed of the allegation, and the Administrator acknowledged that the correct process was not followed, as the investigation should have been initiated and the staff member in question should have been removed from duty pending the investigation.
Failure to Ensure Cognitive Capacity for Arbitration Agreement
Penalty
Summary
The facility failed to ensure that a resident had the cognitive capacity to understand the nature and implications of entering into a binding arbitration agreement. This deficiency was identified for one resident, who was admitted with diagnoses including a leg fracture, heart complications, and difficulty walking. A comprehensive assessment indicated that the resident had severely impaired cognition. Despite this, the resident signed an arbitration agreement without the involvement of a legal representative, which was contrary to the facility's policy that requires a legal representative to sign if the resident is not cognitively intact. Interviews with staff and the resident's representative revealed that the resident was confused and unaware of signing the arbitration agreement. The resident's representative, who held power of attorney, was not informed of the agreement and stated that the resident was not capable of understanding or signing documents. Staff involved in the admission process acknowledged that the resident's cognitive impairment should have necessitated the legal representative's signature on the arbitration agreement. The failure to ensure proper understanding and representation during the signing of the arbitration agreement led to the identified deficiency.
Inadequate Implementation of Infection Control Measures
Penalty
Summary
The facility failed to implement components of their infection prevention and control precautions regarding Legionella testing protocols and procedures. The facility's Water Management Plan (WMP) was not adequately followed, as evidenced by the lack of monthly flushing of water heaters and sanitization of the ice machine. Over a ten-month period, these tasks were only completed three times, leaving seven months without proper maintenance. During an inspection, a black, fuzzy, mold-like biofilm was observed on the underside of the ice collecting bin in the ice machine, indicating a failure to maintain control measures. Interviews with facility staff revealed a lack of awareness and involvement in the development and execution of the WMP. The Maintenance Director, who was not involved in the WMP's creation, admitted to not knowing the process if control measures were unmet. The Maintenance Assistant also confirmed that the ice machine was not sanitized in the past month. The facility's Administrator acknowledged that the biofilm growth showed control measures were not within acceptable ranges, and the Infection Preventionist confirmed that the ice machine appeared to have mold growth, which should have been regularly cleaned.
Latest citations in Washington
A resident with cerebral palsy and a court-appointed guardian experienced multiple episodes of nausea, vomiting, loose stools, abdominal discomfort, fatigue, and later refusal of meals and medications, leading to changes in the care plan including close monitoring, lab testing, and IV fluid administration. Despite a facility policy recognizing court-appointed guardians as resident representatives with decision-making authority, staff did not document any notification to the guardian during these changes in condition or treatment decisions. The guardian reported not being contacted when the resident stopped eating or developed stomach issues and felt the facility did not respect the guardianship, while the DON acknowledged there were multiple missed opportunities to notify the guardian of the resident’s change from baseline.
A resident with depression, anxiety, moderate cognitive impairment, and urinary incontinence, care-planned for q2h checks and assistance with toileting, was found by a visitor to be soaking wet, unusually agitated, and reporting they had been told to wait to be changed and referred to with a derogatory remark. The visitor filed a written grievance alleging abuse/neglect related to delayed incontinence care and removal of the resident’s tablet as a consequence. Although an incident report noted that the matter was reported to the state and that the resident was not soaking wet, a CNA who actually changed the resident later reported the resident’s brief, pants, wheelchair, and socks were soaked and that the resident was acting timid and repeatedly saying they had to sit for five minutes, but this CNA was never interviewed. The DON acknowledged not investigating the resident’s behavior or interviewing this CNA, and the grievance official acknowledged the facility did not fully investigate or communicate findings and resolution to the complainant, resulting in a failure to follow the facility’s grievance policy.
A resident with dementia, respiratory failure, and heart failure developed new shortness of breath with an O2 sat of 90%, and a physician ordered transfer to the ED for tx and eval. An RN completed an SBAR, notified the MD and family, and reported to the oncoming nurse that the resident needed ED transfer and that paramedics should be contacted, then left the facility. Instead of calling 911 for this emergent respiratory distress, staff arranged non-emergent transport through a contracted ambulance service, resulting in the resident remaining at the facility for several hours without pickup until the dispatcher later instructed staff to call 911. The DON stated that 911 is expected to be used for emergent conditions and the contracted service only for non-emergent transport.
