The Broadview Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Seattle, Washington.
- Location
- 13023 Greenwood Avenue North, Seattle, Washington 98133
- CMS Provider Number
- 505416
- Inspections on file
- 29
- Latest survey
- December 15, 2025
- Citations (last 12 mo.)
- 14 (1 serious)
Citation history
Health deficiencies cited at The Broadview Center during CMS and state inspections, most recent first.
A resident with a recent fracture and altered mental status experienced a decline in consciousness and oxygen saturation, but staff did not consistently monitor vital signs, initiate oxygen therapy when indicated, or offer prompt hospital transfer. Despite clear signs of deterioration and a full treatment POLST, appropriate escalation of care was not documented, and the resident later died following emergency intervention.
A resident was allowed to vape unsupervised in their room despite a facility policy prohibiting smoking and vaping, with staff failing to secure the device or complete a required smoking assessment. In a separate incident, a staff member's unleashed dog entered the dining area, startled a resident in a wheelchair, and caused the resident to fall and sustain a head laceration, violating the facility's pet policy requiring animals to be leashed and supervised at all times.
The facility's assessment lacked a completed risk assessment, a detailed list of medical and non-medical equipment, and documentation of contracts or agreements with third parties for services or equipment during both routine and emergency operations. Administrators confirmed the absence of these required elements and could not locate referenced appendices, resulting in an incomplete evaluation of the facility's capacity to meet resident needs.
The facility did not conduct thorough investigations or implement corrective actions following alleged abuse and a resident-to-resident altercation. Investigations lacked key details, such as the timing of incidents, and interviews with residents about safety concerns were not properly conducted or documented. Residents with severe cognitive impairment were inappropriately interviewed, and care plans were not updated to address new behaviors or protect those involved. Staff acknowledged these deficiencies, and required procedures for investigation and care plan revision were not followed.
The facility did not consistently provide or document scheduled bathing and showering for several dependent residents. In multiple cases, residents received only one or two showers or bed baths over a month, with no record of care being offered or refused on other scheduled days. Staff interviews confirmed that refusals should have been documented, and the absence of such documentation indicated the care was not provided as required by policy.
The facility did not accurately complete and post daily nurse staffing forms with actual hours worked, instead displaying only scheduled hours. Staff interviews confirmed that actual hours were not updated on the same day, and the administrator acknowledged this practice did not meet requirements for informing residents and visitors.
The facility did not maintain proper food temperatures during meal service, as food items were served below the required 140°F despite being transported on warm plates and in covered carts. Several residents without cognitive impairment reported that their meals were consistently cold or lukewarm, leading to dissatisfaction and, in some cases, decreased food intake. Staff were aware of ongoing complaints about food temperature and palatability, but the issue persisted.
A facility licensed for over 200 residents failed to employ a qualified full-time social worker as required, with none of the reviewed social workers meeting the necessary educational or supervised experience standards. Administrators were unable to provide documentation of qualifications or job descriptions, and interviews confirmed a lack of compliance with regulatory requirements.
Two residents' preferences for bathing routines were not honored, as care plans and EHR schedules did not reflect their stated wishes for shower or bed bath frequency and timing. Staff confirmed that these preferences were not accommodated, resulting in unmet care needs.
Two residents did not have comprehensive care plans addressing their use of assistive devices, independent community outings, or refusal of incontinent care. One resident regularly used a motorized wheelchair and left the facility unsupervised, but this was not documented in the care plan, nor were safety interventions included. Another resident consistently refused incontinent care, but the care plan did not reflect this behavior or the intervention to notify the resident's representative. Staff interviews confirmed these omissions.
A resident with a history of muscle weakness and cauda equina syndrome reported right ankle pain after an incident involving their motorized wheelchair and ankle-foot orthosis. The resident's pain was initially documented and treated with pain medication, but there was no ongoing monitoring or timely provider assessment for several days, despite facility policy. The lack of communication between therapy and nursing, and failure to continue alert charting, led to a delayed diagnosis of a tibial fracture and subsequent complications, as confirmed by staff interviews and internal investigation.
A resident with chronic Stage 4 pressure injuries and osteomyelitis did not receive the recommended Dolphin Mattress for pressure relief, despite repeated wound care consultant recommendations. Instead, staff provided a different mattress that did not meet the specified requirements, and the recommended mattress was never replaced, as confirmed by staff and administration interviews.
Two residents missed multiple doses of ordered IV antibiotics for serious infections because the facility's pharmacy stopped delivering IV medications, and staff were unclear on how to obtain them. One resident experienced symptoms after missed doses, while another was transferred to the hospital after not receiving any IV antibiotics.
Staff failed to consistently keep isolation room doors closed and did not use required PPE, such as N95 respirators and gowns, when caring for two residents with active COVID-19. Observations showed staff entering and exiting rooms without proper protection, and interviews confirmed that these actions were not in line with facility policy or posted instructions.
The facility did not maintain or make accessible the required three years of survey results and associated plans of correction, as only the most recent survey documents were available in the designated binder. This prevented residents, their representatives, and visitors from reviewing past survey outcomes and the facility's corrective actions, as confirmed by the DON and Administrator.
The facility did not ensure guardianship papers were current for a resident with intellectual disabilities and failed to offer or document assistance with advance directives for two other residents, including one who wished to designate a DPOA. Staff interviews revealed confusion about responsibility for maintaining these records, and required discussions and documentation were missing from the EHR.
The facility did not consistently monitor or document side effects and target behaviors for residents prescribed psychotropic medications, including both antidepressants and antipsychotics. Required assessments, such as the AIMS for antipsychotic use, were not completed within the recommended timeframe, and staff confirmed that expected documentation was missing from medical records.
Surveyors found that multiple residents did not have comprehensive care plans developed or implemented for essential needs such as nail care, toileting hygiene, bed positioning, nutrition, dental care, pain management, and activities. Observations and interviews revealed that care was not provided or documented as required, and residents' specific needs and preferences were not addressed, resulting in unmet care needs.
The facility did not accurately complete and post daily nurse staffing forms with actual hours worked for each shift, as required by policy. Observations and staff interviews confirmed that only planned hours were displayed, and actual hours worked were omitted from the posted forms over a seven-day period.
The facility did not consistently complete or document monthly Medication Regimen Reviews (MRRs) for several residents, including missing pharmacist recommendations and incomplete physician follow-up. Staff interviews confirmed that required MRRs were not available in the EHR or facility records for multiple months, contrary to facility policy and regulatory expectations.
Surveyors found expired medications and medical supplies on several medication carts and in a storage room, with staff confirming these items should have been discarded according to facility policy. Additionally, daily temperature logs for a medication room refrigerator were incomplete, with several days missing entries, despite staff expectations for daily monitoring. These deficiencies were confirmed through staff interviews and review of facility policy.
Surveyors found that food items in the kitchen and dining room storage areas were not consistently labeled with open or use-by dates, and several expired items were not discarded as required by facility policy. Staff confirmed that bread, condiments, dairy products, and prepared foods were not properly dated or removed when expired, despite clear policies mandating these practices.
The facility did not review its infection control policies annually as required, failed to keep a urinary catheter drainage bag off the floor for a resident with obstructive uropathy, and did not disinfect a sit-to-stand lift between uses for two residents. Staff also did not consistently use required PPE or perform hand hygiene when providing care to two residents on Enhanced Barrier Precautions, as confirmed by staff interviews.
A resident with severe cognitive impairment and limited mobility had their bed positioned against the wall without assessment, evaluation, or informing the resident or their representative about the risks and benefits. Staff interviews and record reviews confirmed the absence of a physician order and lack of required communication or documentation.
Two residents did not have their preferences for twice-weekly showers or baths honored, as documented in their care plans. ADL records and staff interviews confirmed that both residents received fewer showers or baths than preferred, with no refusals documented, due to staffing issues and changes in staff assignments. Facility policy required honoring resident bathing preferences, but these were not consistently followed.
Two residents had their medical information discussed and assessments performed by an ARNP in common areas, including the TV room and a bench near the nurse's station, without privacy. Staff confirmed that these interactions did not meet expectations for confidentiality and privacy during provider visits.
A resident reported concerns about inadequate supplies and described this as a form of elder abuse. The facility's investigation included reviewing supply records and interviewing the resident, but did not include interviews with other residents or staff. The administrator later acknowledged that the investigation was incomplete and did not follow usual procedures.
