Sunshine Health & Rehab
Inspection history, citations, penalties and survey trends for this long-term care facility in Spokane, Washington.
- Location
- 10410 East Ninth Avenue, Spokane, Washington 99206
- CMS Provider Number
- 505411
- Inspections on file
- 25
- Latest survey
- January 30, 2026
- Citations (last 12 mo.)
- 13
Citation history
Health deficiencies cited at Sunshine Health & Rehab during CMS and state inspections, most recent first.
A resident with severe visual impairment was not fully informed about their care and treatment in a way they could understand. The resident was given important paperwork regarding Medicare coverage termination without adequate explanation or opportunity to ask questions, and there was no documentation of attempts to involve their representative as requested.
A resident who experienced a fall was assisted back into their wheelchair by a nursing assistant before a licensed nurse could assess them for injuries, contrary to facility policy. The resident exhibited pain and swelling in the ankle and required further evaluation. The assigned nurse was on break, and although another nurse was available, the nursing assistant did not seek their help before moving the resident.
The facility submitted inaccurate direct care staffing information to CMS for a reporting quarter because census data used from MDS assessments was not current at the time of PBJ submission, resulting in reported staffing levels below mandated requirements.
The facility failed to uphold residents' rights to retain personal property as a condition of admission. Admission agreements discouraged bringing valuables, and staff interviews revealed that valuables were stored in a facility safe with limited access. Residents, including those cognitively intact and impaired, were affected by this policy, which was acknowledged by staff as potentially violating resident rights.
The facility failed to annually review infection control policies and demonstrated poor hand hygiene practices, with staff not adhering to protocols during resident care. Additionally, transmission-based precautions were improperly implemented for residents, risking infection spread.
The facility failed to ensure that the designated Infection Preventionist, who had been in the role since March 2024, met the necessary qualifications for experience, education, training, and/or certification. Interviews revealed that Staff C was still in the process of completing the required training, and no documentation was provided to confirm their qualifications. This placed all residents, staff, and visitors at risk of communicable diseases due to unmet infection control issues.
The facility failed to submit MDS data to CMS within the required timeframe for several residents, leading to late assessments. The MDS Coordinator struggled with the workload, resulting in delayed submissions confirmed by validation reports. The Administrator acknowledged the issue, expecting timely completion according to the RAI manual.
The facility failed to provide scheduled bathing services for two residents, leading to deficiencies in personal hygiene care. One resident, requiring substantial assistance, received only 2 out of 7 scheduled showers due to staffing shortages. Another resident, who valued regular showers, received only 2 out of 5 scheduled showers, with no refusals documented. The DON acknowledged the oversight.
The facility failed to accurately reconcile controlled drugs, including Ativan, in the Victorian Rose medication room. Observations revealed that Ativan was stored improperly and not tracked accurately, increasing the risk of drug diversion. Staff were unable to verify the Ativan count due to lack of access to the electronic medication dispensing machine, and documentation lacked sufficient detail for reconciliation.
The facility failed to maintain food safety standards, as staff did not check food temperatures before serving, leading to unsafe temperature levels for cold foods. Incomplete kitchen temperature logs and improper food storage, including uncovered and expired items, were also observed. The Dietary Services Director acknowledged these lapses in food safety protocols.
The facility failed to provide education on vaccination benefits and side effects, offer pneumococcal and influenza vaccines, and document these actions in residents' records. Three residents lacked documentation of education or offers for the 2024-2025 flu season, despite facility policies requiring such actions.
The facility failed to document the required 12-hours of annual in-service training for nursing assistants, including dementia and abuse prevention training. Despite efforts to provide training, the facility lacked records to verify compliance, with only eight out of nineteen nursing assistants attending a mandatory skills fair.
A facility failed to assess a resident for safe self-administration of medications, as required by policy. The resident, who was cognitively intact, had medications left at their bedside without a proper assessment or provider order. Staff interviews revealed a lack of awareness and adherence to the facility's process, posing potential safety issues.
A facility failed to maintain a medication error rate below five percent, with two errors occurring during 26 medication administrations, resulting in a 7.69% error rate. A resident with GERD and IBS received Metoclopramide and Pantoprazole after breakfast, contrary to the prescribed schedule. The RN responsible admitted the error, and the DON confirmed the late administration as a medication error.
The facility failed to employ a dietician with the necessary Washington State licensure, as required by state regulations. The Corporate Dietician, although nationally registered, did not possess state-specific credentials, placing residents at risk for unmet nutritional needs. The facility's policy requires tracking of professional licenses, but documentation of the dietician's state licensure was not provided when requested.
A resident was inappropriately prescribed antibiotics for a UTI without exhibiting symptoms, contrary to the facility's antibiotic stewardship policy. Despite the absence of urinary symptoms, antibiotics were administered, and subsequent urine culture results did not meet the McGeer Criteria for a UTI diagnosis. Interviews revealed that staff did not adhere to established protocols, leaving decisions to the provider without ensuring criteria were met, risking multi-drug-resistant organisms and adverse side effects.
A resident with a history of falls and COPD was at risk for tripping over their oxygen tubing, a hazard not addressed in their care plan. Despite staff observations of the resident getting tangled in the tubing, the care plan lacked interventions for this risk. The resident experienced an unwitnessed fall, resulting in fractures, highlighting the need for individualized care plans that consider unique environmental risks.
A resident with COPD and atrial fibrillation was transported from the hospital to the LTC facility without the prescribed oxygen, leading to low blood pressure and chest pain. The facility's transportation staff did not apply oxygen, assuming the resident was stable without it. The facility lacked a specific policy for hospital transport, contributing to the oversight.
Failure to Inform Visually Impaired Resident of Care in Understandable Manner
Penalty
Summary
Facility staff failed to ensure that a resident with severe visual impairment was fully informed about their care and treatment in a manner they could understand. The resident, who had a left eye prosthetic and was legally blind in the right eye, was given a Notice of Medicare Non-Coverage (NOMNC) to sign. The NOMNC included important information about the termination of skilled nursing facility services and instructions for appeal, which required timely action. Despite the resident's blindness, staff did not adequately explain the paperwork or allow the resident to ask questions, as reported by the resident during an interview. The resident ultimately had to rely on a family member to communicate with staff about their lack of understanding regarding the NOMNC. Staff E from Social Services stated that they typically reviewed such paperwork with visually impaired residents and would involve a representative if requested. In this case, Staff E attempted to reach the resident's representative but was unsuccessful, after which the resident agreed to proceed without their representative. However, there was no documentation in the progress notes of any attempts to contact the representative on or before the date the NOMNC was served. This lack of appropriate communication and documentation resulted in the resident not being fully informed in a manner they could understand.
