Three Creeks Post Acute
Inspection history, citations, penalties and survey trends for this long-term care facility in Pullman, Washington.
- Location
- Northwest 1310 Deane, Pullman, Washington 99163
- CMS Provider Number
- 505246
- Inspections on file
- 42
- Latest survey
- March 3, 2026
- Citations (last 12 mo.)
- 9 (1 serious)
Citation history
Health deficiencies cited at Three Creeks Post Acute during CMS and state inspections, most recent first.
The facility did not complete required PASRR Level I and Level II processes for several residents with depression, anxiety, and major depressive disorder. For some residents, Level I screens identified indicators of serious mental illness but the necessary Level II evaluations were never done, and for another resident the Level I screen was delayed until weeks after admission. A resident admitted under a 30‑day hospital exemption remained beyond that period without a new PASRR screen or Level II evaluation. The Social Services Director reported not being aware that PASRR screenings and evaluations had to be completed before admission.
A resident with schizophrenia, a history of suicide attempts, and moderate depression was admitted with a care plan identifying paranoid schizophrenia and an intervention for psych consult as needed. Nursing notes repeatedly documented the resident as anxious and restless over time, and the resident reported longstanding mental illness, traumatic experiences, and a belief they would benefit from mental health services, which they had received in other settings. Despite this, the EMR showed no mental health provider involvement during the stay, and the Social Services Director acknowledged the resident’s expressed interest in such services while stating the facility had no contracted mental health provider or available mental health services.
During an extended power outage, staff failed to monitor and discard potentially hazardous foods (PHFs) such as milk that were stored above safe temperatures. Despite knowing the refrigerator temperature had reached 50°F, the affected milk was served to all residents during subsequent meals, and no food was discarded. The incident was identified as immediate jeopardy due to the risk of foodborne illness.
A resident with major depressive disorder and vascular dementia was admitted without completion of a required PASRR Level II evaluation, as indicated by their Level I screening. Facility staff did not review the necessary documentation or make the required referral prior to admission, and the resident's record lacked behavioral health provider notes and the Level II evaluation summary.
During a power outage caused by a winter storm, the facility's outdated backup generator failed to provide heat, resulting in indoor temperatures dropping to between 62 and 65°F. Staff monitored the situation and provided extra blankets, but all residents were affected by the cold conditions throughout the building.
A resident with multiple health conditions, including diabetes and recurrent C. difficile infection, was verbally abused by the DON during a care conference, where the DON made humiliating remarks about the resident's incontinence and stated the resident did not belong at the facility. Multiple witnesses confirmed the incident, and the resident expressed distress and a desire to avoid further contact with the DON. The administrator and other staff were informed but did not immediately address or report the incident.
Two residents did not receive their prescribed antibiotics as ordered due to errors in medication stop dates and missed doses. One resident's Vancomycin was discontinued earlier than intended because of a miscommunication and typographical error, while another resident missed a scheduled dose of Doxycycline, as confirmed by MAR review and staff interviews.
During a COVID-19 outbreak, the facility failed to complete required testing for 8 staff members and did not implement its respiratory protection program timely for 4 staff members. The outbreak involved 10 residents and 5 staff testing positive. Additionally, there was no documentation of COVID-19 testing for 29 residents, despite claims of twice-weekly testing. Inconsistent leadership during the outbreak may have contributed to these deficiencies.
The facility failed to store, label, and discard food according to professional standards, as observed in the kitchen. Expired and unlabeled food items, including wilted lettuce, undated crispy fried onions, and moldy milk, were found in various storage areas. The Dietary Manager acknowledged the oversight, which posed a risk for foodborne illness.
A facility failed to ensure a completed POLST was present for a resident who was cognitively intact and capable of making healthcare decisions. The resident was documented as a full code, but no POLST form was found in their medical record or the facility's binder. The resident confirmed no discussion about their CPR preferences had occurred. The Administrator and DON acknowledged the oversight and confirmed it was being addressed.