A resident was discharged from hospice services, but the required Significant Change in Status Assessment (SCSA) MDS was completed 13 days late, beyond the 14-day regulatory timeframe. Staff interviews and record reviews confirmed that the MDS coordinator was responsible for the delay, and the DON acknowledged the assessment was not completed on time.
Surveyors identified that three residents had inaccurate MDS assessments: one was incorrectly coded as receiving antidepressants, another was not marked as edentulous despite documentation and observation, and a third was marked as receiving hospice care without supporting orders or documentation. Staff interviews confirmed the inaccuracies and the expectation for accurate MDS completion.
The facility failed to complete and document required PASARR screenings for two residents. One resident did not receive a new Level I PASARR after remaining in the facility beyond the exempted hospital discharge period, and another resident's Level II PASARR referral was not documented despite indications of mental health decline. These actions did not follow the facility's policy for screening and referral for mental disorders or intellectual disabilities.
The facility did not notify the State PASARR Coordinator or mental health authority after three residents with mental health or intellectual disability diagnoses experienced significant changes in condition. Required referrals for PASARR Level II evaluations were either delayed or not completed, as confirmed by documentation and staff interviews.
Care plans for three residents were not updated to reflect significant changes, including discontinuation of hospice services, initiation of comfort care, and stopping of antidepressant medication. Staff and DON confirmed that care plans still contained outdated information and did not accurately represent current care needs.
A resident who was cognitively intact and expressed interest in specific activities was not provided with an ongoing activity program or access to leisure supplies, as required by facility policy and their care plan. Observations and interviews confirmed the resident was not offered or participating in group or individual activities, and there was no documentation of activity participation or refusal in the medical record.
Two residents experienced deficiencies in care: one had untreated and undocumented skin injuries following a fall, while another did not have required daily weights recorded despite being on diuretic therapy. Staff were unaware of the skin injuries and failed to follow protocols for documentation and monitoring, placing both residents at risk for unmet care needs.
A resident with gastroparesis and Type I diabetes was not provided with the physician-ordered small, frequent meals, instead receiving regular-sized portions despite clear care plan instructions. Staff interviews and record reviews confirmed the failure to follow the therapeutic diet, resulting in significant weight loss for the resident.
Staff did not properly store or label respiratory equipment and failed to consistently document O2 saturation as ordered for a resident with COPD and acute hypoxic respiratory failure. The O2 humidifier bottle was repeatedly undated, and the BiPAP tubing and nasal cannula were found improperly stored, including on the floor. Staff interviews confirmed these practices did not meet facility expectations.
Three residents received calcium and vitamin D supplements that did not match their physician orders, with staff administering different formulations and dosages than prescribed. Both nursing staff and the in-house pharmacy failed to clarify discrepancies with the physician or pharmacist before administration, resulting in medication errors that were confirmed by the unit manager, consultant pharmacist, and DON.
A resident with a broken tooth was not referred for dental services despite staff awareness and facility policy requiring such referrals. The resident experienced difficulty chewing, and interviews with nursing, social services, and the DON confirmed that no referral or documentation was made for dental care.
Two residents with intact cognition did not have their meal preferences honored, as staff failed to follow their menu selections and specific food requests. Despite residents clearly indicating their choices and expressing dissatisfaction, staff delivered meals that did not match their preferences, and multiple staff members acknowledged that the residents' choices should have been followed.
A resident's clinical status, vital signs, and departure for a planned diagnostic procedure were not documented in the medical record. Both the assigned LPN and the DON confirmed the absence of required documentation, resulting in incomplete and inaccurate records for the resident.
A resident was not offered or administered the required annual influenza and pneumococcal vaccines, and there was no documentation of vaccine offers, refusals, or informed consent in the medical record. Staff interviews and record reviews confirmed inconsistent practices and missing documentation, despite facility policy requiring these actions.
The facility did not include a contingency plan or strategies for maximizing direct care staff recruitment and retention in its most recent facility-wide assessment. The Administrator confirmed these omissions during an interview.
A resident with impaired memory and a known history of wandering and elopement risk was able to leave the facility unsupervised, despite being redirected by staff earlier. The resident exited through the front door and was later found walking alone on a busy street, indicating a failure to provide adequate supervision as required by facility policy.
Two residents who were dependent on staff for all ADLs did not receive timely assistance with toileting and changing after incontinence and vomiting incidents. Staff interviews confirmed that one resident was left in a wet bed after a brief change, and another was not promptly changed after soiling clothing and linens. The DON acknowledged that staff did not meet the care needs as outlined in the residents' care plans.
The facility failed to maintain resident dignity by not knocking before entering rooms, inadequately covering urinary catheter bags, leaving mechanical lift slings under residents, and standing while assisting residents with meals. These actions affected multiple residents and were against the facility's policies.
The facility failed to inform residents and/or their representatives of the risks and benefits before implementing safety devices and treatments, including bed placement, use of a tilt-in-space wheelchair, a transfer pole, and psychoactive medication. Staff interviews and record reviews confirmed the lack of required assessments and consents.
The facility failed to periodically review resident rights with all 16 residents reviewed. Resident Council minutes from February 2023 to April 2024 showed no discussions on resident rights. Interviews with residents and staff confirmed that resident rights were not reviewed during Resident Council meetings, and the Administrator acknowledged that this should be done yearly.
The facility failed to provide the website address of the Washington State Long-Term Care Ombudsman on posted contact information in seven areas, including notice boards and an elevator. The Administrator confirmed that the contact information had not been updated recently, acknowledging it should be updated annually. This placed residents at risk of not being able to report concerns online.
The facility failed to maintain the privacy and confidentiality of residents' personal and medical information. Residents' weights were posted publicly, a computer screen with medical records was left unattended, and contact information for residents' representatives was visible from the hallway. Additionally, a resident received a medical treatment in a public area, exposing their back to others.
The facility failed to provide a homelike environment by serving meals on trays in the dining rooms, contrary to policy. Staff members, including CNAs and Culinary Service Aides, were observed not removing trays after serving meals, and interviews revealed a lack of training and adherence to the policy.
Failure to Monitor Change in Condition and Initiate Timely Intervention
Penalty
Summary
A deficiency occurred when facility staff failed to adequately monitor a resident who experienced a change in level of consciousness and decreased oxygen saturation. The resident, who had been admitted for rehabilitation following a left leg fracture and had a history of muscle weakness and altered mental status, was initially alert and oriented. Over the course of her stay, documentation showed a decline in her mental status, with increasing somnolence and uncooperative behavior, as well as decreasing oxygen saturation levels, including a reading as low as 88% on room air. Despite these significant changes, staff did not consistently perform or document frequent assessments of the resident's vital signs or mental status as required by facility policy and the medical provider's instructions. Oxygen therapy was not initiated when the resident's oxygen saturation dropped below 90%, and there was no documentation of follow-up assessments or escalation of care. Additionally, neither the resident nor her representative was offered a prompt transfer to the hospital for further evaluation, even though the resident's POLST indicated a preference for full treatment, including hospital transfer if indicated. Interviews with staff revealed a lack of clarity and follow-through regarding monitoring protocols, initiation of oxygen therapy, and the process for offering hospital transfer. Staff acknowledged that vital signs were not taken as frequently as expected and that opportunities to escalate care or offer transfer were missed. The resident ultimately experienced increased respiratory distress, required emergency intervention, and was pronounced dead after resuscitation efforts.
Failure to Supervise Smoking Materials and Restrain Pet Results in Resident Injury
Penalty
Summary
The facility failed to provide adequate assessment and supervision for the use of electronic cigarettes and did not ensure the safe storage of smoking materials for a resident. Despite the facility's policy prohibiting smoking and vaping within the building and on its grounds, a resident with a history of tobacco use and cognitive intactness was observed vaping unsupervised in their room on multiple occasions. Staff were aware of the resident's vaping but did not intervene to secure the device or conduct a required smoking assessment, and there was confusion among staff regarding whether the policy included vaping devices. Documentation showed that the resident had refused nicotine patches and continued to use a vape device independently, with staff failing to follow the policy for safe storage and supervision of smoking materials. Additionally, the facility failed to supervise and restrain a staff member's dog, resulting in an accident involving another resident. The facility's pet policy required that animals be leashed and supervised at all times and prohibited their presence in dining areas. However, the dog was left unleashed and unsupervised, entered the dining room, and crawled under a table where a resident in a wheelchair was eating. The resident was startled, causing their wheelchair to tip backward, resulting in a laceration to the back of their head and requiring transport to the hospital for evaluation. Multiple staff interviews confirmed that the dog was not on a leash and that this was a direct violation of facility policy. These failures led to significant safety hazards, including the risk of fire or explosion from unsupervised vaping and a preventable injury to a resident due to the presence of an unrestrained animal in a resident area. Staff interviews and record reviews consistently indicated a lack of understanding and enforcement of facility policies regarding both smoking materials and pet supervision, directly contributing to the deficiencies identified.