Failure to Ensure Timely Nursing Assessment After Resident Fall
Penalty
Summary
The facility failed to ensure that nursing assessments following a resident fall were conducted in accordance with professional standards and facility policy. Specifically, after a resident experienced a fall in their bathroom, a nursing assistant assisted the resident back into their wheelchair before a licensed nurse assessed the resident for injuries. The progress notes indicated that the resident had pain and swelling to their ankle and required ice and further diagnostics to determine the extent of the injury. According to facility policy, nursing staff are required to complete fall risk assessments and assess the level of injury before moving a resident after a fall. Interviews revealed that the assigned nurse was on a lunch break at the time of the fall, and although another nurse was available in a different hallway, the nursing assistant did not request their assistance and proceeded to move the resident. The Director of Nursing confirmed that the nursing assistant had been employed at the facility for four years and was aware of the policy requiring a nurse to assess a resident before they are moved after a fall. This lapse in following established protocols resulted in the resident being moved prior to a proper nursing assessment.
Inaccurate PBJ Staffing Data Submission Due to Outdated Census Information
Penalty
Summary
The facility failed to ensure that direct care staffing information submitted to the Centers for Medicare and Medicaid Services (CMS) for Quarter 3 of 2024 was accurate. Specifically, the Payroll Based Journal (PBJ) submission included staffing data that was reported at a level lower than required by mandated staffing levels. This occurred because resident census data, which was used to calculate staffing levels, was pulled from Minimum Data Set (MDS) assessments that were not current at the time of the PBJ submission. Staff responsible for payroll verified that the census data error was present during the initial submission, resulting in inaccurate staffing information being reported to CMS.
Violation of Resident Rights to Personal Property
Penalty
Summary
The facility failed to uphold residents' rights to retain personal property, including items of value, as a condition of admission. This deficiency was identified through interviews and record reviews for four residents. The facility's policy on resident rights, revised in February 2018, stated that residents have the right to keep and use their personal belongings as long as it does not interfere with others' rights, health, or safety. However, the admission agreements for Residents 23, 76, 184, and 185 included a clause that discouraged bringing valuables such as jewelry, money, and credit cards into the facility, which was signed by the residents or their representatives. Resident 23, who was cognitively intact, expressed that they were told not to bring money or personal items into the facility due to safety concerns, which led them to rely on their child for financial needs. Staff interviews revealed that while residents were allowed to bring personal items, valuables were inventoried and stored in a facility safe, which was not easily accessible after hours. Staff members, including the Social Service Director and Admission RNs, acknowledged that the admission agreement's wording appeared to restrict residents' rights to have personal possessions. Resident 184, also cognitively intact, had no items of value listed on their personal effect inventory sheet, and their spouse signed the agreement. Resident 185, with severe cognitive impairment, was unable to sign the agreement, yet it was electronically signed in their name. Resident 76, who was cognitively intact, had no personal effect inventory sheet found in their records. The Director of Nursing reviewed the admission agreement and acknowledged that the verbiage seemed to violate residents' rights to bring personal belongings into the facility.
Infection Control Deficiencies in Policy Review and Hand Hygiene
Penalty
Summary
The facility failed to review and update its infection prevention and control policies annually as required. Key policies, including those related to vaccinations, antibiotic stewardship, and COVID-19, had not been reviewed since their last revisions, some dating back several years. Interviews with staff, including the Charge Nurse, Infection Preventionist, and Director of Nursing, revealed uncertainty about the process and documentation for policy reviews, indicating a systemic issue in maintaining up-to-date infection control protocols. The facility also demonstrated significant lapses in hand hygiene practices. Observations showed staff failing to perform hand hygiene at critical times, such as before and after resident contact, after glove removal, and before administering medications. Specific instances included a Nursing Assistant not washing hands after handling soiled items and a Registered Nurse administering injections without gloves or hand hygiene. Interviews with staff confirmed a lack of understanding and adherence to hand hygiene protocols, which are essential for preventing the spread of infections. Additionally, the facility did not properly implement and discontinue transmission-based precautions for residents with specific needs. For example, Resident 135, who had a multidrug-resistant organism (MDRO) infection, was not consistently managed under contact precautions, as staff and visitors entered the room without appropriate personal protective equipment. Similarly, Resident 23 was unnecessarily placed under enhanced barrier precautions without a current medical justification. These failures in implementing appropriate precautions put residents, staff, and visitors at risk of infection transmission.
Inadequate Qualifications for Infection Preventionist Role
Penalty
Summary
The facility failed to ensure that the designated Infection Preventionist met the necessary qualifications for experience, education, training, and/or certification required for the role. This deficiency was identified during interviews and record reviews, where it was found that Staff C, who was appointed as the facility's Infection Preventionist, had not completed the specialized infection prevention and control training. Despite being in the role since March 2024, Staff C was still in the process of completing the required training as of October 2024. Interviews with various staff members, including the Administrator, Director of Nursing, and Admissions Registered Nurse, confirmed that Staff C was the sole infection prevention and control staff member at the facility. Staff C themselves acknowledged being new to the role and still learning. The lack of documentation proving the completion of the necessary training for Staff C was noted, and the Administrator expressed an expectation for the Infection Preventionist to have sufficient training to perform their duties effectively.
Delayed MDS Data Submission
Penalty
Summary
The facility failed to encode and transmit resident assessment data to the Centers for Medicare & Medicaid Services (CMS) within the required timeframe for seven sampled residents. This deficiency was identified through interviews and record reviews, which revealed that the Minimum Data Set (MDS) assessments for these residents were not completed and submitted within the mandated 7-day period following the assessment observation end date. The residents affected by this delay were discharged from the facility between August and September 2024, but their assessments were not completed until late October 2024. The report highlights specific cases where the MDS assessments were completed significantly later than required. For instance, Resident 6 was discharged on August 15, 2024, but the assessment was not completed until October 23, 2024. Similarly, Resident 7 was discharged on August 30, 2024, with the assessment completed on October 22, 2024. Other residents, including Residents 8, 25, 48, 50, and 53, also experienced similar delays in the completion and submission of their assessments, with some assessments not being completed as of late October 2024. Interviews with facility staff, including the MDS Coordinator and the Administrator, revealed that the MDS Coordinator struggled to manage the workload, leading to late submissions. The facility's MDS batch report and iQIES MDS validation report confirmed the late submissions, with multiple warning messages indicating that assessments were completed more than 14 days after the assessment reference date. The Administrator acknowledged the issue, stating that MDSs were expected to be completed within the required timeframes according to the RAI manual.