A resident with anoxic brain injury, dysarthria, and documented lack of decisional capacity alleged physical abuse and expressed fear of their identified representative, yet social services only reported the allegation to the state and did not complete an incident report, revise the care plan, or implement protective interventions. The same representative continued to be treated as the resident’s decision-maker and visited frequently, with staff noting suspicious odors of foreign substances and concerns about possible illicit substance use. Psychiatry later documented concern that the representative was providing illicit substances, and the resident was subsequently hospitalized for altered mental status and overdose, after which the representative was banned. Key staff, including the DON, unit manager, and administrator/abuse coordinator, were unaware of the initial abuse allegation, and social services did not timely explore or clarify legal decision-making authority or alternative representation for the resident.
A resident with severe cognitive impairment, osteoarthritis, and spinal spondylosis, care planned for 2-person Hoyer transfers, was being moved by two CNAs using a mechanical lift when one corner loop of the sling became disengaged, causing the resident to fall about four feet, strike the floor and the lift, and sustain head abrasion, multiple rib fractures, and lumbar vertebral fractures. Facility policy required staff to verify secure sling attachment, examine hooks, clips, fasteners, and strap stability, and ensure the sling bar was sound before lifting, but during this transfer the sling loop detached despite staff believing it was properly fastened and hearing it click into place; post-incident assessment showed the loop had come loose, the sling appeared in good condition, and a CNA later reported thinking one of the round metal disks on the lift might have been slightly loose, while maintenance logs documented no prior concerns with the lifts or slings.
The facility failed to revise and individualize care plans to reflect current needs and preferences for multiple residents, including one cognitively intact resident with hemiplegia, hemiparesis, and mononeuropathy who had bilateral shoulder surgery and could not tolerate BP measurements on the upper arms but preferred forearm readings. Despite repeatedly informing staff, this preference was not documented in the care plan or Kardex, and direct care staff and the RN/UM were unaware of it. Another cognitively intact resident with hemiplegia, contractures, and weakness reported they were supposed to get out of bed for two hours daily, but some NACs did not know this, even though the MAR/TAR contained an order to document times up and back to bed. The surveyors concluded that care plans were not accurately revised for several residents, placing them at risk for unidentified and unmet care needs and diminished quality of life.
Surveyors found that two residents with hemiplegia, hemiparesis, weakness, and contractures did not receive restorative nursing services, including ROM exercises and splint/brace or orthotic assistance, after therapy discharge. Although PT and OT discharge summaries documented established restorative ROM and transfer programs, recommended PROM to affected extremities, and recommended splint/brace use and assistance with orthotic wear, these recommendations were not entered as restorative referrals in the EHR. As a result, the residents’ care plans and records showed no restorative programs, and both residents reported that therapy and restorative exercises had stopped, while the DON, rehab director, and MDS coordinator confirmed they were unaware of and had not implemented the recommended restorative services.
A resident with cancer, cognitive impairment, and declining strength experienced multiple unwitnessed falls, most occurring while attempting to toilet or move toward the bathroom, culminating in a fractured ankle requiring ED treatment. Although assessments identified fall and incontinence risks and the facility’s policy required individualized interventions, the comprehensive care plan lacked a toileting plan and did not include several interventions that were discussed in incident investigations, such as consistent wheelchair placement and frequent rounding for bathroom assistance. Staff reported relying on verbal reminders and education to use the call light, despite acknowledging the resident’s impulsivity and failure to call for help, and the resident’s bed remained furthest from the bathroom while repeated bathroom-related falls occurred without the trend being recognized or addressed in the care plan.
A resident with a history of acute urinary retention and acute kidney injury had a Foley catheter deemed permanent by the hospital, with instructions that it not be removed in the SNF. At a later urology visit, the catheter was removed, and the resident returned with no new orders documented. Facility staff did not document bladder assessments, post-void residuals, or urine output, and CNA documentation showed the resident did not void that evening. Over the next day, the resident had vomiting, poor intake, altered level of consciousness, tachycardia, hypotension, and no documented wet briefs. A bladder scan eventually showed more than 2000–2500 mL of retained urine, and a new catheter drained a large volume. The resident and a roommate reported moaning, crying out in pain, and repeatedly alerting staff that the resident was not urinating and that the catheter was not draining, while nurses documented catheter care when no catheter was in place and later had to flush and replace the catheter due to continued complaints.