Removal Plan
- Remove the smoking materials in Resident 7's room for safe storage
- Complete a smoking assessment and update Resident 7's care plan with the facility providing supervised vaping
- Interview and observe all residents and their rooms to ensure smoking materials are stored safely
- Educate all residents and/or resident representatives, and staff on the facility's non-smoking policy
Incomplete Facility Assessment and Missing Resource Documentation
Penalty
Summary
The facility failed to ensure that its facility-wide assessment included all required components necessary to determine the resources needed to competently care for residents during both routine operations and emergencies. Specifically, the assessment did not contain a completed facility-based and community-based risk assessment, nor did it include a comprehensive list of medical and non-medical equipment descriptions. Additionally, documentation of contracts, memorandums of understanding, and other agreements with third parties to provide services or equipment during normal and emergency situations was missing. During interviews, facility administrators acknowledged that the assessment was incomplete and that referenced appendices containing critical information could not be located. The assessment also contained outdated information regarding the facility's admission policy for active COVID-19 residents, which did not reflect current practices. These omissions were identified through record review and staff interviews, indicating a lack of thorough documentation and assessment as required by facility policy.
Failure to Conduct Thorough Abuse Investigations and Update Care Plans
Penalty
Summary
The facility failed to conduct thorough investigations and implement corrective actions to prevent recurrence of incidents involving alleged abuse and resident-to-resident altercations. For one resident with diagnoses including anxiety disorder, hemiplegia, hemiparesis, and dementia, the investigative summary did not identify when the alleged incident occurred. Additionally, interviews with several residents regarding safety concerns were not conducted correctly, and follow-up on their expressed concerns was inadequately documented. Some residents with severe cognitive impairment were inappropriately interviewed instead of their representatives, contrary to the facility's stated process. In another incident involving two residents, the investigation documented that one resident attempted to push another back to their room, leading to a physical altercation where one resident scratched and hit the other's arms, resulting in visible bruising. The investigation summary and care plans for both residents did not include any new or revised interventions to prevent recurrence of such incidents. Staff interviews confirmed that the only immediate action taken was to separate the residents, and there was no documentation of further corrective actions or care plan updates addressing the behaviors or protection for the involved residents. Facility staff, including the DON, RN Unit Manager, and Administrator, acknowledged gaps in the investigation process, such as lack of documentation regarding corrective actions, failure to update care plans with new interventions, and improper interview procedures for residents with cognitive impairment. The facility's policies required thorough investigation, identification of the incident's specifics, and care plan revisions to minimize recurrence, but these steps were not consistently followed in the reviewed cases.
Failure to Provide and Document Scheduled Bathing and Showering for Dependent Residents
Penalty
Summary
The facility failed to consistently provide bathing and showering assistance to residents who were unable to perform these activities independently, as required by their care plans and facility policy. For four residents reviewed, documentation showed that scheduled showers or bed baths were either not provided or not properly documented as offered or refused. In several cases, the electronic health records (EHR) indicated that showers were only given once or twice in a 30-day period, with the remaining scheduled days marked as "Not Applicable" and lacking any indication of whether care was offered or declined. Specifically, one resident required extensive assistance with bathing and was scheduled for weekly showers, but only received two showers in a 30-day period, with no documentation of offers or refusals for the other days. Another resident, dependent on staff for bathing, received only one shower during a similar timeframe, again with no documentation of refusals. A third resident, who preferred bed baths and required limited assistance, did not receive any bed baths over a nearly two-week period, and there was no documentation to show if the care was offered or refused. A fourth resident, newly admitted and scheduled for weekly showers, did not receive a shower until 11 days after admission, with no documentation of offers or refusals during that period. Interviews with facility staff, including the unit manager RN, DON, and administrator, confirmed that refusals should have been documented and that the lack of documentation meant the care was not provided. The facility's policy required that residents unable to perform ADLs independently receive necessary services, and that refusals be documented along with communication of risks and benefits to the resident or representative. The failure to provide or document bathing and showering as scheduled constituted a deficiency in meeting residents' ADL needs.
Failure to Accurately Post Actual Nurse Staffing Hours
Penalty
Summary
The facility failed to ensure that the daily nurse staffing forms were accurately completed with the actual hours worked for each shift on 7 out of 10 days reviewed. Observations and record reviews showed that the posted forms did not reflect the actual nursing hours worked, but instead displayed the scheduled hours. Interviews with staff revealed that the receptionist posted the scheduled hours in the morning and added evening and night shift hours later, without ever updating the forms to show the actual hours worked. The staffing coordinator confirmed that actual hours were typically filled in the next day or later, rather than on the same day. The administrator acknowledged that actual nursing hours should be posted on the same day to inform residents and visitors, but this was not being done.
Failure to Serve Food at Safe and Appetizing Temperatures
Penalty
Summary
The facility failed to ensure that food was served at proper temperatures on the Transitional Care Unit (TCU), as evidenced by direct observation, interviews, and record review. During a meal service, the Dietary Manager measured food temperatures and found that baked beans, hamburger patties, corn on the cob, and chicken noodle soup were all below the expected 140 degrees Fahrenheit, with some items as low as 105 degrees Fahrenheit. The food had left the kitchen less than ten minutes prior to being tested, yet did not maintain the required temperature. The Dietary Manager acknowledged that the food should have remained at 140 degrees Fahrenheit for up to forty minutes but did not do so, despite being served on warm plates, covered, and transported in a closed food cart. Multiple residents without cognitive impairment reported that their meals were consistently served cold or lukewarm, affecting their willingness to eat and their satisfaction with the food. Residents described the food as always cold, with one stating they sometimes skipped meals due to the temperature, and another expressing a desire to have food delivered from outside the facility. Staff interviews confirmed awareness of ongoing complaints about cold and unpalatable food, and it was noted that previous efforts to address these complaints had not resolved the issue.
Failure to Employ Qualified Social Worker in Facility with Over 120 Beds
Penalty
Summary
The facility, licensed to provide care for 211 residents, failed to employ a qualified full-time social worker who met the educational and supervised experience requirements as mandated for facilities with more than 120 beds. Review of staff records and interviews revealed that none of the four social workers reviewed (including three full-time and one per diem) possessed the required qualifications. Specifically, one social worker held a master's degree in theology, which is not considered a human services field, and another had only an associate's degree without a bachelor's in social work or a related field. The qualifications for the remaining social workers were not provided despite multiple requests. Interviews with facility administrators confirmed a lack of familiarity with the required qualifications for social workers in such a setting. Documentation such as job descriptions, policies, and evidence of one year of supervised social work experience in a healthcare setting were not provided for any of the social workers. This deficiency was identified through staff interviews, record reviews, and email correspondence, with administrators acknowledging gaps in compliance with regulatory requirements.
Failure to Accommodate Resident Bathing Preferences
Penalty
Summary
The facility failed to reasonably accommodate the bathing preferences of two residents, resulting in unmet care needs. For one resident, documentation showed a clear preference for morning showers twice a week, as indicated in both a "Shower Preference Questionnaire" and through staff interviews. However, the resident's care plan did not reflect these preferences, and the electronic health record (EHR) scheduled showers only once a week in the evening, contrary to the resident's stated wishes. Staff confirmed that the resident's preferences were not being honored at the time of review. Another resident expressed a preference for bed baths twice a week in the evening, which was documented in the care plan and confirmed during interviews. Despite this, the EHR showed the resident was scheduled for showers or baths on specific evenings, and records indicated the resident did not receive the preferred bed baths during a specified period. Staff acknowledged that the resident's preferences were not honored and that refusals, if any, were not documented. These failures were in direct conflict with the facility's policy to honor resident choices and preferences regarding activities of daily living.