Failure to Provide Scheduled Bathing Services
Penalty
Summary
The facility failed to consistently provide scheduled bathing services for two residents, leading to deficiencies in personal hygiene care. Resident 28, who was cognitively intact and required substantial assistance for bathing due to conditions such as heart failure and malnutrition, was scheduled to receive showers twice a week. However, records indicated that Resident 28 only received 2 out of 7 scheduled showers over a three-week period, with numerous instances marked as 'N/A' due to staffing shortages. Interviews with Resident 28 and staff confirmed the missed showers and the lack of reattempts to provide the service. Similarly, Resident 234, who required assistance with transfers and valued regular showers, was also affected by the facility's failure to adhere to the bathing schedule. Despite being scheduled for showers twice weekly, Resident 234 only received 2 out of 5 scheduled showers, with no documentation of refusals or alternative bathing options offered. Interviews revealed that the facility did not staff a bathing aide for the evening shift, contributing to the missed showers. The Director of Nursing acknowledged the oversight and confirmed that Resident 234 should have received the scheduled showers.
Deficiency in Controlled Drug Reconciliation
Penalty
Summary
The facility failed to implement a detailed system for accurately reconciling all controlled drugs, including the emergency medication supply, in the Victorian Rose medication room. The facility's policy required controlled substances to be stored in double-locked compartments and inventoried by two licensed nurses at each shift change. However, during observations and interviews, it was found that the Ativan, a controlled substance, was stored in a clear removable box within the refrigerator, not in a permanently affixed compartment. Staff members, including RNs and the Director of Nursing, were unsure of the frequency of pharmacy checks and tracking of the Ativan, and they acknowledged that the current storage and tracking system did not allow for accurate reconciliation or detection of potential drug diversion. The report highlighted that the Ativan was part of the facility's emergency medication supply and was supposed to be tracked in the electronic medication dispensing machine. However, staff were unable to verify the Ativan count or balance due to lack of access to the machine. The Director of Nursing and the pharmacist admitted that the current system allowed staff to access both insulin and Ativan without proper tracking, increasing the risk of drug diversion. Documentation provided by the facility, including activity transaction reports and inventory replenishment reports, lacked sufficient detail to accurately reconcile the emergency Ativan supply, further indicating a deficiency in the facility's medication management system.
Food Safety and Storage Deficiencies
Penalty
Summary
The facility failed to adhere to professional standards for food safety in their kitchen, as observed during a survey. Staff members did not check the temperatures of food items before serving them, which is a critical step in ensuring food safety. During a tray line service, dietary staff were observed serving meals without verifying the temperatures of hot and cold food items. When prompted by the surveyor, staff members were unsure of the required temperature ranges and had to seek assistance from another staff member. The temperatures of several food items, including salads and fruit cups, were found to be above the safe temperature threshold for cold foods, which should be kept at or below 41 degrees Fahrenheit. Additionally, the facility's kitchen temperature logs were incomplete, lacking documentation of temperature checks before tray line service or mid-service. This lack of documentation indicates a failure to consistently monitor food temperatures throughout the meal service process. The Registered Dietician and Dietary Services Director confirmed that food temperatures should be checked at multiple points during meal preparation and service to ensure safety and palatability. However, the logs only showed final cooking and holding temperatures, with no records of checks during the tray line or mid-service. The facility also failed to properly store food items in the kitchen. During observations, a pan of cooked bacon was found uncovered and undated in the walk-in refrigerator, and several expired food items were discovered in the walk-in freezer. These included a package of frozen shrimp and resealable bags of chicken wings, chicken strips, and potato wedges, all past their expiration dates. The Dietary Services Director acknowledged that these items should have been discarded according to food safety regulations.
Deficiency in Vaccination Education and Documentation
Penalty
Summary
The facility failed to provide routine education on the benefits and potential side effects of vaccinations, offer pneumococcal and influenza vaccinations when indicated, and document these actions in the residents' medical records. This deficiency was identified in three out of five sampled residents. The facility's policies, revised in 2012 and 2014, required that all residents be offered vaccinations and provided with pertinent information, with documentation of education and any refusals in the residents' medical records. However, the review of records for Residents 4, 52, and 78 showed a lack of documentation regarding education, offers, or administration of the influenza vaccine for the 2024-2025 flu season, and a lack of documentation of education for the pneumococcal vaccine for Resident 4. Resident 4, who was cognitively intact and had a diagnosis of respiratory failure, was not documented as having been educated or offered the influenza vaccine for the 2024-2025 flu season, despite having refused the pneumococcal vaccine. Resident 78, also cognitively intact, had received the influenza vaccine outside the facility but had no documentation of education or offer for the current flu season. Resident 52's records similarly lacked documentation of education or offer of the influenza vaccine. Interviews with facility staff confirmed the absence of documentation regarding education on the risks and benefits of vaccinations when offered or refused, which was contrary to the facility's stated policies.
Deficiency in Nursing Assistant Training Documentation
Penalty
Summary
The facility failed to provide documented evidence of the required annual 12-hours of in-service training for nursing assistants, which included dementia training and abuse prevention. This deficiency was identified for five nursing assistants reviewed for continuing education, with two of them lacking documentation for abuse prevention training. The facility's assessment tool and employee handbook both stipulated the necessity of these trainings, yet the facility did not maintain adequate records to verify compliance. During interviews, the Director of Nursing admitted that while they attempted to provide individual training for those who missed mandatory sessions, these efforts were not documented. The Skills Fair itinerary reviewed did not include dementia management as a topic, and the attendance sheet showed that only eight out of nineteen nursing assistants attended the mandatory event. Staff B, the Director of Nursing, acknowledged the lack of verification for the required 12 hours of continuing education for nursing assistants. Despite efforts to remind staff of mandatory trainings through various communication methods, the facility could not ensure that all nursing assistants received the necessary training, placing residents at risk of being cared for by inadequately trained staff.
Failure to Assess Resident for Safe Self-Administration of Medications
Penalty
Summary
The facility failed to ensure that Resident 23 was evaluated and assessed by the interdisciplinary team (IDT) for the safe self-administration of medications, as required by the facility's policy. The policy mandates that residents who wish to self-administer medications must be assessed for cognitive, physical, and visual abilities, and a provider's order must be obtained. However, there was no documentation indicating that Resident 23 underwent such an evaluation or that a provider's order was obtained. Despite being cognitively intact and having no impairments that would prevent self-administration, Resident 23's records lacked any assessment or care plan related to self-administration of medications. During an observation, Resident 23 was found with a cup containing nine pills on their bedside table, which they stated were left by staff for them to take slowly with yogurt. This practice was not in line with the facility's policy, as medications should not be left at the bedside without a proper assessment and provider order. Interviews with staff, including a Nursing Assistant, a Registered Nurse, the Director of Nursing, and the Administrator, revealed a lack of awareness and adherence to the facility's process for self-administration of medications. Staff acknowledged that medications should not be left unattended at the bedside without following the appropriate procedures, highlighting a gap in compliance with the facility's policy and potential safety issues for residents.