A facility failed to provide a Notification of Medicare Non-Coverage (NOMNC) to a resident two days before a planned discharge, preventing the resident from appealing the termination of Medicare services. The resident, who had a history of Myocardial Infarction and recent Coronary Artery Bypass, was alert and oriented. The DON confirmed the omission of the required notice.
A facility failed to document a resident's hospital transfer adequately, leaving the transfer form incomplete and lacking critical information about the resident's care needs and status. Interviews with staff confirmed that the expected documentation and notification procedures were not followed, as no progress note was made in the resident's record.
A facility failed to provide a bed-hold notice to a resident with cognitive impairment and other diagnoses when they were transferred to the hospital for unresponsiveness. The required notice was not documented in the resident's record, and staff interviews confirmed the oversight.
A resident with COPD and heart failure did not have current and complete oxygen orders, despite requiring supplemental oxygen for about a month. Observations showed varying oxygen flow rates and improper use of the nasal cannula. The care plan lacked respiratory interventions, and there was no physician order for oxygen until mid-November, placing the resident at risk for respiratory complications.
The facility did not employ sufficient staff with the necessary certifications for nutritional services, affecting 30 residents. The Dietary Manager lacked the required certification, as confirmed by both the manager and the facility's Administrator. Additionally, the facility did not have a full-time Registered Dietician.
A resident with a history of hip fracture and dementia fell and sustained a lower leg injury, which was not documented or assessed until five days later. The delay in treatment led to a necrotic, contagious wound infection, extending the resident's stay in the facility. The infection was resistant to many antibiotics, requiring a change in discharge plans to prevent spreading the bacteria.
A resident with a history of hip fracture and dementia fell and sustained a skin tear after standing from a wheelchair. The facility failed to notify the resident's representative of the incident until five days later, as confirmed by staff interviews. This delay in communication raised concerns about the severity of the injury and the involvement of the representative in healthcare decisions.
A resident with dementia and a history of hip fracture experienced a worsening wound on their leg after a fall, which was not documented or assessed for several days. The wound increased in size and severity due to delayed medical treatment. Despite staff awareness, the incident was not reported as required, indicating a failure to comply with reporting policies.
A resident with dementia and a history of hip fracture fell after getting out of their wheelchair unassisted, resulting in a skin tear. The facility delayed initiating an investigation and implementing preventative measures for five days, despite the incident being witnessed by the administrator. This delay was a repeat deficiency from a previous report.
The facility failed to provide sufficient nursing staff, resulting in delayed responses to call lights and unmet care needs for residents. Residents experienced long wait times for assistance, leading to incontinence episodes and missed showers. Staff interviews revealed chronic understaffing, with administrative staff aware but not addressing the issue. The Resident Council also documented complaints about long wait times and insufficient nursing assistants.
Two residents received meals at unsafe temperatures, with one resident's meal served cold and not reheated by staff. The facility's food temperature monitoring was incomplete, and the Food Service Manager admitted to not using the correct form since a kitchen transition.
Failure to Complete Required PASRR Screenings and Evaluations for Residents With Mental Illness
Penalty
Summary
The facility failed to ensure required Preadmission Screening and Resident Review (PASRR) processes were completed prior to or in conjunction with admission for multiple residents with mental health diagnoses. One resident with depression and anxiety was admitted with a Level I PASRR screen indicating serious mental illness, but the required Level II evaluation was never completed. Another resident with major depressive disorder also had a Level I screen showing indicators of serious mental illness, yet no Level II evaluation was performed. A third resident with depression and anxiety did not have a Level I PASRR screening completed until several weeks after admission, rather than prior to admission as required. In addition, a resident with depression was admitted under a 30‑day hospital exemption and had a Level I PASRR screen that did not indicate the need for a Level II evaluation. This resident remained in the facility beyond the 30‑day exemption period, but a new PASRR screening and Level II evaluation were not completed after the exemption expired. During an interview, the Social Services Director, who began employment in July 2025, stated they were not aware that PASRR screens and Level II evaluations were required to be completed before residents were admitted, and acknowledged the importance of incorporating evaluator recommendations into the care plan and providing behavioral health services.
