Touchmark On South Hill Nursing
Inspection history, citations, penalties and survey trends for this long-term care facility in Spokane, Washington.
- Location
- 2929 South Waterford Drive, Spokane, Washington 99203
- CMS Provider Number
- 505498
- Inspections on file
- 26
- Latest survey
- January 13, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Touchmark On South Hill Nursing during CMS and state inspections, most recent first.
The facility failed to label food items with the date opened and discard expired food, risking food-borne illnesses. Observations revealed unlabeled chips, cereal, marshmallows, crackers, and juice, along with expired barbeque sauce and chocolate milk. Staff acknowledged the need for proper labeling and disposal.
The facility failed to offer influenza and pneumococcal vaccines to two residents, as required. Both residents, capable of making decisions about their care, had no documentation in their records indicating they were offered these vaccines. Forms related to the vaccines were found blank, undated, and unsigned, indicating a lapse in the facility's vaccination protocol.
The facility failed to obtain informed consents for psychotropic medications for three residents, violating resident rights. A resident with depression was given Aripiprazole, another with dementia and depression received Fluoxetine and Risperidone, and a third with Parkinson's disease was administered Clonazepam, all without documented consents. The DON confirmed the oversight, noting consents should have been obtained prior to medication administration.
Three residents experienced misappropriation of personal belongings and money due to inadequate security measures and inconsistent documentation. A resident reported missing cash and gift cards, which were later removed by staff for safekeeping but went missing from the facility safe. Another resident's wallet with bank cards and identification was lost, causing significant distress. A third resident's money clip and cash were believed to be discarded accidentally. Staff interviews revealed inconsistencies in handling personal items, and the facility's administrator acknowledged a pattern of missing items.
The facility failed to properly assess and monitor wounds for three residents, leading to the development and worsening of pressure injuries. A resident admitted with existing pressure injuries did not receive appropriate interventions, resulting in new wounds. Another resident developed a stage 1 pressure injury due to prolonged periods of lying on their back, while a third resident developed a pressure injury on their right buttock due to inadequate monitoring and interventions.
The facility failed to report and investigate potential misappropriation of property for two residents who reported missing items shortly after admission. Resident 2's missing wallet contained sensitive information, while Resident 3's missing money clip included cash. Staff interviews revealed a lack of awareness and understanding of the incidents, which were not logged or investigated as required by facility policies.
A resident was admitted to a facility with pressure injuries, but the initial MDS assessment inaccurately documented no injuries. Later assessments revealed unstageable and Stage 3 pressure injuries, which were not reflected in the MDS as of the ARD. Staff interviews confirmed the presence and worsening of these injuries, highlighting a significant oversight in documentation.
Two residents in an LTC facility experienced significant medication errors due to transcription mistakes and failure to adhere to administration parameters. One resident received an incorrect dosage of Torsemide, worsening their respiratory condition, while another was given Carvedilol without proper vital sign checks, leading to potential health risks. Staff interviews highlighted lapses in following medication protocols.
The facility failed to implement effective infection control measures, as evidenced by improper application of transmission-based precautions and inadequate signage for residents with infections. A resident with severe cognitive impairment continued communal activities despite gastrointestinal symptoms, while another resident had precautions removed prematurely. Staff interviews highlighted a lack of understanding of required PPE, contributing to the deficiency.
A resident with a history of a repaired hip fracture and unsteadiness was left naked and cold on the toilet by a nursing assistant after their wet clothing was removed. The resident felt humiliated and distressed, and the incident led to the termination of the nursing assistant involved.
The facility failed to provide necessary supervision to a high fall risk resident who was confused and agitated. Despite being frequently moved to the nurses' station for closer monitoring, the resident was found with bruising on their face and a small acute intracranial hemorrhage indicative of a fall. The Director of Nursing acknowledged that the resident must have hit their head while at the facility.
Failure to Label and Discard Expired Food Items
Penalty
Summary
The facility failed to ensure proper labeling and disposal of food items, which placed residents at risk for food-borne illnesses. During an initial tour of the facility kitchen, surveyors observed a bag of Ruffles potato chips and a container of Raisin Bran cereal without labels indicating the date they were opened. Additionally, a jug of barbeque sauce was found with an expired date. In the resident nourishment refrigerator/freezer, an opened bag of marshmallows, snack-sized bags of graham crackers and saltine crackers, a carton of chocolate milk with an expired date, and a jar of unidentified juice without a label were found. Staff C, the Dietary Manager, acknowledged the need to discard unlabeled and expired items, while Staff D, the Dietary Director, confirmed awareness of the issue and the requirement for all food to be labeled and discarded when expired.