Surveyors found that nurses and nurse aides did not consistently administer medications according to professional standards and facility policy. Multiple residents reported that agency nurses were slow with medications, did not fully follow instructions, and often gave routine meds late. Observations showed an LPN administering expired Humalog/Lispro insulin well past the scheduled time, an LPN giving several scheduled meds (including Tizanidine) late and all at once, and an RN attempting to give sliding-scale insulin nearly two hours late, which a resident refused after already eating. Another resident received Methocarbamol two hours late after questioning the RN, and a resident on scheduled Tramadol had doses given without timely documentation, with a discrepancy between the narcotic count and pills remaining. These events demonstrated failures in timely administration, use of non-expired medications, and immediate, accurate MAR and narcotic documentation.
Failure to Notify Court-Appointed Guardian of Resident’s Clinical Changes
Penalty
Summary
The deficiency involves the facility’s failure to notify a resident’s court-appointed guardian of significant clinical changes and care decisions, contrary to its own policy and state requirements. The facility’s policy on Resident Representatives, revised 02/2021, states that a resident representative includes a court-appointed guardian or conservator and that the facility treats the representative’s decisions as those of the resident to the extent delegated or required by the court. Resident 1, admitted with cerebral palsy, had a Superior Court guardianship letter dated 02/07/2025 indicating a guardian of person and conservator of the estate with full authority, identifying Collateral Contact 1 (CC1) as the guardian. Despite this, multiple clinical events and changes in condition were documented without any corresponding documentation that CC1 was notified. Progress notes and provider notes show that Resident 1 experienced an episode of nausea and vomiting, frequent loose stools, abdominal discomfort, bloating, worsening fatigue, generalized weakness, and later refusal of meals and medications over at least a 24-hour period, with observations that the resident appeared frailer, more fatigued, and had no energy or interest to talk. The provider developed care plans including close monitoring for deterioration, sending stool to the lab, and later initiating IV fluids for rehydration, with a plan to call family/POA for discussion. However, there was no documentation that the guardian was notified at any of these points, including when IV fluids were started. CC1 reported that they were not contacted when the resident stopped eating or developed stomach issues, and expressed that the facility did not respect their guardianship and that involvement in care planning took too long. The DON confirmed on record review that there were many opportunities to notify the guardian when the resident’s condition changed from baseline and that there was no evidence staff did so.
Failure to Thoroughly Investigate and Resolve Resident Grievance Regarding Incontinence Care and Staff Conduct
Penalty
Summary
The deficiency involves the facility’s failure to thoroughly investigate and resolve a grievance alleging neglect and disrespect toward a resident, as required by its grievance policy. The resident had depression, anxiety, moderate cognitive impairment, occasional urinary incontinence, and required moderate assistance with toileting, with a care plan directing staff to check the resident every two hours, ask about toileting needs, and ensure they were clean and dry. A collateral contact reported arriving to visit the resident and finding them soaking wet and agitated, with behavior that was not typical for the resident. The collateral contact documented in a written grievance that the resident’s tablet was off, the resident appeared upset, and the resident reported being told they had to wait five minutes to be changed and that staff would change their “nasty *ss” in five minutes, leading the collateral contact to believe the resident had been given a consequence of no tablet and sitting in wet clothes, which they characterized as abuse/neglect and requested immediate removal of the responsible staff and a report filed. The facility documented receipt of the grievance and created an incident report indicating the matter was reported to the state agency, and that the unit manager interviewed the collateral contact and the resident, with the resident described as confused and denying being soaking wet. The incident report stated that a different nursing assistant was assigned to assist with the brief change and that the unit manager believed the resident was not soaking wet, and that the resident and collateral contact were satisfied when they left the room. However, a CNA who actually changed the resident reported that the resident’s brief was soaked through their pants onto the wheelchair and their socks were soaked, and that the resident was timid, repeatedly saying they had to sit for five minutes, and not acting like themselves; this CNA stated they were never interviewed or asked about the grievance or the resident’s condition. The DON acknowledged not interviewing this CNA or investigating the resident’s behavior and why they were upset, and the unit manager did not recall whether the collateral contact was present during follow-up and did not believe they followed up with the collateral contact regarding the grievance. The administrator, identified as the Grievance Official, stated the facility should have thoroughly investigated the grievance and discussed findings and resolution with the collateral contact, indicating the grievance process was not fully carried out in accordance with policy and WAC 388-97-0460.