Failure to Develop Comprehensive Care Plans for Assistive Device Use, Community Outings, and Refusal of Care
Penalty
Summary
The facility failed to develop and implement comprehensive care plans for two residents, as required by policy and regulation. For one resident with a history of muscle weakness and use of a motorized wheelchair, the care plan did not document the use of the assistive device or the resident's independent community outings, despite the resident regularly leaving the facility unsupervised in their motorized wheelchair. Staff interviews revealed a lack of awareness regarding the resident's use of the motorized wheelchair and their independent outings, and the care plan lacked specific interventions or safety measures related to these activities. For another resident diagnosed with anxiety disorder, hemiplegia, hemiparesis, and dementia, the care plan did not address the resident's consistent refusal of incontinent care. Facility documentation and staff interviews confirmed that the resident often refused to be changed, which posed a risk for skin breakdown. Although staff were instructed to notify the resident's representative and re-approach the resident when care was refused, these interventions were not included in the resident's care plan. The facility's policy required that comprehensive, person-centered care plans be developed for each resident, incorporating identified problem areas, risk factors, and promoting resident safety. However, the care plans for both residents lacked documentation of key needs and interventions, including assistive device use, independent outings, and refusal of care, as well as associated safety measures and communication protocols.
Failure to Monitor and Promptly Evaluate Change in Condition After Resident Injury
Penalty
Summary
The facility failed to ensure appropriate monitoring and prompt medical evaluation for a resident who experienced a change in condition following an incident involving their right ankle. The resident, who had a history of generalized muscle weakness and cauda equina syndrome and was cognitively intact, reported injuring their right foot when their ankle-foot orthosis became caught on a store display while using a motorized wheelchair outside the facility. Upon return, the resident reported the incident and pain to a physical therapist, who performed passive range of motion but did not notify nursing, as the resident was not on the therapy caseload. The resident later reported pain to a CNA, who notified a nurse. The nurse documented the pain and administered oxycodone, noted the incident in the communication book, and placed the resident on alert charting for monitoring. Despite the initial documentation, there was no evidence of continued alert charting or provider assessment for the resident's right ankle pain over the following three days. The resident continued to receive pain medication and non-pharmacological interventions such as rest and cold/ice, but there was no documentation of ongoing monitoring or follow-up assessments by nursing or the medical provider during this period. The facility's policies required prompt notification of the provider and ongoing documentation for changes in a resident's condition, but these were not followed. The lack of communication between therapy and nursing, as well as the absence of continued monitoring, resulted in a delay in medical evaluation. Eventually, the resident was assessed by a provider, who ordered an x-ray that revealed a right tibial fracture, leading to the resident's transfer to the hospital. During hospitalization, the resident was also diagnosed with a left leg deep vein thrombosis and acute pulmonary embolism, conditions attributed to immobilization following the fracture. Interviews with facility staff confirmed that the expected procedures for monitoring and documentation were not followed, and the incident was not communicated effectively among the interdisciplinary team. The facility's internal investigation corroborated that the resident was not placed on alert charting as required, and there was no evidence of timely provider follow-up.
Failure to Provide Recommended Pressure-Relieving Mattress for Pressure Ulcer Care
Penalty
Summary
The facility failed to provide or replace a pressure-relieving Dolphin Mattress for a resident with a history of chronic Stage 4 pressure injuries and osteomyelitis, despite multiple recommendations from a wound care consultant. The resident, who required assistance with bed mobility and transfers, had a documented need for a Dolphin Mattress to prevent further skin breakdown and assist in wound healing. The wound care consultant repeatedly communicated the necessity of this specific mattress to the nursing staff, noting that the replacement mattress in use was not sufficient for offloading pressure. Despite these recommendations, the facility replaced the broken Dolphin Mattress with a MATT-EASY AIR mattress, which operates by alternating air rather than fluid. Staff interviews confirmed that the wound care recommendations were received and acknowledged, but the Dolphin Mattress was never replaced. The Director of Nursing indicated that the previous administration was aware of the recommendation but opted not to replace the mattress, possibly due to cost concerns. At the time of observation, the resident continued to use the non-recommended mattress, contrary to the wound care consultant's orders.
Failure to Provide IV Antibiotics Due to Pharmacy Service Disruption
Penalty
Summary
The facility failed to ensure that two residents were free from significant medication errors related to the administration of intravenous (IV) antibiotics. One resident, who had been readmitted with a diagnosis of pelvic osteomyelitis, had physician orders for Meropenem IV every 8 hours. The medication was not administered on four occasions over a two-day period due to the facility's inability to obtain the IV antibiotic from the pharmacy. Nursing documentation confirmed the missed doses, and the resident reported experiencing symptoms such as chills and feeling feverish after missing the antibiotics. Staff interviews revealed that the pharmacy previously contracted to provide IV medications had ended their service, and nursing staff were unclear about how to obtain IV medications under the new arrangement. Another resident was admitted with a right hip peri-prosthetic joint infection and had physician orders for Daptomycin and Ertapenem IV antibiotics. The resident did not receive the ordered IV antibiotics because the pharmacy was unable to deliver them, resulting in the resident being transferred back to the hospital the day after admission. Staff interviews confirmed that the facility was unable to secure IV antibiotics for this resident due to the change in pharmacy services, leading to missed doses and the need for hospital transfer.
Failure to Maintain Aerosol Contact Precautions and PPE Use for COVID-19 Positive Residents
Penalty
Summary
The facility failed to implement proper aerosol contact precautions for residents who tested positive for COVID-19. Observations revealed that doors to isolation rooms, which were required to remain closed per facility policy and posted signage, were found open on multiple occasions. Staff members, including nursing assistants, were observed entering and exiting these rooms without wearing the required personal protective equipment (PPE), such as N95 respirators, gowns, gloves, and face shields. Specifically, one staff member was seen wearing only a surgical mask while exiting a COVID-19 isolation room, contrary to the posted instructions and facility policy. Interviews with staff, including nursing assistants, LPNs, the unit manager, and the director of nursing, confirmed that the expectation was for doors to remain closed and for staff to use appropriate PPE when entering rooms under aerosol contact precautions. Documentation showed that two residents had tested positive for COVID-19 and were admitted to the transitional care unit with orders for isolation and appropriate PPE use. Despite these protocols, staff did not consistently follow the required infection prevention and control measures, as evidenced by both direct observation and staff admissions during interviews.
Failure to Provide Access to Required Survey Results and Plans of Correction
Penalty
Summary
The facility failed to ensure that the survey result binder included the most recent three years of recertification survey results and their associated plans of correction, as required by policy. Upon review, it was found that the binder only contained the 2024 annual recertification survey results and plan of correction, while the 2022 and 2023 survey results and their associated plans of correction were missing. This omission was confirmed during multiple reviews of the binder and through interviews with the Director of Nursing and the Administrator, both of whom acknowledged the absence of the required documents. The facility's policy mandates that copies of the most recent and three preceding years of standard surveys, including any follow-up reports and state-approved plans of correction, be accessible in an area frequented by residents, their representatives, and visitors. The lack of the 2022 and 2023 survey results and plans of correction in the binder prevented residents, their representatives, and visitors from exercising their right to review past survey results and the facility's responses to deficiencies.
Failure to Maintain Guardianship Documentation and Offer Advance Directives
Penalty
Summary
The facility failed to obtain and/or renew guardianship papers and did not offer or document assistance in formulating advance directives for three of four residents reviewed. For one resident with a diagnosis of unspecified intellectual disabilities, guardianship papers were found to be expired, and there was no clear assignment of responsibility among staff for ensuring these documents were current and available in the electronic health record (EHR). Interviews with staff revealed confusion about who was responsible for maintaining up-to-date guardianship documentation, and the administrator was unaware of the process. Another resident with intact cognition had no documentation in their EHR regarding advance directives, nor was there evidence that the topic was discussed or that assistance was offered. Staff confirmed that there was no record of such a discussion, despite facility policy requiring that residents be offered information and assistance with advance directives upon admission. A third resident, who was their own decision-maker, expressed interest in designating a Durable Power of Attorney (DPOA) for health care but reported that the facility did not request a copy of an advance directive or offer the option to establish one. The social worker acknowledged that a conversation with the resident’s contact about DPOA was not documented. The administrator confirmed that residents should be given the opportunity to delegate DPOA and that these directives should be documented and accessible, but this was not done for the resident in question.