Failure to Offer Required Vaccinations
Penalty
Summary
The facility failed to ensure that influenza and pneumococcal immunizations were offered to two residents, as required. Resident 13, who was documented as capable of making decisions regarding their care, had no documentation in their record indicating that they were offered the pneumococcal vaccine. Although a form titled Pneumococcal (PPV) and Pneumococcal (PCV-13) was present in the resident's record, it was blank, undated, and unsigned, failing to show whether the resident had been offered or declined the vaccine. Similarly, Resident 14, also documented as capable of making decisions regarding their care, had no documentation in their record indicating that they were offered either the influenza or pneumococcal vaccines. The forms titled Flu Vaccine and Pneumococcal (PPV) and Pneumococcal (PCV-13) were found in the resident's record but were also blank, undated, and unsigned, failing to indicate whether the resident had been offered or declined the vaccines. This lack of documentation and offering of vaccines was confirmed during interviews with the facility's Administrator and Infection Preventionist.
Failure to Obtain Informed Consents for Psychotropic Medications
Penalty
Summary
The facility failed to obtain informed consents for the administration of psychotropic medications for three residents, which is a violation of resident rights. Resident 5, who had moderate cognitive impairment and a diagnosis of depression, was prescribed Aripiprazole without a documented consent. Similarly, Resident 13, with severe cognitive impairment and diagnoses of dementia and depression, was administered Fluoxetine and Risperidone without consents. Resident 11, diagnosed with Parkinson's disease and receiving Clonazepam for insomnia, also lacked a documented informed consent. Interviews with the Director of Nursing (DON) confirmed the absence of informed consents for these medications. The DON acknowledged that consents should have been obtained prior to the administration of any psychotropic medication. This oversight was attributed to missed consents before the current DON assumed their role, indicating a lapse in the facility's protocol for ensuring residents are fully informed and able to participate in their treatment decisions.
Misappropriation of Resident Property
Penalty
Summary
The facility failed to protect residents from the misappropriation of their personal belongings and money, affecting three residents. Resident 1, who was cognitively intact, reported missing cash and gift cards shortly after admission. Despite having a locking nightstand, the lock was not functional, leading to the loss of $526. Later, additional cash and gift cards were removed from Resident 1's room by staff for safekeeping in the facility safe, but these items also went missing. Interviews with staff revealed inconsistencies in the handling and documentation of personal items, and the facility's policy on liability for lost items was unclear. Resident 2, also cognitively intact, reported a missing wallet containing various bank cards and personal identification shortly after admission. The family confirmed that cash was taken home, but the wallet and its contents were left with the resident. Despite a search, the wallet was not found, and the facility offered to reimburse only the cost of a new wallet, not the contents. This incident led to significant distress for Resident 2, who exhibited suicidal ideation and refused care. Resident 3, who had bilateral below-knee amputations, reported a missing money clip with cash shortly after admission. The resident believed the items were accidentally discarded due to incontinence issues. The facility credited the resident's account for the lost cash but did not recover the money clip. Interviews with staff indicated a lack of awareness and documentation regarding the missing items. The facility's administrator acknowledged a pattern of missing items, suggesting a systemic issue with securing residents' personal belongings.
Inadequate Pressure Ulcer Care and Monitoring
Penalty
Summary
The facility failed to consistently and accurately assess, monitor, and evaluate wounds for three residents, leading to the development and worsening of pressure injuries. Resident 4, who was admitted with existing pressure injuries, did not receive appropriate interventions such as pressure reduction devices or a turning/repositioning program. Despite being at risk for skin breakdown, the resident's wounds were not properly documented or measured, and new wounds developed during their stay. The resident's reluctance to use offloading boots and preference for lying on their back further contributed to the deterioration of their skin condition. Resident 5, admitted with no pressure injuries, developed a stage 1 pressure injury on their right buttock due to prolonged periods of lying on their back. Despite being at risk for pressure injuries, the facility did not implement adequate preventative measures, and the resident's condition was only addressed after they reported pain. The resident's recent illness and weight loss may have contributed to their increased vulnerability to skin breakdown. Resident 6, also admitted with no pressure injuries, developed a stage 1 pressure injury on their right buttock. The resident required assistance with activities of daily living and wore a back brace, which may have limited their mobility. The facility's failure to implement timely interventions and adequately monitor the resident's skin condition led to the development of the pressure injury. Staff interviews revealed inconsistencies in the documentation and assessment of wounds, contributing to the deficiencies observed.
Failure to Report and Investigate Missing Resident Property
Penalty
Summary
The facility failed to identify and report potential misappropriation of resident property to the State Survey Agency as required for two of three sampled residents. This deficiency involved Resident 2 and Resident 3, who both reported missing personal items shortly after their admission to the facility. The facility's policies on personal property, grievances, and abuse required that such incidents be reported and investigated as potential misappropriation, but this was not done in these cases. Resident 2, who was cognitively intact, reported a missing wallet containing debit and credit cards, social security information, and other personal items the day after their admission. Despite the significant contents of the wallet, the incident was not logged as a reportable event, nor was it investigated as potential misappropriation. Interviews with staff members revealed a lack of awareness and understanding of the incident, and it was acknowledged that the situation should have been reported and investigated according to the facility's policies. Similarly, Resident 3, also cognitively intact, reported a missing money clip with cash shortly after admission. The incident was not recorded in the facility's reporting log, and although the resident's account was credited for the lost money, the event was not treated as potential misappropriation. Staff interviews indicated a misunderstanding of the difference between a missing item and potential misappropriation, and it was recognized that the incident should have been reported and investigated. The facility administrator acknowledged a pattern of missing items and the high risk of theft or misappropriation, yet the incidents involving Resident 2 and Resident 3 were not appropriately addressed.