Failure to Obtain Timely Emergency Transport for Resident in Respiratory Distress
Penalty
Summary
The deficiency involves the facility’s failure to obtain timely emergency medical services for a resident experiencing new-onset respiratory distress. The resident had dementia, respiratory failure, and heart failure, with severe cognitive impairment and a need for substantial assistance with activities of daily living. On the day the resident was sent to the hospital, a collateral contact observed the resident having difficulty breathing, appearing unable to get enough air, and looking as if they were sleeping or unconscious, and reported this to staff with a request to contact the doctor. An SBAR Communication Form documented that the resident was experiencing shortness of breath that had not occurred before, with an oxygen saturation of 90%. The physician was notified and ordered the resident sent to the emergency department for treatment and evaluation, and the collateral contact was notified shortly thereafter. Progress notes later documented that, despite the order for emergency department transfer, the resident was still awaiting pickup by Olympic transportation several hours later, with no estimated time of arrival. At approximately 3:30 AM, the dispatcher informed the facility that they could not provide transportation and instructed that 911 be called; only then was 911 contacted and the resident transported to the hospital via ambulance for respiratory distress. The RN caring for the resident stated they completed the SBAR, notified the physician and family, and at the end of their shift reported to the oncoming nurse that the resident needed to be sent to the emergency department for respiratory distress and that paramedics should be contacted, then left assuming 911 would be called. The DON stated that staff are expected to contact 911 for emergent conditions such as shortness of breath or respiratory distress, and that Olympic Ambulance is used only for non-emergent transport.
Failure to Provide Social Service Advocacy After Abuse Allegation and Questionable Representative
Penalty
Summary
The deficiency involves the facility’s failure to provide appropriate medically-related social services and advocacy for a resident following an allegation of abuse and concerns about the resident’s representative. The resident had an anoxic brain injury, dysarthria, moderate cognitive impairment, and was dependent on staff for activities of daily living. A hospital palliative care note documented that the resident lacked decisional capacity, had no DPOA, that the legal next of kin (CC4) did not want to be part of care decisions, and that care decisions were being deferred to another contact (CC5). CC5 accompanied the resident on admission, signed admission forms, and was listed as the primary contact in the medical record profile. On a date in February, during communication therapy, the resident reported that CC5 had done something to them, pounded their hands on their chest, recalled being hit in the back of the head by an unknown person, and stated they were sometimes afraid of CC5. A social services staff member reported this allegation to the state agency but did not complete a facility incident report, did not initiate care plan changes or interventions, and took no further action. CC5 continued to be treated as the resident’s representative, and progress notes documented CC5 at the bedside on multiple dates, including an entry noting the room smelled like foreign substances and that CC5 was seen waking the resident and then asking the nurse to administer pain medications. A psychiatry note later documented concern that CC5 was providing the resident with illicit substances and stated it would be prudent for the resident to identify a POA. Subsequently, the resident was found unresponsive, transported to the hospital, and later readmitted after altered mental status and overdose, with a provider note stating that CC5 posed a significant danger to the resident and was banned from visiting. After readmission, staff attempted to contact CC4 for consent to treat but initially reached someone who stated they were not CC4. The social service director acknowledged that, beyond reporting the initial allegation, no additional interventions were implemented, that CC5 continued to be used as the resident’s representative after the allegation, and that they had not explored legal authority for decision making following the abuse allegation or concerns about substances. The social service assistant reported they did not speak with the resident about the hospital stay or CC5 and did not complete an incident report or care plan changes after the allegation. The unit manager and DON were unaware of the initial abuse allegation, and the administrator, who served as abuse coordinator, also stated they were unaware of the allegation and that an investigation should have been initiated and a representative for the resident investigated at a minimum.