Failure to Monitor and Document Psychotropic Medication Use
Penalty
Summary
The facility failed to ensure adequate monitoring and documentation for residents prescribed psychotropic medications, including antidepressants and antipsychotics. For one resident, an antidepressant was initiated and the dose increased, but there was no monitoring or documentation of target behaviors or potential adverse side effects in the Medication Administration Record (MAR). Staff confirmed that such monitoring and documentation were expected but missing from the records. Another resident had been on antipsychotic medication for an extended period, but the required Abnormal Involuntary Movement Scale (AIMS) assessment was completed late, exceeding the recommended six-month interval. The consultant pharmacist had previously advised the facility to document AIMS assessments every six months to remain compliant, but staff acknowledged that the assessment was overdue. Additional residents were also prescribed antipsychotic medications without evidence of monitoring for side effects or target behaviors in the physician's orders or MAR. Staff interviews confirmed that monitoring and documentation were expected for all residents on psychotropic medications, but these were not present in the records reviewed. The facility's policy required nursing staff to observe and document the effectiveness of interventions and monitor for side effects, but this was not consistently followed.
Failure to Develop and Implement Comprehensive Care Plans
Penalty
Summary
Multiple deficiencies were identified in the facility's development and implementation of comprehensive care plans for several residents. For nail care, a resident who required substantial assistance with personal hygiene was observed to have long, discolored, and unclean fingernails and toenails. Despite the resident's requests for help and staff acknowledgment of responsibility for nail care or referral to a podiatrist, there was no care plan addressing nail care, no documentation of podiatrist visits, and no evidence that nail care was provided. In the area of toileting hygiene, a resident dependent on staff for toileting and incontinent care reported not receiving assistance during the night shift, despite care plans specifying assistance every 2-3 hours and the resident's request to be woken for changes. Documentation showed frequent missing entries for toileting hygiene, and staff interviews confirmed that care was expected but not consistently documented or provided, with no records of resident refusal. Additional deficiencies included the lack of a care plan for bed positioning for a resident with a leg fracture and severe cognitive impairment, whose bed was placed against the wall without assessment or documentation of risks and benefits. Another resident with gastroparesis did not receive the prescribed small, frequent meals, and a resident with a broken tooth was not referred to dental services as indicated in their care plan. Furthermore, a resident with pain-related diagnoses had no pain management care plan, and a cognitively intact resident did not receive or have documentation of participation in activities as outlined in their care plan. These failures to develop and implement care plans resulted in unmet care needs for multiple residents.
Failure to Accurately Post Daily Nurse Staffing Information
Penalty
Summary
The facility failed to ensure that the daily nurse staffing form was accurately completed and posted with actual hours worked after the start of each shift for seven consecutive days. Observations revealed that the posted staffing forms only displayed planned hours and did not include the actual hours worked by staff, as required by the facility's own policy. The policy specified that the posting must include the facility name, current date, resident census, total number and actual hours worked by staff, and reflect staff absences due to callouts and illness for each shift. However, multiple observations on different days confirmed that the actual hours worked were not shown on the posted forms. Interviews with the staffing coordinator, DON, and administrator confirmed that the posted forms were missing a column for actual hours worked and that this information was not being displayed as expected. The staffing coordinator stated that planned hours, callouts, and illness were documented in the schedule book but not on the posted form. Both the DON and administrator acknowledged that the forms should have included the total number and actual hours worked per shift, but this was not being done. No information was provided regarding any specific residents affected or their medical conditions.
Failure to Complete and Document Monthly Medication Regimen Reviews
Penalty
Summary
The facility failed to ensure that monthly Medication Regimen Reviews (MRRs) were consistently completed and documented for several residents, as required by both facility policy and regulatory guidelines. For one resident, a pharmacist's recommendation to order a new Basic Metabolic Panel due to persistently high Blood Urea Nitrogen levels was not completed by the physician, and the corresponding form was not finalized or scanned into the resident's electronic health record (EHR). Staff interviews confirmed that the expected process for handling pharmacist recommendations was not followed, resulting in incomplete documentation and lack of physician response. Additionally, two other residents did not have documented MRRs for multiple months, with no records found in either the facility's MRR binder or the residents' EHRs for the specified periods. Despite written requests for additional documentation, staff were unable to provide evidence that the required monthly reviews had been performed. Both the administrator and the director of nursing acknowledged that MRRs should be completed monthly and available in the EHR, but the documentation was missing for the residents in question.
Expired Medications and Incomplete Refrigerator Temperature Monitoring
Penalty
Summary
Surveyors observed multiple instances where expired medications and medical supplies were not disposed of in a timely manner across several medication carts and storage rooms. Specifically, expired scalpels, dermal curettes, and wound care supplies were found in the medication storage room, and staff interviews confirmed these items should have been discarded. Additionally, expired medications such as Neomycin eye ointment, Milk of Magnesia, Hemoccult Sensa Developer, Sani-cloth bleach wipes, Bisacodyl suppositories, silver collagen wound gel, and Nitroglycerin tablets were found on various medication carts. Staff acknowledged that these items were expired and should have been removed according to facility policy, which requires the disposal or return of outdated drugs and supplies. Further deficiencies were identified in the monitoring and documentation of medication refrigerator temperatures. Temperature logs for the 500-unit medication room refrigerator showed missing daily entries for both May and June, contrary to staff expectations that temperatures should be checked and recorded daily. Staff interviews confirmed that the lack of daily monitoring was not in line with facility procedures. The facility's policy mandates that all drugs and biologicals be stored safely and securely, and that expired or discontinued items be promptly removed, but these standards were not consistently met as evidenced by the survey findings.
Failure to Properly Label, Date, and Discard Food Items
Penalty
Summary
Surveyors identified multiple failures in the facility's food handling and storage practices across various locations, including the kitchen dry storage room, several kitchen refrigerators, a seasoning shelf, and dining room refrigerators. Observations revealed that numerous food items, such as bread, condiments, dairy products, and prepared foods, were not labeled with expiration or use-by dates as required by facility policy. In several instances, opened food items were found without proper dating, and some items were past their use-by or expiration dates but had not been discarded. Staff interviews confirmed that the facility's process required food items removed from the freezer or opened to be labeled with the date and, when applicable, a use-by date. However, staff acknowledged that these procedures were not consistently followed. For example, bread removed from the freezer was not dated, and various condiments and dairy products in the refrigerators lacked use-by dates. Additionally, expired items such as Dijon mustard, cherry filling, ground coriander, cranberry juice, thickened apple juice, and a sandwich were found and had not been discarded as required. The facility's policies on food receiving, storage, and date marking were reviewed and clearly stated the need for labeling and timely discarding of food items. Despite these policies, the observed deficiencies placed residents at risk for foodborne illness and cross-contamination. The administrator confirmed that the expectation was for staff to regularly check, date, and discard food items as appropriate, but this was not consistently done.
Infection Control Deficiencies: Policy Review, Equipment Disinfection, and PPE Use
Penalty
Summary
The facility failed to ensure that its Infection Prevention and Control Program (IPCP) policies and procedures were reviewed annually as required. The Infection Control Program policy was last reviewed on 10/24/2022, despite the policy stating that reviews should occur at least annually. Interviews with the Infection Preventionist, Director of Nursing, and Administrator confirmed that the policy had not been reviewed within the required timeframe, even though all acknowledged the expectation for annual review. During observations, a resident with a diagnosis of obstructive uropathy and an ostomy was found lying in bed with their urinary catheter drainage bag touching the floor. Staff entering the room did not correct the issue, and the Certified Nursing Assistant (CNA) later admitted that the drainage bag should not have been on the floor but did not know how it happened. Both the Registered Nurse Unit Manager and the Director of Nursing confirmed that catheter drainage bags should not touch the floor, as this is an infection control issue. Additionally, staff failed to disinfect or sanitize medical equipment between resident use. A CNA was observed moving a sit-to-stand lift from one resident's room to another without cleaning or disinfecting it, only wiping the handle with an adult washcloth and not using the proper disinfectant wipes. Furthermore, staff did not consistently follow Enhanced Barrier Precautions (EBP) for residents on EBP, as staff were observed transferring residents without wearing the required gowns and gloves and, in one instance, not performing hand hygiene after care. Staff interviews confirmed that the expected protocols for PPE and equipment disinfection were not followed.
Failure to Inform Resident or Representative About Bed Positioning Risks and Benefits
Penalty
Summary
A deficiency occurred when the facility failed to inform a resident and/or their representative about the risks and benefits of positioning the resident's bed against the wall. The facility's policy requires that residents be fully informed of their health status and any changes in care or treatment, but review of the electronic health record (EHR) showed no evidence that the resident was assessed, evaluated, or informed regarding the bed's position. The resident in question had severe cognitive impairment, was unable to walk, and had limited range of motion in both lower legs. Multiple observations confirmed the bed was positioned against the wall on several occasions. Interviews with facility staff, including registered nurses and the Director of Nursing, revealed that there was no physician order for the bed's position and no documentation that the resident or their representative had been informed or involved in the decision. Staff acknowledged that the expected process of assessment, evaluation, and communication regarding the bed's position had not occurred for this resident.