Failure to Provide Mental Health Services for Resident With Schizophrenia and Depression
Penalty
Summary
The facility failed to ensure that a resident with known schizophrenia and moderate depression received necessary mental health services during their stay. The resident was admitted with diagnoses including a fractured right hip and schizophrenia, and their admission MDS documented a depression screening with a score indicating moderate depression. The resident’s care plan identified a focus on paranoid schizophrenia with delusions, hallucinations, and paranoia, and included an intervention for a psychiatric consult as needed. Progress notes documented that the resident had a history of three prior suicide attempts, the most recent in 2019 following the unexpected death of their mother, and that they had scored moderately depressed on a PHQ-9 assessment. Nursing progress notes repeatedly described the resident as anxious and/or restless on multiple occasions and at various times, yet the electronic medical record showed no evidence that the resident had been seen by any mental health provider during their stay. In an interview, the resident reported a long history of schizophrenia since their teen years, frequent hospital and facility admissions, traumatic life experiences, and concern about their future after discharge. The resident stated they believed they would benefit from mental health services and that such services had always been offered and utilized in other medical settings, but none had been offered at this facility. In a separate interview, the Social Services Director confirmed that the resident had expressed interest in mental health services and was thought to benefit from them, but stated the facility was not contracted with any mental health provider and that no mental health services were available.
Failure to Discard and Monitor PHFs During Power Outage Leads to Immediate Jeopardy
Penalty
Summary
The facility failed to maintain safe storage and handling of potentially hazardous foods (PHFs) during an extended power outage, resulting in the service of milk and other PHFs that were held above safe temperature guidelines. The power outage began early in the morning and lasted for over ten hours, during which the backup generator did not supply power to kitchen appliances, including refrigerators and freezers. Kitchen staff were instructed to keep appliance doors closed, but the refrigerator containing milk and juice was opened multiple times for meal service, and no consistent temperature monitoring was performed during the outage. After the outage, staff observed that the refrigerator temperature had risen to 50 degrees Fahrenheit, well above the safe limit for PHFs. Despite this, no food was discarded, and the milk stored in the affected refrigerator was served to residents during subsequent meal services. Staff interviews confirmed that neither the cook nor the dietary manager took or documented further temperature readings after the initial high temperature was noted, and the dietary manager acknowledged serving the milk for dinner and breakfast following the outage. Temperature logs for the day of the outage were marked as out of service, and no corrective action regarding the food was taken at that time. All 33 residents in the facility were served PHFs that had been stored above safe temperatures for an extended period. The deficiency was identified when a complaint investigator interviewed kitchen staff and reviewed records, confirming that the facility did not follow established food safety guidelines for discarding PHFs held above 45 degrees Fahrenheit for more than four hours. The incident was classified as immediate jeopardy due to the risk of foodborne illness to all residents.
Removal Plan
- Discarding affected PHFs
- Education to food service staff
- Implementing safety protocols for food temperature monitoring
- Updating policies and procedures
Failure to Complete Required PASRR Level II Evaluation Prior to Admission
Penalty
Summary
The facility failed to ensure that the Preadmission Screening and Resident Review (PASRR) process was properly completed for a resident with a diagnosis of major depressive disorder and vascular dementia. Record review showed that a PASRR Level I screening indicated the presence of a serious mental illness (SMI) and required a Level II evaluation prior to admission. However, there was no evidence in the resident's record that a PASRR Level II evaluation was completed before the resident was admitted. Additionally, the resident's record lacked behavioral health provider notes and the required Level II evaluation summary, despite documentation of severely impaired cognition after admission. Interviews with facility staff revealed that the standard admission process was not followed for this resident, who was transferred from a sister facility. The Admissions Director and Administrator In Training both stated they did not review the resident's PASRR documentation prior to admission and were unaware that a Level II evaluation was required. The PASRR Level I was also filled out incorrectly, and the necessary referral for a Level II evaluation was not made before the resident's admission.