Injury from Mechanical Lift Sling Detachment During Transfer
Penalty
Summary
The facility failed to ensure a safe mechanical lift transfer when a resident was being moved with a Hoyer lift and sling, resulting in a fall and injury. Facility policy for using a mechanical lifting machine required staff to securely attach sling straps to the sling bar according to manufacturer’s instructions, double-check the security of the sling attachment before lifting, examine all hooks, clips, or fasteners, check strap stability, and ensure the sling bar was securely attached and sound. Despite these requirements, during a transfer for dinner, two CNAs placed the sling under the resident, attached the loops at each corner of the sling to the lift, and raised the resident off the bed into the space between the bed and wheelchair when the bottom left corner of the sling became disengaged from the lift. The resident involved had multiple diagnoses including osteoarthritis, cervical and thoracic spondylosis, and Alzheimer’s disease, with the Minimum Data Set documenting severely impaired cognitive skills for daily decision-making. The resident’s care plan required the assistance of two staff during Hoyer lift transfers. During the transfer, the resident fell approximately four feet, landing on her buttocks, bouncing, and then falling backward and striking her head on the leg of the Hoyer lift. Hospital records documented that the resident sustained an abrasion to the back of the head, fractures of the 6th, 7th, 8th, and 10th ribs, and fractures of the 1st and 2nd lumbar vertebra. Staff interviews and observations showed that staff believed the sling loops had been securely fastened and reported hearing the loops click into place before lifting. One CNA stated that they had barely lifted the resident off the bed when the bottom left loop became disconnected and the resident fell. Another CNA reported being shocked and unable to figure out what had happened. A nurse who assessed the resident and then examined the equipment after the fall noted that one of the loops of the sling had become disengaged but stated the sling appeared to be in good condition. During a later demonstration, a CNA indicated she thought one of the round metal disks on the lift might have been a little loose. Maintenance logs for Hoyer slings and lifts for the preceding months documented no concerns with the slings or lifts, and the DON acknowledged expecting a citation due to the resident’s injury from the fall.
Failure to Revise Care Plans to Reflect Resident Needs and Preferences
Penalty
Summary
The deficiency involves the facility’s failure to revise and individualize comprehensive care plans to reflect residents’ current needs and preferences, as required by its own care planning policy. For one resident with hemiplegia, hemiparesis following cerebrovascular disease, and mononeuropathy of the upper limb, the admission MDS showed intact cognition and upper extremity impairment. This resident reported having bilateral shoulder surgery and an inability to tolerate blood pressure measurements on the upper arms due to pain, and stated a preference for BP measurements on the forearms. The resident reported having informed multiple nursing staff of this preference, but staff continued to place the cuff on the upper arms. Review of the resident’s care plan and Kardex showed no interventions or instructions regarding forearm BP cuff placement. A NAC confirmed they were unaware of the preference until the resident told them directly and that this instruction was not documented in the Kardex. The RN/Unit Manager, who stated they were responsible for revising and reviewing care plans when there were changes, also confirmed they were not aware of the resident’s preference and that it should have been updated in the care plan. Another resident, readmitted with hemiplegia and hemiparesis following a nontraumatic subarachnoid hemorrhage, contracture of the left hand, and weakness, was cognitively intact and required maximum assistance for bed mobility per a quarterly MDS. This resident stated they were supposed to get out of bed for two hours every day, but some NACs were not aware of this care requirement. Review of the resident’s March 2026 MAR/TAR showed an order to document the time the resident got up and the time they returned to bed daily. The report states that, overall, the facility failed to revise care plans accurately to reflect residents’ needs for three of four residents reviewed for care plan revision, placing them at risk for unidentified and unmet care needs and a diminished quality of life.