Failure to Honor Resident Bathing Preferences
Penalty
Summary
The facility failed to honor and facilitate resident choices and preferences regarding showering and bathing for two residents reviewed for Activities of Daily Living (ADLs). Facility policy required that residents be offered at least two full baths or showers per week, with their preferences for type and frequency of bathing to be considered and honored. However, documentation and interviews revealed that these preferences were not consistently followed. One resident with moderate cognitive impairment had a care plan indicating a preference for showers twice a week. Review of ADL records showed that this resident received a combination of bed baths and tub baths, and did not receive showers as preferred, with at least one week where no shower was provided and no refusal was documented. Staff interviews confirmed that the resident's preference for twice-weekly showers was not met, often due to staffing issues and the absence of a regular shower aide. Another resident with intact cognition also had a care plan specifying a preference for bathing twice a week. ADL records indicated that this resident did not receive a bath or shower during a specific week and only had one tub bath the following week, with no refusals documented. Staff interviews corroborated that the resident's bathing preferences were not honored as outlined in their care plan, and that changes in management and staff assignments contributed to the inconsistency in providing preferred bathing routines.
Failure to Ensure Privacy During Provider Visits
Penalty
Summary
The facility failed to maintain privacy and confidentiality of medical information during provider visits for two residents. Observations showed that an Advanced Registered Nurse Practitioner (ARNP) conducted medical discussions with one resident in the Memory Care Unit (MCU) TV room, a common area where other residents were present. The ARNP discussed specific medical conditions and laboratory results with the resident in this public setting. Staff interviews confirmed that the visit occurred in a common area and that privacy was not provided, contrary to facility expectations. A second resident was seen by the same ARNP while seated on a bench between the MCU nurse's station and dining room, another public area. The ARNP asked about specific medical conditions and attempted a physical assessment in this location. Staff interviews again confirmed that the visit was not conducted in private and that the expectation was for such visits to occur in a private setting. The Director of Nursing also acknowledged that provider visits should be conducted privately.
Failure to Conduct Thorough Abuse Investigation
Penalty
Summary
The facility failed to conduct a thorough investigation into an allegation of abuse made by a resident. The resident reported concerns about inadequate resources, such as running out of trash bags, briefs, moisturizers, and wipes, and expressed the belief that this constituted a form of elder abuse. The facility's investigation included notifying the state agency, informing the administrator and DON, interviewing the resident, revising the care plan, reviewing supply invoices, and checking supply rooms for adequate stock. However, the investigation report did not include interviews with other residents or staff members. During a subsequent interview, the administrator acknowledged that the investigation was not as thorough as usual and confirmed that interviews with other residents and staff were not documented or conducted. This incomplete investigation did not meet the facility's policy or regulatory requirements for a systematic and comprehensive review of abuse allegations.
Late Completion of Significant Change in Status Assessment After Hospice Discharge
Penalty
Summary
The facility failed to timely complete a Significant Change in Status Assessment (SCSA) Minimum Data Set (MDS) for one resident following a significant change in condition, specifically after the resident was discharged from hospice services. According to the Long-Term Care Resident Assessment Instrument (RAI) 3.0 User's Manual, an SCSA MDS must be completed within 14 days of a resident revoking hospice benefits. In this case, the resident was discharged from hospice, but the SCSA MDS was completed 13 days late, exceeding the required timeframe. Record reviews and staff interviews confirmed that the MDS coordinator was responsible for updating the SCSA MDS after such significant changes. Both the Registered Nurse and the MDS Coordinator acknowledged that the assessment was not completed within the required period. The Director of Nursing also confirmed that the assessment was late, which did not meet the facility's expectations for timely completion of MDS assessments.
Inaccurate MDS Assessments for Medications, Oral Status, and Hospice Care
Penalty
Summary
The facility failed to ensure accurate completion of the Minimum Data Set (MDS) assessments for three residents, resulting in deficiencies related to oral/dental status, medication use, and hospice care. For one resident, the quarterly MDS indicated the use of an antidepressant medication during the seven-day look-back period, but the Medication Administration Record (MAR) showed the antidepressant had been discontinued and was last administered prior to the assessment period. The MDS Registered Nurse acknowledged that Section N was not coded accurately based on the resident's actual medication administration. Another resident's admission MDS failed to indicate that the individual was edentulous, despite both a nutritional risk assessment and direct observation confirming the absence of natural teeth. The MDS nurse stated that Section L should have been coded to reflect the resident's edentulous status, as supported by documentation and resident interview. The Director of Nursing confirmed the expectation that MDS assessments be completed accurately. A third resident's quarterly MDS was marked to indicate receipt of hospice care, but a review of physician orders and the electronic health record did not show any documentation of hospice services. Staff interviews confirmed that the resident was not under a hospice program but was instead receiving comfort care. The MDS nurse acknowledged that hospice care should not have been marked in the assessment. The Director of Nursing reiterated the facility's expectation for accurate MDS coding.
Deficient PASARR Screening and Documentation for Residents with Mental Health Needs
Penalty
Summary
The facility failed to ensure proper completion and documentation of the Preadmission Screening and Resident Review (PASARR) process for two residents. For one resident, the Level I PASARR was marked as 'No level II evaluation indicated at this time due to exempted hospital discharge,' with a note that a Level II must be completed if discharge does not occur. Despite the resident remaining in the facility for more than 30 days, no new Level I PASARR was completed as required. Staff interviews confirmed that a new Level I PASARR should have been completed after the 30-day stay, but it was not found in the resident's electronic health record. For another resident, a Level I PASARR identified a diagnosis of mood disorders and a recent decline in mood, indicating the need for a Level II PASARR referral. Although staff stated that a referral was made, there was no documentation in the electronic health record to confirm that the referral was sent. The facility's policy requires that all new admissions and readmissions be screened for mental disorders, intellectual disabilities, or related disorders, and that referrals for Level II evaluations be made when indicated by the Level I screen. The lack of documentation and failure to complete required screenings resulted in deficiencies in the PASARR process for both residents.
Failure to Notify PASARR Coordinator After Significant Change in Condition
Penalty
Summary
The facility failed to notify the State PASARR Coordinator or appropriate mental health authority after residents with mental disorders or intellectual disabilities experienced a significant change in condition. For three residents reviewed, documentation and interviews confirmed that required referrals for PASARR Level II evaluations were either delayed or not completed at all. In one case, a resident with major depressive disorder and PTSD was discharged from hospice, which constituted a significant change, but the referral to the PASARR Coordinator was not made promptly. Staff interviews confirmed the delay and acknowledged the expectation for timely notification. Another resident with anxiety disorder and major depressive disorder had a Level I PASARR indicating the need for a Level II referral upon significant change, but there was no evidence of a completed Level II evaluation or timely follow-up with the PASARR Coordinator. Additionally, a resident with bipolar disorder had a significant change in status, but no new or updated PASARR was completed, and the Coordinator was not notified. Staff interviews consistently revealed lapses in following the required notification and referral process after significant changes in condition for residents with mental health or intellectual disability diagnoses.
Failure to Timely Revise Care Plans for Changes in Hospice, Comfort Care, and Medication
Penalty
Summary
The facility failed to ensure that care plans were revised in a timely and accurate manner to reflect significant changes in residents' care, including discontinuation of hospice services, initiation of comfort care, and discontinuation of medication. For one resident, the care plan continued to indicate enrollment in hospice for end-of-life care even after hospice services had been discontinued, as confirmed by both nursing staff and the DON. Another resident's care plan inaccurately stated that the resident was receiving a low dose of antidepressant medication, despite the medication having been discontinued and no current physician order for it. Staff interviews confirmed that the care plan had not been updated to reflect this change. Additionally, a third resident who had transitioned to an end-of-life comfort care program did not have this change reflected in their care plan. Staff interviews and record reviews confirmed that the care plan lacked documentation of comfort care or end-of-life goals and treatments. In each case, staff acknowledged that the care plans should have been updated promptly to reflect the residents' current status and care needs, but this was not done.