Failure to Maintain Safe and Comfortable Temperature During Power Outage
Penalty
Summary
The facility failed to maintain a comfortable and safe temperature for all 33 residents during an extended power outage caused by a winter storm. The backup generator in use was outdated, undersized, and only powered a limited number of lights, outlets, and the fire suppression system, but did not provide heat to the building. Staff interviews confirmed that temperatures inside the facility dropped to between 62 and 65 degrees Fahrenheit, with the coldest areas being at the ends of the hallways where residents resided. Staff responded by offering extra blankets to residents, but all areas of the building were affected by the low temperatures. Maintenance staff were aware of the limitations of the generator and had communicated the temperature readings to other staff to monitor resident safety. The administrator in training acknowledged that the generator was insufficient and that the issue had been known since the facility was acquired by the current corporation. All residents present during the outage were affected by the drop in temperature, and staff confirmed that the generator did not provide adequate heating during the incident.
Resident Subjected to Verbal Abuse by Director of Nursing During Care Conference
Penalty
Summary
A deficiency occurred when a resident, who was cognitively intact and had multiple medical conditions including diabetes, recurrent Clostridium Difficile infection, malnutrition, and adult failure to thrive, was subjected to verbal abuse by the facility's Director of Nursing (DON) during a care conference. The resident required staff assistance with hygiene and transfers due to weakness. During the care conference, the DON made humiliating statements about the resident's bowel incontinence, told the resident they did not belong at the facility, and referred to the resident as a "nasty little man" in front of family members and other staff. Multiple witnesses, including family members, a state worker, and the Social Services Director, confirmed the DON's statements and the resident's distress as a result of the interaction. The incident was reported immediately after the care conference by the resident's family to the facility administrator, but the administrator did not address the concern at that time. The Social Services Director also reported the incident up the chain of command, expecting an investigation to begin, but found the following day that no one had spoken to the resident and the DON was still working in the building. The state worker present at the meeting did not report the incident to the required State Agency, assuming the facility would handle it. Interviews with the resident and family members revealed that the resident felt humiliated, unwanted, and disliked by the DON, and expressed a desire to remain at the facility but to have no further contact with the DON. The DON later admitted to making the derogatory statement and described the resident as acrimonious and belittling, but maintained that the conversation was not one-sided. The administrator acknowledged awareness of the incident but initially did not consider it verbal abuse, only later recognizing it as reportable and requiring investigation.
Medication Administration Errors Result in Missed Antibiotic Doses
Penalty
Summary
The facility failed to ensure that residents received their medications as ordered, resulting in significant medication errors for two residents. For one resident with osteomyelitis and sepsis, the hospital discharge order specified Vancomycin treatment for six weeks, ending on 10/13/2025. However, the medication was discontinued early on 10/03/2025 due to an error in the stop date entered by staff, which was based on a miscommunication and a typographical mistake in the order. The pharmacy confirmed the original order was through 10/13/2025, but the facility's records reflected the incorrect earlier stop date, leading to premature discontinuation of the antibiotic. Another resident with diabetes, hypertension, and an amputation had two overlapping orders for Doxycycline. The first order was for a seven-day course, and the second was to continue the medication indefinitely. The Medication Administration Record (MAR) showed that the evening dose on 11/05/2025 was not administered, as indicated by a blank entry and a red mark in the MAR, which staff confirmed meant the medication was not given. Staff interviews acknowledged the error and the importance of administering the full course of antibiotics as ordered.
Failure to Adhere to COVID-19 Testing and Respiratory Protection Guidelines
Penalty
Summary
The facility failed to adhere to federal guidelines for COVID-19 testing during an outbreak, affecting 8 out of 10 staff members. The outbreak, which lasted from December 10, 2024, to January 6, 2025, involved 10 residents and 5 staff members testing positive for COVID-19. According to the Centers for Disease Control and Prevention (CDC) guidelines, asymptomatic residents and staff with close contact to someone infected should undergo a series of three viral tests. However, the facility did not complete the required testing for the staff, increasing the risk of delayed identification and treatment of COVID-19. Additionally, the facility did not implement its respiratory protection program in a timely manner for 4 out of 10 staff members. The program required annual fit testing of N95 respirator masks, which was not conducted within the stipulated 12 months for several staff members. This lapse potentially contributed to the transmission of the virus within the facility. The staff fit testing records revealed that some staff had not been fit tested since late 2023, and one staff member had not been tested since their hire date in November 2024. The facility also failed to document COVID-19 testing results for all 29 residents during the outbreak. Despite the Director of Nursing stating that testing was supposed to occur twice weekly, there was no documentation to support this claim. The facility's leadership was inconsistent during the outbreak, as both the Administrator and Director of Nursing tested positive for COVID-19 at the beginning of the outbreak, which may have contributed to the oversight in testing and documentation.