Medication Error Rate Exceeds Acceptable Threshold
Penalty
Summary
The facility failed to maintain a medication error rate of less than five percent, as evidenced by two medication errors identified during 26 medication administration opportunities, resulting in an error rate of 7.69%. This deficiency was observed during the administration of medications to a resident who was admitted with diagnoses including Gastroesophageal Reflux Disease (GERD) and Irritable Bowel Syndrome (IBS). The resident was alert and capable of communicating their needs. On the morning of the observation, a registered nurse, Staff N, administered Metoclopramide and Pantoprazole to the resident after they had already eaten breakfast, despite the medications being scheduled for administration before meals. The resident's Medication Administration Record (MAR) indicated that Pantoprazole should be taken on an empty stomach, and Metoclopramide was to be given before meals. Staff N acknowledged the error, admitting the medications were given late. The Director of Nursing, Staff B, confirmed that these late administrations constituted medication errors.
Dietician Lacks State Licensure
Penalty
Summary
The facility failed to employ a dietician with the necessary licensure and certification to practice as a Registered Dietician in Washington State, as required by state regulations. This deficiency was identified during a review of the facility's staff credentials, which revealed that the Corporate Dietician, referred to as Staff U, did not possess a Washington State license or certification. Although Staff U was registered nationally with the Commission on Dietetics Registration, they acknowledged during an interview that they lacked the state-specific credentials needed to practice in Washington. The facility's policy on professional licenses mandates that all professional licenses be tracked using an online human resources management system, and employees with lapsed licenses are to be removed from the schedule until the issue is resolved. Despite this policy, the facility did not provide documentation of Staff U's Washington State Dietician licensure when requested by the State Survey Agency. This oversight placed all residents at risk for unmet nutritional needs and diminished quality of life, as the dietician responsible for their care was not properly credentialed according to state requirements.
Inadequate Antibiotic Stewardship Leads to Inappropriate Prescriptions
Penalty
Summary
The facility failed to implement antibiotic protocols effectively, leading to inappropriate antibiotic prescription for a resident. The facility's policy on antibiotic stewardship, revised in July 2016, required that all clinical infections treated with antibiotics undergo review by the infection preventionist or designee within 48 hours of antibiotic initiation to determine if continued therapy was justified. However, this protocol was not followed for a resident who was prescribed antibiotics for a urinary tract infection (UTI) without exhibiting any signs or symptoms of a UTI, as per the McGeer Criteria. The resident, who was cognitively intact and able to communicate their needs, was admitted to the facility with a surgical incision and an abdominal drain. Despite the absence of urinary symptoms, the resident was started on antibiotics for UTI prevention, and the facility's antibiotic stewardship surveillance spreadsheet marked the McGeer criteria as not applicable. Subsequent urine culture results did not meet the McGeer Criteria for a positive UTI diagnosis, as they showed less than 10,000 colony-forming units of mixed urogenital flora, which is insufficient to justify antibiotic use according to the criteria. Interviews with facility staff revealed a lack of adherence to the established antibiotic stewardship protocols. The charge nurse stated that the decision to prescribe antibiotics was left to the provider, and they did not review antibiotics to ensure they met the criteria for appropriate usage. The infection preventionist and director of nursing acknowledged that the provider did not always follow the McGeer criteria, and there was no documentation to show that the criteria were considered when prescribing antibiotics. This oversight placed residents at risk of developing multi-drug-resistant organisms and experiencing adverse side effects.
Failure to Address Oxygen Tubing Hazard in Resident's Care Plan
Penalty
Summary
The facility failed to develop an individualized care plan for a resident with unique environmental fall risk concerns. The resident, who had a history of falls and wore oxygen, was at risk for tripping over their lengthy oxygen tubing. This risk was not identified or included in their fall prevention care plan, despite the facility's protocol requiring hazard identification and individualized interventions to reduce fall risk. The resident had a history of falls and was cognitively intact but forgetful at times. They required partial/moderate assistance for transfers and wore oxygen due to chronic obstructive pulmonary disease (COPD). On one occasion, the resident experienced an unwitnessed fall while attempting to transfer from their wheelchair to their bed without assistance, resulting in a fractured left hip and elbow. The fall investigation noted that the resident's oxygen tubing was a potential environmental tripping hazard, but this was not addressed in the care plan. Staff interviews revealed that the resident frequently self-transferred without using their call light and had poor safety awareness. Staff had observed the resident getting tangled in their oxygen tubing on multiple occasions. Despite these observations, the care plan was not updated to include interventions related to the oxygen tubing hazard, and the Director of Nursing was unaware of the tubing being a potential contributor to the resident's fall.
Failure to Implement Oxygen Orders During Resident Transport
Penalty
Summary
The facility failed to implement the prescribed oxygen orders for a resident during transportation from the hospital to the facility, leading to a health deficiency. The resident, who had a history of COPD and atrial fibrillation, was transported without oxygen despite hospital discharge instructions indicating the need for continuous oxygen at 2 liters via nasal cannula. Upon arrival at the facility, the resident experienced low blood pressure and chest pain, necessitating a return to the emergency department for evaluation. Interviews and record reviews revealed that the facility's transportation staff did not apply oxygen to the resident during the transfer. The staff relied on hospital personnel to attach the oxygen to the facility's portable tank, but in this instance, the resident was not wearing oxygen when picked up. The transportation staff assumed the resident was stable for transport without oxygen, as they were not permitted to apply it themselves. The admission nurse, responsible for reviewing hospital records, acknowledged difficulties in determining oxygen needs from discharge instructions, which contributed to the oversight. The facility lacked a specific policy for transporting residents from the hospital, which may have contributed to the miscommunication and oversight. The Director of Nursing and other staff members recognized the need for complete discharge orders and better coordination with the hospital to ensure residents' needs are met during transport. The deficiency was identified as a failure to provide appropriate treatment and care according to orders, resident preferences, and goals, as required by regulations.
Latest citations in Washington
A resident with cerebral palsy and a court-appointed guardian experienced multiple episodes of nausea, vomiting, loose stools, abdominal discomfort, fatigue, and later refusal of meals and medications, leading to changes in the care plan including close monitoring, lab testing, and IV fluid administration. Despite a facility policy recognizing court-appointed guardians as resident representatives with decision-making authority, staff did not document any notification to the guardian during these changes in condition or treatment decisions. The guardian reported not being contacted when the resident stopped eating or developed stomach issues and felt the facility did not respect the guardianship, while the DON acknowledged there were multiple missed opportunities to notify the guardian of the resident’s change from baseline.