Failure to Provide and Document Resident Activity Program
Penalty
Summary
The facility failed to provide an ongoing activity program to meet the needs of a resident who was cognitively intact and had expressed preferences for specific activities, such as listening to music, keeping up with the news, engaging in favorite activities, and going outside for fresh air. Despite the facility's policy requiring daily activities and resident involvement in planning and participation, observations and interviews revealed that the resident did not have access to leisure activity supplies in their room and was not participating in group or individual activities as outlined in their care plan. The resident reported not being offered activities and only going outside once with a visitor. Record reviews showed a lack of documentation regarding the resident's participation or refusal of activities, contrary to facility policy and staff expectations. The Activities Director acknowledged that the resident was not attending group activities and had not received one-on-one visits as planned. The Administrator confirmed that activities should have been offered and documented for each instance of participation or refusal, but this was not done for the resident in question.
Failure to Assess and Treat Skin Injuries and Monitor Weights for Residents on Diuretics
Penalty
Summary
The facility failed to perform appropriate skin evaluations and implement necessary monitoring and treatment for a resident who sustained skin injuries. One resident was observed with multiple scabs on their knees and shins, which were not being treated. Staff interviews revealed that the injuries were not documented in the resident's weekly skin assessments, and nursing staff were unaware of the injuries. The facility's protocol required that all skin injuries be documented, reported to the provider and family, and treated according to physician orders, but these steps were not followed for this resident. Additionally, the facility did not monitor and obtain daily weights for another resident who was on diuretic therapy. Documentation showed that daily weights were missing for several consecutive days, despite the resident receiving two diuretic medications. Staff confirmed that daily weights should have been recorded for residents on diuretics, but this was not done. These failures were identified through observation, interviews, and record reviews.
Failure to Provide Prescribed Therapeutic Diet for Resident with Gastroparesis
Penalty
Summary
The facility failed to follow a prescribed therapeutic diet of small, portioned meals for a resident diagnosed with gastroparesis and Type I diabetes mellitus. The resident's care plan and electronic health record (EHR) included clear instructions for small, frequent meals—specifically, 4-5 small meals per day and a small particle diet. Despite these orders, multiple observations showed the resident consistently received regular-sized meal portions, and staff interviews confirmed that the resident was not provided with the prescribed small portions. The dietary manager also confirmed that the meal slip did not indicate the need for small-portioned meals, and the kitchen provided regular servings. The resident experienced a significant weight loss of more than five percent within one month, as documented in the EHR. Staff, including a registered dietician and the director of nursing, acknowledged that the resident should have been receiving small, frequent meals in accordance with their care plan and medical needs. The failure to provide the prescribed therapeutic diet was confirmed through observation, record review, and staff interviews, with no evidence that the dietary orders were being followed.
Failure to Properly Store, Label, and Document Respiratory Care Equipment and Monitoring
Penalty
Summary
Facility staff failed to ensure proper storage and labeling of respiratory equipment and did not consistently document oxygen saturation levels as ordered for a resident with chronic obstructive pulmonary disease and acute hypoxic respiratory failure. Observations revealed that the resident's oxygen humidifier bottle was repeatedly found undated and unlabeled on multiple occasions. The BiPAP tubing nose piece and nasal cannula were observed not properly stored, with the nasal cannula found laying on the floor several times. Staff interviews confirmed that the equipment should have been labeled, dated, and stored in a clean manner, such as in a clear plastic bag when not in use, but these practices were not followed. Additionally, review of the resident's medical records showed missing documentation of required oxygen saturation checks during several night shifts, despite a physician's order to monitor and record these values each shift. Staff acknowledged the expectation to document oxygen saturation per the physician's order and to maintain proper storage and labeling of respiratory equipment, but these procedures were not consistently implemented for the resident.
Failure to Administer and Clarify Physician-Ordered Medications as Prescribed
Penalty
Summary
The facility failed to ensure that physician orders for medication administration were followed and/or clarified in accordance with professional standards of practice for three residents. For one resident, the physician order specified administration of Calcium 600+D3 (Calcium Carbonate-Cholecalciferol) 600-10 mg-mcg once daily, but staff administered Citracal + D (Calcium citrate-Vitamin D3) 315 mg-250 IU instead. This was observed during medication administration, and both the nurse and the unit manager confirmed that the medication given did not match the physician's order in terms of both formulation and dosage. For two other residents, physician orders required administration of Calcium Carbonate-Vitamin D Oral Tablet 600-5 mg-mcg, but staff administered Caltrate + D (Calcium Carbonate-Vitamin D3) 600 mg-400 IU, which did not match the prescribed dosage of Vitamin D. Both the LPN and the unit manager acknowledged that the medications administered differed from the physician's orders and that clarification with the physician and pharmacist should have occurred prior to administration. The facility's in-house pharmacy dispensed the medications that did not match the physician orders, and the consultant pharmacist confirmed that the orders should have been clarified with the physician before dispensing. The Director of Nursing also stated that staff were expected to clarify medication orders with the physician and that the pharmacist was expected to dispense medications as prescribed.
Failure to Refer Resident for Dental Services After Broken Tooth
Penalty
Summary
The facility failed to ensure that dental services were offered or provided to a resident who had a broken tooth. The resident's representative notified facility staff about the broken tooth, but there was no documentation or evidence that the resident was referred to dental services. Staff interviews confirmed that both nursing and social services staff were aware of the broken tooth but did not initiate a referral, with some staff stating that a referral was not made because the resident was not experiencing discomfort. The facility's policy required routine and emergency dental services to be available in accordance with the resident's assessment and plan of care, including referrals to community dentists or other dental providers. Observations showed the resident had difficulty chewing food, which was corroborated by the resident's own statements about the challenges of eating due to the broken tooth. Multiple staff members, including the Director of Nursing, acknowledged that a referral should have been made for the broken tooth, but no such referral or documentation was found. The lack of action resulted in the resident not receiving necessary dental care as required by facility policy.
Failure to Honor Resident Meal Preferences
Penalty
Summary
The facility failed to honor and provide meal preferences for two residents with intact cognition, as evidenced by direct observations, interviews, and record reviews. One resident consistently marked their menu selection to indicate disliked items and circled preferred foods, but the kitchen staff did not follow these preferences, resulting in the resident receiving unwanted food items. Both a Certified Nursing Assistant and a Licensed Practical Nurse confirmed that the resident's menu choices were not followed, and the resident expressed annoyance and dissatisfaction with the meals provided. Another resident reported not always receiving their menu or the food they requested, and was observed receiving a tuna sandwich that did not match their specific request. The resident became upset and teary-eyed, stating that the sandwich was not prepared as requested, and staff confirmed that the resident's preferences were not honored. Multiple staff members, including the Dietary Manager, Registered Nurse, and Director of Nursing, acknowledged that the residents' meal choices and preferences should have been followed, but were not in these instances.
Incomplete and Inaccurate Medical Record Documentation for Resident
Penalty
Summary
The facility failed to ensure that clinical and medical records were complete and accurate for one resident. Review of the resident's face sheet and Minimum Data Set indicated admission and a completed death assessment, but there was no documentation in the nursing progress notes or electronic health record regarding the resident's clinical status or condition on the relevant date. Vital signs, including blood pressure, heart rate, and breathing rate, were last documented prior to the date in question, and there was no record of these measurements on the day the resident left the facility for a planned diagnostic procedure. Interviews with the LPN assigned to the resident and the Director of Nursing confirmed the absence of documentation regarding the resident's clinical status, the planned medical appointment, or the resident's departure from the facility. The Director of Nursing acknowledged that there was no documentation about the resident's clinical status or death in the medical record, and that such documentation was expected. The lack of documentation resulted in incomplete and inaccurate medical records for the resident.
Failure to Offer and Document Influenza and Pneumococcal Vaccinations
Penalty
Summary
The facility failed to ensure that the pneumococcal and influenza vaccines were offered to a resident, as required by policy and regulation. Review of the resident's immunization record showed that the resident had received an influenza vaccine in the previous year and a pneumococcal vaccine dose several years prior, but there was no documentation that the annual influenza vaccine or the most current pneumococcal vaccine was offered or administered. Additionally, there was no evidence in the electronic health record that the resident was informed about the risks and benefits of these vaccines or that any refusal was documented. Interviews with facility staff, including the Infection Preventionist, RN Unit Manager, Consultant Pharmacist, and Director of Nursing, revealed inconsistent practices and a lack of documentation regarding vaccine offers, administration, and consent. Staff were unable to locate records of vaccine offers, refusals, or administration for the resident in question, and the state immunization database indicated the resident was past due for both vaccines. The facility's policies required that vaccines be offered and documented, but these procedures were not followed for the resident reviewed.