Failure to Adhere to Food Safety Standards
Penalty
Summary
The facility failed to adhere to professional standards for food safety, as observed during a survey of the kitchen. The produce refrigerator contained three extra-large bags of shredded iceberg lettuce that were brownish, wilted, and soggy, with a use-by date that had already passed. In the dry storage room, a bag of opened crispy fried onions was found undated, and a container of flour was labeled with an expiration date that had also passed. Additionally, a second refrigerator in the common area contained several unlabeled and undated items, including a large container of diced pineapples, a full pitcher of orange juice, and a half bag of BBQ riblets. A large box of prepackaged boiled eggs was also found with an expired label. Further observations revealed that the kitchen freezer contained a half bag of unlabeled and undated sausage patties. In the nourishment refrigerator, three cups of milk with mold on the lids were labeled with an expired date, and an opened commercial pumpkin pie was found without a label or date. The Dietary Manager, Staff E, acknowledged that these items should have been labeled, dated, and discarded by their expiration dates to prevent residents from becoming ill. This oversight placed residents at risk for foodborne illness and diminished their quality of life.
Failure to Complete POLST for Resident
Penalty
Summary
The facility failed to ensure that a completed Physician's Order for Life-Sustaining Treatment (POLST) was present for Resident 6, who was cognitively intact and capable of making their own healthcare decisions. Upon admission, it was documented that Resident 6 was a full code, meaning they would receive cardiopulmonary resuscitation (CPR) if needed. However, there was no completed POLST form in the resident's medical record or in the facility's POLST binder, and no documentation indicated that any education or conversation had occurred regarding the resident's wishes for CPR or other treatments in the event of serious illness. During an interview, Resident 6 confirmed that they had not filled out a POLST form and that no one at the facility had discussed their preferences for CPR since their admission. The facility's Administrator and Director of Nursing acknowledged the absence of a completed POLST form for Resident 6 and confirmed that it was being addressed. This oversight placed Resident 6 at risk of not having their end-of-life care preferences honored.
Failure to Provide Medicare Non-Coverage Notice
Penalty
Summary
The facility failed to provide a Notification of Medicare Non-Coverage (NOMNC) two days prior to a planned discharge for one resident, preventing the resident from exercising their right to appeal and dispute the termination of Medicare-covered services. Resident 136, who was admitted with diagnoses including Myocardial Infarction and recent Coronary Artery Bypass, was alert, oriented, and able to make their needs known. A progress note indicated the resident was to be discharged, but no NOMNC form was found in their record. The Director of Nursing confirmed that the required notice was not given.
Incomplete Documentation of Hospital Transfer
Penalty
Summary
The facility failed to ensure that a resident's medical record contained adequate documentation of a hospital transfer and that the receiving hospital received necessary information about the resident's condition. This deficiency was identified for one of the two sampled residents, who was transferred to the hospital for evaluation due to unresponsiveness. The transfer form for the resident was incomplete, lacking critical information such as the resident's care needs, treatments, or status prior to being sent to the hospital. Interviews with facility staff revealed that the expected procedure for transferring a resident to the hospital includes filling out a transfer form, notifying the hospital of the resident's status, and documenting the transfer in the resident's chart. However, in this case, the transfer form was not thoroughly completed, and no progress note was made in the resident's record. Both the Registered Nurse and the Director of Nursing confirmed the lack of documentation and incomplete transfer form after reviewing the resident's record.