A resident with depression, anxiety, moderate cognitive impairment, and urinary incontinence, care-planned for q2h checks and assistance with toileting, was found by a visitor to be soaking wet, unusually agitated, and reporting they had been told to wait to be changed and referred to with a derogatory remark. The visitor filed a written grievance alleging abuse/neglect related to delayed incontinence care and removal of the resident’s tablet as a consequence. Although an incident report noted that the matter was reported to the state and that the resident was not soaking wet, a CNA who actually changed the resident later reported the resident’s brief, pants, wheelchair, and socks were soaked and that the resident was acting timid and repeatedly saying they had to sit for five minutes, but this CNA was never interviewed. The DON acknowledged not investigating the resident’s behavior or interviewing this CNA, and the grievance official acknowledged the facility did not fully investigate or communicate findings and resolution to the complainant, resulting in a failure to follow the facility’s grievance policy.
A resident with dementia, respiratory failure, and heart failure developed new shortness of breath with an O2 sat of 90%, and a physician ordered transfer to the ED for tx and eval. An RN completed an SBAR, notified the MD and family, and reported to the oncoming nurse that the resident needed ED transfer and that paramedics should be contacted, then left the facility. Instead of calling 911 for this emergent respiratory distress, staff arranged non-emergent transport through a contracted ambulance service, resulting in the resident remaining at the facility for several hours without pickup until the dispatcher later instructed staff to call 911. The DON stated that 911 is expected to be used for emergent conditions and the contracted service only for non-emergent transport.
A resident with anoxic brain injury, dysarthria, and documented lack of decisional capacity alleged physical abuse and expressed fear of their identified representative, yet social services only reported the allegation to the state and did not complete an incident report, revise the care plan, or implement protective interventions. The same representative continued to be treated as the resident’s decision-maker and visited frequently, with staff noting suspicious odors of foreign substances and concerns about possible illicit substance use. Psychiatry later documented concern that the representative was providing illicit substances, and the resident was subsequently hospitalized for altered mental status and overdose, after which the representative was banned. Key staff, including the DON, unit manager, and administrator/abuse coordinator, were unaware of the initial abuse allegation, and social services did not timely explore or clarify legal decision-making authority or alternative representation for the resident.
A resident with severe cognitive impairment, osteoarthritis, and spinal spondylosis, care planned for 2-person Hoyer transfers, was being moved by two CNAs using a mechanical lift when one corner loop of the sling became disengaged, causing the resident to fall about four feet, strike the floor and the lift, and sustain head abrasion, multiple rib fractures, and lumbar vertebral fractures. Facility policy required staff to verify secure sling attachment, examine hooks, clips, fasteners, and strap stability, and ensure the sling bar was sound before lifting, but during this transfer the sling loop detached despite staff believing it was properly fastened and hearing it click into place; post-incident assessment showed the loop had come loose, the sling appeared in good condition, and a CNA later reported thinking one of the round metal disks on the lift might have been slightly loose, while maintenance logs documented no prior concerns with the lifts or slings.
The facility failed to revise and individualize care plans to reflect current needs and preferences for multiple residents, including one cognitively intact resident with hemiplegia, hemiparesis, and mononeuropathy who had bilateral shoulder surgery and could not tolerate BP measurements on the upper arms but preferred forearm readings. Despite repeatedly informing staff, this preference was not documented in the care plan or Kardex, and direct care staff and the RN/UM were unaware of it. Another cognitively intact resident with hemiplegia, contractures, and weakness reported they were supposed to get out of bed for two hours daily, but some NACs did not know this, even though the MAR/TAR contained an order to document times up and back to bed. The surveyors concluded that care plans were not accurately revised for several residents, placing them at risk for unidentified and unmet care needs and diminished quality of life.
Surveyors found that two residents with hemiplegia, hemiparesis, weakness, and contractures did not receive restorative nursing services, including ROM exercises and splint/brace or orthotic assistance, after therapy discharge. Although PT and OT discharge summaries documented established restorative ROM and transfer programs, recommended PROM to affected extremities, and recommended splint/brace use and assistance with orthotic wear, these recommendations were not entered as restorative referrals in the EHR. As a result, the residents’ care plans and records showed no restorative programs, and both residents reported that therapy and restorative exercises had stopped, while the DON, rehab director, and MDS coordinator confirmed they were unaware of and had not implemented the recommended restorative services.
A resident with cancer, cognitive impairment, and declining strength experienced multiple unwitnessed falls, most occurring while attempting to toilet or move toward the bathroom, culminating in a fractured ankle requiring ED treatment. Although assessments identified fall and incontinence risks and the facility’s policy required individualized interventions, the comprehensive care plan lacked a toileting plan and did not include several interventions that were discussed in incident investigations, such as consistent wheelchair placement and frequent rounding for bathroom assistance. Staff reported relying on verbal reminders and education to use the call light, despite acknowledging the resident’s impulsivity and failure to call for help, and the resident’s bed remained furthest from the bathroom while repeated bathroom-related falls occurred without the trend being recognized or addressed in the care plan.
A resident with a history of acute urinary retention and acute kidney injury had a Foley catheter deemed permanent by the hospital, with instructions that it not be removed in the SNF. At a later urology visit, the catheter was removed, and the resident returned with no new orders documented. Facility staff did not document bladder assessments, post-void residuals, or urine output, and CNA documentation showed the resident did not void that evening. Over the next day, the resident had vomiting, poor intake, altered level of consciousness, tachycardia, hypotension, and no documented wet briefs. A bladder scan eventually showed more than 2000–2500 mL of retained urine, and a new catheter drained a large volume. The resident and a roommate reported moaning, crying out in pain, and repeatedly alerting staff that the resident was not urinating and that the catheter was not draining, while nurses documented catheter care when no catheter was in place and later had to flush and replace the catheter due to continued complaints.
Surveyors found that nurses and nurse aides did not consistently administer medications according to professional standards and facility policy. Multiple residents reported that agency nurses were slow with medications, did not fully follow instructions, and often gave routine meds late. Observations showed an LPN administering expired Humalog/Lispro insulin well past the scheduled time, an LPN giving several scheduled meds (including Tizanidine) late and all at once, and an RN attempting to give sliding-scale insulin nearly two hours late, which a resident refused after already eating. Another resident received Methocarbamol two hours late after questioning the RN, and a resident on scheduled Tramadol had doses given without timely documentation, with a discrepancy between the narcotic count and pills remaining. These events demonstrated failures in timely administration, use of non-expired medications, and immediate, accurate MAR and narcotic documentation.