Facility Assessment Lacked Contingency and Staffing Plans
Penalty
Summary
The facility failed to update its facility-wide assessment to include a contingency plan and strategies for maximizing direct care staff recruitment and retention. Review of the facility's assessment document, last updated on 04/25/2025, showed that it did not contain documentation of these required elements. During an interview, the Administrator confirmed that the contingency plan and staff recruitment and retention plans were not referenced in the most recent assessment.
Failure to Supervise Resident at Risk for Elopement
Penalty
Summary
The facility failed to provide necessary supervision to prevent an elopement for one resident who was assessed as being at risk for wandering and elopement. The resident, who had impaired memory and required assistance to walk safely, was documented as wandering in the nursing unit and was redirected from the front desk/lobby area twice by staff. Despite these interventions, the resident was not observed on the unit, and it was discovered that they had exited the facility through the front door and were seen walking on a busy street outside. The resident was found approximately a block away from the facility. Interviews with staff and review of records confirmed that the resident had a history of wandering and elopement risk, as indicated in the initial admission elopement risk assessment. Staff acknowledged that the resident did not receive the level of supervision required to prevent them from leaving the building. The facility's elopement policy required assessment for exit-seeking and wandering behaviors, but the necessary supervision was not maintained, resulting in the resident's unsupervised exit.
Failure to Provide Timely ADL Assistance for Dependent Residents
Penalty
Summary
The facility failed to provide timely and necessary assistance with activities of daily living (ADLs) for two residents who were dependent on staff for care. One resident, with impaired thinking and memory, was found in a wet environment after their brief had been changed but the bed remained soaked with urine, indicating incomplete care. Staff interviews confirmed that the resident had not been changed for a while and was soaked through to the bed linens. The resident's care plan documented total dependence on staff for toileting and incontinence care. Another resident, also dependent on staff for all ADLs and with moderately impaired thinking, was left in soiled clothing and bed linen after vomiting, and was not changed for a significant amount of time. Staff interviews revealed that while rounds were conducted, the frequency and thoroughness of care varied depending on the resident's needs. The Director of Nursing Services acknowledged that the nursing staff did not meet the care needs of these residents, as required by their care plans and facility policy.
Failure to Maintain Resident Dignity
Penalty
Summary
The facility failed to maintain and promote resident dignity in several instances. Staff O, a Certified Nursing Assistant (CNA), entered Resident 34's room without knocking or identifying themselves, which was against the facility's policy. Both Staff H, a Registered Nurse (RN), and Staff B, the Director of Nursing Services, confirmed that staff are expected to knock, introduce themselves, and ask for permission before entering a resident's room. This failure to follow protocol compromised Resident 34's right to privacy and dignity. The facility also failed to ensure the privacy of residents using urinary catheters. Resident 110's catheter bag was observed multiple times with the bottom exposed and visible from the hallway, and it was even touching the ground. Staff J, a CNA, and Staff H acknowledged that the catheter bag covers were inadequate for privacy. Similarly, Resident 17's urinary catheter bag was visible to their roommate and from the hallway, and Staff Q, an RN, confirmed that it should have been covered. Staff B reiterated that catheter bags should be covered to maintain resident privacy. Additionally, the facility did not properly manage the use of mechanical lift slings and meal assistance. Resident 99 was observed sitting on a mechanical lift sling left underneath them, which Staff O and Staff EEE admitted was due to the difficulty of reapplying the sling. Staff GGG, an RN, and Staff B confirmed that the sling should have been removed after the transfer. Furthermore, staff were observed standing while assisting residents with meals, including Residents 99, 46, and 16, which is against the facility's policy. Staff PP, a Resident Care Manager, and Staff B stated that staff should be seated at eye level when assisting residents with meals to maintain dignity and provide proper care.
Failure to Obtain Informed Consent for Safety Devices and Medications
Penalty
Summary
The facility failed to inform residents and/or their representatives of the risks and benefits before implementing certain safety devices and treatments. Specifically, two residents had their beds placed against the wall without documented consent or an explanation of risks and benefits. One resident expressed that they liked their bed against the wall, while another stated that no one asked for their consent. Staff interviews confirmed that assessments and consents were required but were not documented in the residents' clinical records. Additionally, a resident was observed using a tilt-in-space wheelchair without documented consent or an explanation of risks and benefits. Staff interviews revealed that an assessment, physician order, and consent should have been obtained before the use of the wheelchair, but these were not found in the resident's clinical records. Another resident used a transfer pole daily for mobility, but there was no documented consent for its use, as confirmed by staff during interviews and record reviews. Lastly, a resident was administered a psychoactive medication, sertraline, without a signed consent form. Although verbal consent was initially obtained from the resident's representative, the signed consent was not documented in the medical records. Staff interviews confirmed that a signed consent should have been obtained as soon as possible after the verbal consent. These failures placed the residents at risk of not being fully informed before making decisions regarding their healthcare and treatment options.
Failure to Review Resident Rights Periodically
Penalty
Summary
The facility failed to periodically review resident rights with residents during their stay for all 16 residents reviewed. This was evidenced by the absence of resident rights discussions in the Resident Council minutes from February 2023 to April 2024. Interviews with residents confirmed that staff did not review their rights with them. The Social Worker acknowledged that resident rights were not reviewed during Resident Council meetings and could not recall the last time it was done. The Administrator admitted that resident rights should be reviewed yearly and noted that it used to be part of the Resident Council meeting agenda in the past.
Failure to Update Ombudsman Contact Information
Penalty
Summary
The facility failed to provide the website address of the Washington State Long-Term Care Ombudsman on the posted contact information in seven facility areas, including notice boards in units 100, 300, 400, 500, 600, 700, and inside one elevator. Observations on multiple occasions showed that the posted information lacked the website address. During a joint observation and interview with the Administrator, it was confirmed that the contact information had not been updated recently, and the Administrator acknowledged that it should have been updated at least annually. This deficiency was identified based on observation, interview, and record review, and it placed residents at risk of not being able to report their concerns online to the State Long-Term Care Ombudsman.
Failure to Maintain Resident Privacy and Confidentiality
Penalty
Summary
The facility failed to maintain the privacy and confidentiality of residents' personal and medical information. Observations revealed that residents' weights were posted on pieces of paper outside the shower room on the 300 unit, making this private information visible to anyone passing by. Staff members, including a CNA, Resident Care Manager, and the Director of Nursing Services, acknowledged that this information should not have been publicly displayed in the hallway. Additionally, a computer screen displaying a resident's Medical Administration Record (MAR) was left unattended and visible in the hallway, further compromising resident privacy. In another instance, the facility did not ensure the privacy of residents' representatives' contact information. Observations showed that the names and phone numbers of Resident 17's representatives were posted on a whiteboard above the sink, visible to the roommate and from the hallway. Similarly, Resident 16 had family members' names and phone numbers posted on the wall by their bed and sink, which were also visible from the hallway. Staff members admitted that this information should have been placed in a more private location within the residents' rooms. Lastly, the facility failed to provide privacy during the administration of medication. Resident 100 had a Lidocaine patch applied to their lower back in the dining room, exposing their back in the presence of other staff and residents. Although the resident had requested the patch be applied in the dining room, staff acknowledged that treatments should be conducted in private settings. These incidents collectively demonstrate a failure to uphold the privacy and confidentiality standards expected in the care of residents.
Failure to Provide Homelike Dining Environment
Penalty
Summary
The facility failed to provide a homelike environment for residents in the 100 Unit Dining Room and the 500 Unit Dining Room by serving meals on trays instead of placing meal items directly on the dining tables. Observations revealed that multiple residents were eating their meals on trays during both breakfast and lunch times. Staff members, including CNAs and Culinary Service Aides, were observed delivering meal trays and not removing the trays after serving the meals, contrary to the facility's policy. Interviews with staff indicated a lack of training and adherence to the policy, with some staff members stating that it was easier to leave the trays on the tables. Further interviews with the Culinary Director and the Director of Nursing confirmed that the expectation was for staff to remove the trays after delivering meals to residents in the dining rooms. Despite this, the practice of leaving trays on the tables persisted, with some staff attributing the behavior to habits formed during the COVID-19 pandemic. This failure to remove meal trays compromised the residents' right to a homelike environment and diminished their quality of life.
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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