Failure to Provide Bed-Hold Notice for Hospitalized Resident
Penalty
Summary
The facility failed to provide a bed-hold notice to a resident and/or their representative at the time of discharge or within 24 hours of transfer to the hospital. This deficiency was identified for one of the two sampled residents, Resident 31, who was reviewed for hospitalization. Resident 31 had cognitive impairment and diagnoses including malnutrition and a fractured left leg. On 11/04/2024, Resident 31 was transferred to the hospital for evaluation due to unresponsiveness. However, there was no documentation in the resident's record indicating that the required bed-hold notice was provided. Interviews with facility staff revealed that bed-hold notices were supposed to be given at the time of transfer or within 24 hours if the transfer was emergent. The Director of Nursing confirmed that a bed-hold notice had not been completed for Resident 31.
Incomplete Oxygen Orders for Resident with COPD
Penalty
Summary
The facility failed to ensure that a resident with chronic obstructive pulmonary disease (COPD) and heart failure had current and complete oxygen orders for respiratory care. The resident was observed on two occasions with varying oxygen flow rates, and at one point, the nasal cannula was not being worn despite the oxygen concentrator being on. A review of the medication administration records from July to November revealed no documentation of a physician's order for oxygen. Additionally, the resident's care plan, dated April, lacked any respiratory care plan or interventions related to the resident's COPD. Interviews with staff and the resident indicated that the resident had been experiencing shortness of breath and required supplemental oxygen for about a month. However, there were no physician orders related to oxygen until mid-November. The Physician-Nursing Communication Book and progress notes also lacked documentation regarding the resident's respiratory status or care needs. This oversight placed the resident at risk for respiratory complications and a diminished quality of life.
Deficiency in Nutritional Services Staffing
Penalty
Summary
The facility failed to employ sufficient staff with the necessary certifications to fulfill the functions of nutritional services for 30 residents. Specifically, the Dietary Manager, referred to as Staff E, did not possess the required certification for their role. During an interview, Staff E confirmed that they had not completed the necessary training to obtain the credentials required for their position. Additionally, the facility's Administrator, Staff A, acknowledged the absence of a full-time Registered Dietician and confirmed that Staff E had not completed the certification process.
Failure to Timely Assess and Treat Resident's Injury
Penalty
Summary
The facility failed to perform a timely and thorough assessment of a lower leg injury for a resident who fell on 05/01/2024. The resident, who had a history of right hip fracture with surgical repair and dementia, was at risk for falls and required extensive assistance with daily activities. Despite the fall being witnessed by the facility's administrator, there was no documentation of the incident or the resulting injury until 05/06/2024. The resident's skin tear, initially measuring 1.0 by 0.5 by 0.2 inches, was not assessed or treated promptly, leading to an increase in size and the development of a necrotic, contagious wound infection. The delay in assessment and treatment resulted in the resident experiencing harm, as the infection extended their stay in the facility. The wound was not cultured or treated with antibiotics until 05/10/2024, four days after the injury was documented. The infection was resistant to many antibiotics, necessitating a change in the resident's discharge plans to prevent spreading the bacteria to their spouse at their Adult Family Home. The facility's failure to document and address the fall and subsequent injury in a timely manner contributed to the resident's prolonged recovery and additional medical complications.
Failure to Timely Notify Resident's Representative of Fall and Injury
Penalty
Summary
The facility failed to notify a resident's representative of a change in condition in a timely manner, which was identified during a review of the medical records and interviews. The resident, who had a history of a right hip fracture with surgical repair and dementia, was admitted to the facility and required extensive assistance with daily activities. The resident was also at risk for falls. On a specific date, the resident fell after standing up from their wheelchair, resulting in a skin tear to the left lower leg. Despite the incident, the resident's representative was not informed of the fall and injury until five days later. Interviews with facility staff revealed that neither the registered nurse who assisted the resident after the fall nor the charge nurse at the time of the incident contacted the resident's representative. This lack of communication placed the resident at risk of not having their representative involved in the healthcare decision-making process for timely care and services. The delay in notification raised concerns from the resident's representative about the severity of the injury and the facility's communication practices.