Failure to Notify Court-Appointed Guardian of Resident’s Clinical Changes
Penalty
Summary
The deficiency involves the facility’s failure to notify a resident’s court-appointed guardian of significant clinical changes and care decisions, contrary to its own policy and state requirements. The facility’s policy on Resident Representatives, revised 02/2021, states that a resident representative includes a court-appointed guardian or conservator and that the facility treats the representative’s decisions as those of the resident to the extent delegated or required by the court. Resident 1, admitted with cerebral palsy, had a Superior Court guardianship letter dated 02/07/2025 indicating a guardian of person and conservator of the estate with full authority, identifying Collateral Contact 1 (CC1) as the guardian. Despite this, multiple clinical events and changes in condition were documented without any corresponding documentation that CC1 was notified. Progress notes and provider notes show that Resident 1 experienced an episode of nausea and vomiting, frequent loose stools, abdominal discomfort, bloating, worsening fatigue, generalized weakness, and later refusal of meals and medications over at least a 24-hour period, with observations that the resident appeared frailer, more fatigued, and had no energy or interest to talk. The provider developed care plans including close monitoring for deterioration, sending stool to the lab, and later initiating IV fluids for rehydration, with a plan to call family/POA for discussion. However, there was no documentation that the guardian was notified at any of these points, including when IV fluids were started. CC1 reported that they were not contacted when the resident stopped eating or developed stomach issues, and expressed that the facility did not respect their guardianship and that involvement in care planning took too long. The DON confirmed on record review that there were many opportunities to notify the guardian when the resident’s condition changed from baseline and that there was no evidence staff did so.
Failure to Thoroughly Investigate and Resolve Resident Grievance Regarding Incontinence Care and Staff Conduct
Penalty
Summary
The deficiency involves the facility’s failure to thoroughly investigate and resolve a grievance alleging neglect and disrespect toward a resident, as required by its grievance policy. The resident had depression, anxiety, moderate cognitive impairment, occasional urinary incontinence, and required moderate assistance with toileting, with a care plan directing staff to check the resident every two hours, ask about toileting needs, and ensure they were clean and dry. A collateral contact reported arriving to visit the resident and finding them soaking wet and agitated, with behavior that was not typical for the resident. The collateral contact documented in a written grievance that the resident’s tablet was off, the resident appeared upset, and the resident reported being told they had to wait five minutes to be changed and that staff would change their “nasty *ss” in five minutes, leading the collateral contact to believe the resident had been given a consequence of no tablet and sitting in wet clothes, which they characterized as abuse/neglect and requested immediate removal of the responsible staff and a report filed. The facility documented receipt of the grievance and created an incident report indicating the matter was reported to the state agency, and that the unit manager interviewed the collateral contact and the resident, with the resident described as confused and denying being soaking wet. The incident report stated that a different nursing assistant was assigned to assist with the brief change and that the unit manager believed the resident was not soaking wet, and that the resident and collateral contact were satisfied when they left the room. However, a CNA who actually changed the resident reported that the resident’s brief was soaked through their pants onto the wheelchair and their socks were soaked, and that the resident was timid, repeatedly saying they had to sit for five minutes, and not acting like themselves; this CNA stated they were never interviewed or asked about the grievance or the resident’s condition. The DON acknowledged not interviewing this CNA or investigating the resident’s behavior and why they were upset, and the unit manager did not recall whether the collateral contact was present during follow-up and did not believe they followed up with the collateral contact regarding the grievance. The administrator, identified as the Grievance Official, stated the facility should have thoroughly investigated the grievance and discussed findings and resolution with the collateral contact, indicating the grievance process was not fully carried out in accordance with policy and WAC 388-97-0460.
Failure to Obtain Timely Emergency Transport for Resident in Respiratory Distress
Penalty
Summary
The deficiency involves the facility’s failure to obtain timely emergency medical services for a resident experiencing new-onset respiratory distress. The resident had dementia, respiratory failure, and heart failure, with severe cognitive impairment and a need for substantial assistance with activities of daily living. On the day the resident was sent to the hospital, a collateral contact observed the resident having difficulty breathing, appearing unable to get enough air, and looking as if they were sleeping or unconscious, and reported this to staff with a request to contact the doctor. An SBAR Communication Form documented that the resident was experiencing shortness of breath that had not occurred before, with an oxygen saturation of 90%. The physician was notified and ordered the resident sent to the emergency department for treatment and evaluation, and the collateral contact was notified shortly thereafter. Progress notes later documented that, despite the order for emergency department transfer, the resident was still awaiting pickup by Olympic transportation several hours later, with no estimated time of arrival. At approximately 3:30 AM, the dispatcher informed the facility that they could not provide transportation and instructed that 911 be called; only then was 911 contacted and the resident transported to the hospital via ambulance for respiratory distress. The RN caring for the resident stated they completed the SBAR, notified the physician and family, and at the end of their shift reported to the oncoming nurse that the resident needed to be sent to the emergency department for respiratory distress and that paramedics should be contacted, then left assuming 911 would be called. The DON stated that staff are expected to contact 911 for emergent conditions such as shortness of breath or respiratory distress, and that Olympic Ambulance is used only for non-emergent transport.
Failure to Provide Social Service Advocacy After Abuse Allegation and Questionable Representative
Penalty
Summary
The deficiency involves the facility’s failure to provide appropriate medically-related social services and advocacy for a resident following an allegation of abuse and concerns about the resident’s representative. The resident had an anoxic brain injury, dysarthria, moderate cognitive impairment, and was dependent on staff for activities of daily living. A hospital palliative care note documented that the resident lacked decisional capacity, had no DPOA, that the legal next of kin (CC4) did not want to be part of care decisions, and that care decisions were being deferred to another contact (CC5). CC5 accompanied the resident on admission, signed admission forms, and was listed as the primary contact in the medical record profile. On a date in February, during communication therapy, the resident reported that CC5 had done something to them, pounded their hands on their chest, recalled being hit in the back of the head by an unknown person, and stated they were sometimes afraid of CC5. A social services staff member reported this allegation to the state agency but did not complete a facility incident report, did not initiate care plan changes or interventions, and took no further action. CC5 continued to be treated as the resident’s representative, and progress notes documented CC5 at the bedside on multiple dates, including an entry noting the room smelled like foreign substances and that CC5 was seen waking the resident and then asking the nurse to administer pain medications. A psychiatry note later documented concern that CC5 was providing the resident with illicit substances and stated it would be prudent for the resident to identify a POA. Subsequently, the resident was found unresponsive, transported to the hospital, and later readmitted after altered mental status and overdose, with a provider note stating that CC5 posed a significant danger to the resident and was banned from visiting. After readmission, staff attempted to contact CC4 for consent to treat but initially reached someone who stated they were not CC4. The social service director acknowledged that, beyond reporting the initial allegation, no additional interventions were implemented, that CC5 continued to be used as the resident’s representative after the allegation, and that they had not explored legal authority for decision making following the abuse allegation or concerns about substances. The social service assistant reported they did not speak with the resident about the hospital stay or CC5 and did not complete an incident report or care plan changes after the allegation. The unit manager and DON were unaware of the initial abuse allegation, and the administrator, who served as abuse coordinator, also stated they were unaware of the allegation and that an investigation should have been initiated and a representative for the resident investigated at a minimum.