Failure to Implement Restorative Nursing and Splint/Brace Programs After Therapy Discharge
Penalty
Summary
The deficiency involves the facility’s failure to provide restorative nursing services, including range of motion (ROM) exercises and splint/brace assistance, to maintain or prevent decline in mobility and contractures for two residents with significant motor impairments. The facility’s undated Restorative Nursing Services policy stated that residents would receive restorative care as needed to achieve and maintain optimal functioning and that residents may initiate a restorative program upon discharge from rehabilitative care. Despite this, surveyors found that residents with documented hemiplegia, hemiparesis, weakness, and contractures were not placed on restorative programs and had no restorative interventions documented in their electronic health records (EHRs). Resident 1 was admitted with hemiplegia and hemiparesis following cerebrovascular disease, a left lower leg fracture, and weakness, and the admission MDS showed intact cognition, moderate assistance needs for bed mobility and transfers, and one-sided upper and lower extremity impairment. During observation, the resident was seen lying in bed with a bent inward left forearm and hand and reported no longer receiving therapy or nursing-assisted exercises. The care plan initiated in January showed no restorative services, and the care plan history and EHR contained no restorative nursing interventions. However, the PT discharge summary from February documented that restorative ROM and transfer programs had been established and trained, including PROM to the left upper and lower extremities and stand-by assist with transfers, and the OT discharge summary recommended a splint/brace to prevent contracture. The OT stated that the splint/brace was not tried due to lack of time before insurance was discontinued, and both the Director of Rehab and the MDS coordinator confirmed there was no restorative referral in the EHR and they were unaware of the recommendations. Resident 2 was readmitted with hemiplegia and hemiparesis following a nontraumatic subarachnoid hemorrhage, a left-hand contracture, and weakness, and the quarterly MDS showed intact cognition, maximum assistance needs for bed mobility, total assistance for transfers, bilateral upper and lower extremity impairment, and no therapy or restorative programs. The resident reported that therapy had been discontinued months earlier and that no restorative staff were assisting with exercises. The care plan and EHR showed no restorative services. OT evaluation documented left upper extremity ROM impairment, a left-hand contracture, and prior use of a left orthotic to manage flexion tone, and the OT discharge summary recommended restorative care and assistance with donning/doffing the orthotic. The PT discharge summary recommended restorative programs if Medicaid Part B services did not continue. The Director of Rehab confirmed therapy was discontinued and that restorative nursing programs were recommended, but both the Director of Rehab and the MDS coordinator stated there were no restorative referrals in the EHR after readmission, and the MDS coordinator confirmed the resident had no restorative programs since readmission.
Failure to Implement Effective Fall and Toileting Interventions for High-Risk Resident
Penalty
Summary
The deficiency involves the facility’s failure to provide adequate supervision, identify fall trends, and implement progressive, resident-centered interventions for a resident with multiple falls and declining strength. The facility’s own Falls and Fall Risk Management policy required staff to identify interventions related to residents’ specific risks and causes to prevent falls and minimize complications. The resident’s Care Area Assessment identified cancer-related risks for pain, falls, and ADL decline, and stated that falls and urinary incontinence would be addressed in the care plan with an objective of improvement and risk minimization. However, the comprehensive care plan did not include a urinary or ADL care plan and contained no toileting plan, despite the resident’s identified risks and prior fall history. Over a series of falls, the resident repeatedly fell while attempting to toilet or move toward the bathroom, yet the facility did not recognize or address this pattern in its investigations or care planning. The resident had multiple unwitnessed falls: next to the bed while getting up to use the restroom, in the bathroom while standing to use the toilet, and near or in the bathroom on several occasions. Incident investigations and post-fall assessments documented environmental factors such as clutter, items on the floor, water on the floor, and issues with footwear, as well as the resident’s increasing weakness, impulsivity, poor safety awareness, and poor insight into limitations. Interventions documented in investigations and risk reviews included encouraging use of the front-wheeled walker, keeping the wheelchair and walker accessible, ensuring proper footwear and non-skid socks, and providing resident education on safe transfers, ambulation, and assistive device use. However, several of these planned interventions, including placement of the wheelchair and frequent rounding/toileting assistance, were not added to or reflected in the care plan as stated. Staff interviews further showed that the resident frequently fell while trying to go to the bathroom and that staff relied on verbal education and reminders to use the call light, even though the resident often did not use it. Staff acknowledged the resident’s impulsivity and tendency to get up independently despite instructions, and one staff member stated that nursing assistants were verbally instructed to offer bathroom assistance, but this intervention was not documented in the care plan. The resident’s bed remained the one furthest from the bathroom throughout the stay, and none of the facility’s investigations identified the trend of bathroom-related falls or addressed toileting options in the care plan. Ultimately, the resident sustained a left ankle fracture after another bathroom-related fall, requiring transfer to the emergency department for evaluation and treatment, and later records documented additional fractures and a decline in condition. The surveyors concluded that the facility’s failures placed residents at risk of repeated falls and injuries.