Failure to Report and Address Resident Neglect
Penalty
Summary
The facility failed to report an incident of neglect involving a resident who experienced a worsening wound on their left lower leg. The resident, who had a history of a right hip fracture with surgical repair and dementia, was admitted to the facility and required extensive assistance with daily activities. On a specific date, the resident fell and sustained a skin tear on their left lower leg after hitting the footrest of their wheelchair. However, the incident was not documented or assessed until five days later, leading to a delay in medical treatment. The wound, initially measuring 1.0 by 0.5 by 0.2 inches, worsened over time, showing increased redness, pain, swelling, and slough, eventually growing to 2.0 by 1.0 by 0.5 inches. Despite the staff's awareness of the fall and injury, there was no documentation or assessment until several days later, and no treatment orders were obtained until nine days after the fall. The facility's State Reporting Log showed no reporting of staff neglect as required, indicating a failure to comply with the policy on reporting resident mistreatment and neglect.
Delayed Investigation of Resident Fall Incident
Penalty
Summary
The facility failed to conduct a timely and thorough investigation into a fall incident involving a resident, identified as Resident 1, who was at risk for falls due to a right hip fracture with surgical repair and dementia. The resident required extensive assistance with daily activities and was totally dependent on staff for eating and toilet use. On the date of the incident, the resident fell after getting out of their wheelchair unassisted, resulting in a skin tear on their left lower leg. Despite the fall occurring on 05/01/2024, the Director of Nursing was not made aware until 05/06/2024, and the investigation was not initiated until five days after the incident. The facility's policy required staff to review and investigate all allegations of abuse, neglect, and injuries of unknown source, and to complete investigation summaries and analyze occurrences to prevent further incidents. However, the investigation report was only completed on 05/06/2024, and it was noted that the resident had severe cognitive impairments, which prevented them from explaining the reason for the fall. The administrator, who witnessed the fall, confirmed the details of the incident, including the injury sustained. The delay in initiating the investigation and implementing preventative interventions was a repeat deficiency from a previous report dated 12/05/2023.
Inadequate Staffing Leads to Delayed Care and Unmet Needs
Penalty
Summary
The facility failed to provide sufficient nursing staff to meet the needs of residents, resulting in delayed responses to call lights and unmet care needs. Residents reported long wait times for assistance, with some waiting up to 1.5 hours for their call lights to be answered. This lack of timely response led to residents experiencing incontinence episodes and not receiving showers as per their care plans. The facility was often short-staffed, with only one nursing assistant available for 28 or more residents during evening shifts. Resident 3, who required extensive assistance due to diabetes and cellulitis, did not receive showers as ordered by their physician, and was left sitting in urine for over an hour. Resident 1, with a serious illness affecting their nervous system, also experienced delays in receiving showers and assistance, with call light response times exceeding 30 minutes. Other residents, such as Resident 4 and Resident 5, reported similar issues with delayed care and insufficient staffing, impacting their quality of life and personal hygiene. Staff interviews revealed that the facility was chronically understaffed, with many staff members unable to take breaks and feeling overworked. The administration was aware of the staffing issues but failed to address them adequately. Staff members reported that administrative staff, including the Director of Nursing, did not assist with resident care despite being aware of the staffing shortages. The Resident Council Minutes also documented complaints about long call light wait times and insufficient nursing assistants, further highlighting the facility's failure to provide adequate care.
Deficiency in Serving Meals at Safe Temperatures
Penalty
Summary
The facility failed to serve meals at a safe temperature for two residents, leading to a deficiency in food service. Resident 1, who had no cognitive deficits and required assistance with eating due to a serious illness affecting their nervous system, reported receiving cold food multiple times. On a specific occasion, their meal was served cold, with the fish at 88 degrees Fahrenheit and the vegetables at 80 degrees Fahrenheit, despite being initially prepared at higher temperatures. The staff did not attempt to reheat the meal or offer an alternative, and the issue was only addressed after the investigator intervened. Resident 2, who had moderate cognitive deficits and a respiratory disease, also reported consistently receiving cold meals. The facility's food temperature monitoring forms were incomplete, with no documented temperatures for most of the month, indicating a lack of adherence to the facility's policy on monitoring food temperatures. The Food Service Manager acknowledged that the facility had not been using the correct form for monitoring food temperatures since the kitchen transitioned to the existing corporation.
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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