Injury from Mechanical Lift Sling Detachment During Transfer
Penalty
Summary
The facility failed to ensure a safe mechanical lift transfer when a resident was being moved with a Hoyer lift and sling, resulting in a fall and injury. Facility policy for using a mechanical lifting machine required staff to securely attach sling straps to the sling bar according to manufacturer’s instructions, double-check the security of the sling attachment before lifting, examine all hooks, clips, or fasteners, check strap stability, and ensure the sling bar was securely attached and sound. Despite these requirements, during a transfer for dinner, two CNAs placed the sling under the resident, attached the loops at each corner of the sling to the lift, and raised the resident off the bed into the space between the bed and wheelchair when the bottom left corner of the sling became disengaged from the lift. The resident involved had multiple diagnoses including osteoarthritis, cervical and thoracic spondylosis, and Alzheimer’s disease, with the Minimum Data Set documenting severely impaired cognitive skills for daily decision-making. The resident’s care plan required the assistance of two staff during Hoyer lift transfers. During the transfer, the resident fell approximately four feet, landing on her buttocks, bouncing, and then falling backward and striking her head on the leg of the Hoyer lift. Hospital records documented that the resident sustained an abrasion to the back of the head, fractures of the 6th, 7th, 8th, and 10th ribs, and fractures of the 1st and 2nd lumbar vertebra. Staff interviews and observations showed that staff believed the sling loops had been securely fastened and reported hearing the loops click into place before lifting. One CNA stated that they had barely lifted the resident off the bed when the bottom left loop became disconnected and the resident fell. Another CNA reported being shocked and unable to figure out what had happened. A nurse who assessed the resident and then examined the equipment after the fall noted that one of the loops of the sling had become disengaged but stated the sling appeared to be in good condition. During a later demonstration, a CNA indicated she thought one of the round metal disks on the lift might have been a little loose. Maintenance logs for Hoyer slings and lifts for the preceding months documented no concerns with the slings or lifts, and the DON acknowledged expecting a citation due to the resident’s injury from the fall.
Failure to Revise Care Plans to Reflect Resident Needs and Preferences
Penalty
Summary
The deficiency involves the facility’s failure to revise and individualize comprehensive care plans to reflect residents’ current needs and preferences, as required by its own care planning policy. For one resident with hemiplegia, hemiparesis following cerebrovascular disease, and mononeuropathy of the upper limb, the admission MDS showed intact cognition and upper extremity impairment. This resident reported having bilateral shoulder surgery and an inability to tolerate blood pressure measurements on the upper arms due to pain, and stated a preference for BP measurements on the forearms. The resident reported having informed multiple nursing staff of this preference, but staff continued to place the cuff on the upper arms. Review of the resident’s care plan and Kardex showed no interventions or instructions regarding forearm BP cuff placement. A NAC confirmed they were unaware of the preference until the resident told them directly and that this instruction was not documented in the Kardex. The RN/Unit Manager, who stated they were responsible for revising and reviewing care plans when there were changes, also confirmed they were not aware of the resident’s preference and that it should have been updated in the care plan. Another resident, readmitted with hemiplegia and hemiparesis following a nontraumatic subarachnoid hemorrhage, contracture of the left hand, and weakness, was cognitively intact and required maximum assistance for bed mobility per a quarterly MDS. This resident stated they were supposed to get out of bed for two hours every day, but some NACs were not aware of this care requirement. Review of the resident’s March 2026 MAR/TAR showed an order to document the time the resident got up and the time they returned to bed daily. The report states that, overall, the facility failed to revise care plans accurately to reflect residents’ needs for three of four residents reviewed for care plan revision, placing them at risk for unidentified and unmet care needs and a diminished quality of life.
Failure to Implement Restorative Nursing and Splint/Brace Programs After Therapy Discharge
Penalty
Summary
The deficiency involves the facility’s failure to provide restorative nursing services, including range of motion (ROM) exercises and splint/brace assistance, to maintain or prevent decline in mobility and contractures for two residents with significant motor impairments. The facility’s undated Restorative Nursing Services policy stated that residents would receive restorative care as needed to achieve and maintain optimal functioning and that residents may initiate a restorative program upon discharge from rehabilitative care. Despite this, surveyors found that residents with documented hemiplegia, hemiparesis, weakness, and contractures were not placed on restorative programs and had no restorative interventions documented in their electronic health records (EHRs). Resident 1 was admitted with hemiplegia and hemiparesis following cerebrovascular disease, a left lower leg fracture, and weakness, and the admission MDS showed intact cognition, moderate assistance needs for bed mobility and transfers, and one-sided upper and lower extremity impairment. During observation, the resident was seen lying in bed with a bent inward left forearm and hand and reported no longer receiving therapy or nursing-assisted exercises. The care plan initiated in January showed no restorative services, and the care plan history and EHR contained no restorative nursing interventions. However, the PT discharge summary from February documented that restorative ROM and transfer programs had been established and trained, including PROM to the left upper and lower extremities and stand-by assist with transfers, and the OT discharge summary recommended a splint/brace to prevent contracture. The OT stated that the splint/brace was not tried due to lack of time before insurance was discontinued, and both the Director of Rehab and the MDS coordinator confirmed there was no restorative referral in the EHR and they were unaware of the recommendations. Resident 2 was readmitted with hemiplegia and hemiparesis following a nontraumatic subarachnoid hemorrhage, a left-hand contracture, and weakness, and the quarterly MDS showed intact cognition, maximum assistance needs for bed mobility, total assistance for transfers, bilateral upper and lower extremity impairment, and no therapy or restorative programs. The resident reported that therapy had been discontinued months earlier and that no restorative staff were assisting with exercises. The care plan and EHR showed no restorative services. OT evaluation documented left upper extremity ROM impairment, a left-hand contracture, and prior use of a left orthotic to manage flexion tone, and the OT discharge summary recommended restorative care and assistance with donning/doffing the orthotic. The PT discharge summary recommended restorative programs if Medicaid Part B services did not continue. The Director of Rehab confirmed therapy was discontinued and that restorative nursing programs were recommended, but both the Director of Rehab and the MDS coordinator stated there were no restorative referrals in the EHR after readmission, and the MDS coordinator confirmed the resident had no restorative programs since readmission.