Failure to Monitor Urinary Retention After Foley Removal Leading to Prolonged Pain
Penalty
Summary
The deficiency involves the facility’s failure to adequately assess and monitor a resident for complications associated with an indwelling urinary catheter and urinary retention, particularly after catheter removal. The resident had a history of acute kidney injury due to urinary retention, which improved after Foley catheter placement in the hospital. Hospital discharge documentation indicated the catheter was placed for acute urinary retention, was deemed permanent, and included instructions that, given the resident’s significant retention and acute renal failure, staff at the skilled nursing facility should not attempt Foley removal. The facility’s catheter care plan directed staff to empty the catheter as needed and record output in milliliters, but review of the last 30 days of documentation showed continence was not rated due to the indwelling catheter and there was no documented urinary output in milliliters on the treatment administration records. The resident had a scheduled urology appointment at which the urinary catheter was discontinued. Upon return from this appointment, nursing documentation initially indicated no new orders, and an alert note later stated the catheter was discontinued and staff were monitoring for retention or pain. However, there was no documented bladder assessment or urinary output following catheter removal. Nursing assistant documentation showed that the resident did not void on the evening shift that same day. Despite the catheter having been removed, the treatment administration record showed staff continued to document provision of catheter care on subsequent shifts when no catheter was in place. Over the next day, the resident experienced vomiting, decreased oral intake, and an altered level of consciousness, with vital signs showing tachycardia and low blood pressure, and staff documented decreased urine output. A bladder scan performed later revealed more than 2000–2500 milliliters of urine in the bladder, and an indwelling catheter was reinserted, initially draining a large volume of urine. The provider note indicated the resident had not eaten since the prior night, was unable to hold down fluids, and staff were unsure whether the resident had urinated in incontinence briefs, with no wet briefs reported since the resident’s return from the hospital after catheter removal. The provider expressed concern that the documented early-morning wet brief might not be accurate given the large bladder volume on scan and stated this should require further investigation. Subsequent notes described the resident moaning and complaining of pain, with limited urine output in the catheter bag and staff flushing and then replacing the catheter due to continued complaints. Interviews with the resident, the roommate, and staff indicated the resident was crying out and moaning in pain, the roommate repeatedly alerted staff that the resident was not urinating and that the catheter was not draining, and staff had to seek assistance to replace the catheter. Facility leadership and clinical staff later acknowledged that typical practice after catheter removal would include contacting the provider, placing the resident on alert, performing post-void residuals with bladder scans, and documenting monitoring, which was not done in this case.
Medication Administration Delays, Documentation Errors, and Use of Expired Insulin
Penalty
Summary
The deficiency involves the facility’s failure to ensure sufficient nursing staff with appropriate competencies and skill sets to administer medications according to professional standards of practice, facility policy, and prescriber orders. The facility’s medication administration policy required medications to be given as prescribed, in accordance with manufacturers’ specifications and good nursing principles, with no expired medications used, and doses administered within 60 minutes of the scheduled time and documented immediately after administration. Multiple residents reported that agency nurses often gave medications late, did not read full instructions, or were slow in bringing medications, and that routinely scheduled medications were not consistently provided without residents having to ask. Surveyors observed several specific medication administration failures. For a resident with diabetes, an LPN drew up and administered Humalog/Lispro insulin from a multi-dose vial that had been opened and dated “02/16” with no year, making it expired per policy, and administered the dose nearly 1 hour and 45 minutes after it was due. Another resident with care plan instructions to receive medications as ordered had multiple scheduled medications (Gabapentin, Oxybutynin, Baclofen, and Tizanidine) that were ordered at specific times throughout the day; the LPN was observed administering all four together and acknowledged that at least one (Tizanidine) was late, while the resident reported that receiving them together at that time was typical and not at their request. For another diabetic resident, an RN checked blood sugar and prepared sliding scale Humalog/Lispro insulin almost two hours after the scheduled time; the resident refused the insulin, stating they had already finished lunch. Additional deficiencies were identified with other residents’ pain and scheduled medications. One resident with a pain care plan and an order for Methocarbamol four times daily at set times approached the cart requesting Methocarbamol and Tylenol; the RN initially stated the Methocarbamol had already been given, but then administered it two hours after it was due when the resident pointed out the scheduled timing. For another resident with a risk for pain care plan and Tramadol ordered three times daily at specific times, an LPN retrieved a PRN pain medication while the electronic record showed no 8:00 AM medications documented; the LPN stated they had given them but had not yet documented. Later, an RN prepared the 2:00 PM Tramadol dose, and review of the narcotic count showed a discrepancy between the number of pills documented and the number remaining in the card. The RN stated they had given the 8:00 AM Tramadol but had not signed it out, then signed out both the 8:00 AM and 2:00 PM doses at that time. Residents interviewed consistently reported that medications were sometimes or frequently late, that agency nurses did not always follow instructions, and that they often had to request medications that were routinely scheduled.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release May 27, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