Failure to Implement Effective Fall and Toileting Interventions for High-Risk Resident
Penalty
Summary
The deficiency involves the facility’s failure to provide adequate supervision, identify fall trends, and implement progressive, resident-centered interventions for a resident with multiple falls and declining strength. The facility’s own Falls and Fall Risk Management policy required staff to identify interventions related to residents’ specific risks and causes to prevent falls and minimize complications. The resident’s Care Area Assessment identified cancer-related risks for pain, falls, and ADL decline, and stated that falls and urinary incontinence would be addressed in the care plan with an objective of improvement and risk minimization. However, the comprehensive care plan did not include a urinary or ADL care plan and contained no toileting plan, despite the resident’s identified risks and prior fall history. Over a series of falls, the resident repeatedly fell while attempting to toilet or move toward the bathroom, yet the facility did not recognize or address this pattern in its investigations or care planning. The resident had multiple unwitnessed falls: next to the bed while getting up to use the restroom, in the bathroom while standing to use the toilet, and near or in the bathroom on several occasions. Incident investigations and post-fall assessments documented environmental factors such as clutter, items on the floor, water on the floor, and issues with footwear, as well as the resident’s increasing weakness, impulsivity, poor safety awareness, and poor insight into limitations. Interventions documented in investigations and risk reviews included encouraging use of the front-wheeled walker, keeping the wheelchair and walker accessible, ensuring proper footwear and non-skid socks, and providing resident education on safe transfers, ambulation, and assistive device use. However, several of these planned interventions, including placement of the wheelchair and frequent rounding/toileting assistance, were not added to or reflected in the care plan as stated. Staff interviews further showed that the resident frequently fell while trying to go to the bathroom and that staff relied on verbal education and reminders to use the call light, even though the resident often did not use it. Staff acknowledged the resident’s impulsivity and tendency to get up independently despite instructions, and one staff member stated that nursing assistants were verbally instructed to offer bathroom assistance, but this intervention was not documented in the care plan. The resident’s bed remained the one furthest from the bathroom throughout the stay, and none of the facility’s investigations identified the trend of bathroom-related falls or addressed toileting options in the care plan. Ultimately, the resident sustained a left ankle fracture after another bathroom-related fall, requiring transfer to the emergency department for evaluation and treatment, and later records documented additional fractures and a decline in condition. The surveyors concluded that the facility’s failures placed residents at risk of repeated falls and injuries.
Failure to Monitor Urinary Retention After Foley Removal Leading to Prolonged Pain
Penalty
Summary
The deficiency involves the facility’s failure to adequately assess and monitor a resident for complications associated with an indwelling urinary catheter and urinary retention, particularly after catheter removal. The resident had a history of acute kidney injury due to urinary retention, which improved after Foley catheter placement in the hospital. Hospital discharge documentation indicated the catheter was placed for acute urinary retention, was deemed permanent, and included instructions that, given the resident’s significant retention and acute renal failure, staff at the skilled nursing facility should not attempt Foley removal. The facility’s catheter care plan directed staff to empty the catheter as needed and record output in milliliters, but review of the last 30 days of documentation showed continence was not rated due to the indwelling catheter and there was no documented urinary output in milliliters on the treatment administration records. The resident had a scheduled urology appointment at which the urinary catheter was discontinued. Upon return from this appointment, nursing documentation initially indicated no new orders, and an alert note later stated the catheter was discontinued and staff were monitoring for retention or pain. However, there was no documented bladder assessment or urinary output following catheter removal. Nursing assistant documentation showed that the resident did not void on the evening shift that same day. Despite the catheter having been removed, the treatment administration record showed staff continued to document provision of catheter care on subsequent shifts when no catheter was in place. Over the next day, the resident experienced vomiting, decreased oral intake, and an altered level of consciousness, with vital signs showing tachycardia and low blood pressure, and staff documented decreased urine output. A bladder scan performed later revealed more than 2000–2500 milliliters of urine in the bladder, and an indwelling catheter was reinserted, initially draining a large volume of urine. The provider note indicated the resident had not eaten since the prior night, was unable to hold down fluids, and staff were unsure whether the resident had urinated in incontinence briefs, with no wet briefs reported since the resident’s return from the hospital after catheter removal. The provider expressed concern that the documented early-morning wet brief might not be accurate given the large bladder volume on scan and stated this should require further investigation. Subsequent notes described the resident moaning and complaining of pain, with limited urine output in the catheter bag and staff flushing and then replacing the catheter due to continued complaints. Interviews with the resident, the roommate, and staff indicated the resident was crying out and moaning in pain, the roommate repeatedly alerted staff that the resident was not urinating and that the catheter was not draining, and staff had to seek assistance to replace the catheter. Facility leadership and clinical staff later acknowledged that typical practice after catheter removal would include contacting the provider, placing the resident on alert, performing post-void residuals with bladder scans, and documenting monitoring, which was not done in this case.
Medication Administration Delays, Documentation Errors, and Use of Expired Insulin
Penalty
Summary
The deficiency involves the facility’s failure to ensure sufficient nursing staff with appropriate competencies and skill sets to administer medications according to professional standards of practice, facility policy, and prescriber orders. The facility’s medication administration policy required medications to be given as prescribed, in accordance with manufacturers’ specifications and good nursing principles, with no expired medications used, and doses administered within 60 minutes of the scheduled time and documented immediately after administration. Multiple residents reported that agency nurses often gave medications late, did not read full instructions, or were slow in bringing medications, and that routinely scheduled medications were not consistently provided without residents having to ask. Surveyors observed several specific medication administration failures. For a resident with diabetes, an LPN drew up and administered Humalog/Lispro insulin from a multi-dose vial that had been opened and dated “02/16” with no year, making it expired per policy, and administered the dose nearly 1 hour and 45 minutes after it was due. Another resident with care plan instructions to receive medications as ordered had multiple scheduled medications (Gabapentin, Oxybutynin, Baclofen, and Tizanidine) that were ordered at specific times throughout the day; the LPN was observed administering all four together and acknowledged that at least one (Tizanidine) was late, while the resident reported that receiving them together at that time was typical and not at their request. For another diabetic resident, an RN checked blood sugar and prepared sliding scale Humalog/Lispro insulin almost two hours after the scheduled time; the resident refused the insulin, stating they had already finished lunch. Additional deficiencies were identified with other residents’ pain and scheduled medications. One resident with a pain care plan and an order for Methocarbamol four times daily at set times approached the cart requesting Methocarbamol and Tylenol; the RN initially stated the Methocarbamol had already been given, but then administered it two hours after it was due when the resident pointed out the scheduled timing. For another resident with a risk for pain care plan and Tramadol ordered three times daily at specific times, an LPN retrieved a PRN pain medication while the electronic record showed no 8:00 AM medications documented; the LPN stated they had given them but had not yet documented. Later, an RN prepared the 2:00 PM Tramadol dose, and review of the narcotic count showed a discrepancy between the number of pills documented and the number remaining in the card. The RN stated they had given the 8:00 AM Tramadol but had not signed it out, then signed out both the 8:00 AM and 2:00 PM doses at that time. Residents interviewed consistently reported that medications were sometimes or frequently late, that agency nurses did not always follow instructions, and that they often had to request medications that were routinely scheduled.
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