Inaccurate MDS Assessment for Resident with Pressure Injuries
Penalty
Summary
The facility failed to accurately reflect the status of a resident, identified as Resident 4, as of the assessment reference date (ARD) in their Minimum Data Set (MDS) assessment. This inaccuracy was discovered during a review of the resident's medical records and interviews with staff. Resident 4 was admitted to the facility with diagnoses including muscle weakness and ischemic cardiomyopathy and was at risk for pressure injury development. However, the initial admission assessment inaccurately documented that Resident 4 had no pressure injuries, while a modified assessment later indicated the presence of two unstageable and two Stage 3 pressure injuries. The deficiency was further highlighted by discrepancies in the documentation of Resident 4's skin condition. Hospital notes from prior to the resident's admission to the facility indicated the presence of pressure injuries and abrasions, which were not accurately reflected in the initial MDS assessment. Subsequent skin assessments and wound team evaluations documented the worsening of these injuries, including the development of new wounds, which were not captured in the MDS assessment as of the ARD. Interviews with facility staff, including a Registered Nurse, Resident Care Manager, and Wound Care Nurse, confirmed the presence and deterioration of these wounds, yet the MDS Coordinator acknowledged that the MDS did not accurately reflect the resident's condition at the time of the ARD. The failure to accurately document Resident 4's pressure injuries in the MDS assessment as of the ARD was a significant oversight. The MDS Coordinator admitted that the data used for the assessment was not within the appropriate time frame, and the original MDS inaccurately showed no pressure injuries upon admission. This inaccuracy placed the resident at risk of unmet care needs and diminished quality of life, as the MDS is a critical tool for assessing a resident's status and planning their care.
Medication Administration Errors in LTC Facility
Penalty
Summary
The facility failed to accurately transcribe provider orders and consistently administer medications as ordered, resulting in significant medication errors for two residents. Resident 1, who was admitted with severe cardiorespiratory conditions, was prescribed 50mg of Torsemide daily to manage fluid retention and shortness of breath. However, due to a transcription error, the medication was entered as 10mg daily in the electronic medical record, and Resident 1 received the incorrect dosage for five days. This error led to worsening respiratory symptoms, weight gain, and eventually a discussion about hospice care. Resident 2, admitted with heart failure and chronic lung disease, was prescribed Carvedilol with specific blood pressure and heart rate parameters for administration. The facility failed to document vital signs consistently and administered the medication without adhering to the prescribed parameters on several occasions. This included administering Carvedilol when blood pressure readings were below the threshold for safe administration, as well as holding doses when parameters were met, without proper documentation or notification to the provider. Interviews with facility staff revealed a lack of adherence to medication administration protocols, including double-checking orders and documenting reasons for withheld medications. Staff acknowledged the errors and the importance of following medication parameters to prevent harm to residents. The facility's policies on medication administration and error reporting were not effectively implemented, contributing to the deficiencies observed.
Inadequate Infection Control and Precaution Implementation
Penalty
Summary
The facility failed to implement an effective infection prevention and control program, as evidenced by their inability to consistently apply transmission-based precautions and post appropriate signage for residents with infections. The facility's policy required documentation of signs and symptoms of communicable diseases and the implementation of immediate precautions to prevent the spread of infections. However, during a gastrointestinal outbreak, the facility did not adhere to these protocols, placing residents at risk of infection transmission. Resident 3, who had severe cognitive impairment and a history of stroke, dementia, and GERD, experienced multiple episodes of loose stools and vomiting. Despite these symptoms, Resident 3 continued to participate in communal dining and social activities, contrary to the facility's policy that required residents with gastrointestinal symptoms to remain in their rooms until symptom-free for 24 hours. Staff interviews confirmed that Resident 3 should not have been allowed to engage in group activities or communal dining during this period. Similarly, Resident 2, who was frequently incontinent and had a history of heart failure and chronic lung disease, was placed on contact enteric precautions for gastrointestinal upset. However, the precautions were prematurely removed before Resident 2 was symptom-free for 24 hours. Additionally, inappropriate signage was posted outside Resident 2's room, which did not align with the CDC guidelines for a skilled nursing environment. Staff interviews revealed a lack of understanding of the required personal protective equipment for different types of transmission-based precautions, further contributing to the deficiency.
Failure to Assist Resident with Activities of Daily Living
Penalty
Summary
The facility failed to provide necessary assistance with activities of daily living for a resident who was dependent on staff for care. The resident, who had a history of a repaired left hip fracture and unsteadiness on their feet, required staff assistance for toileting, transfers, personal hygiene, and dressing. On one occasion, a nursing assistant left the resident naked and cold on the toilet after removing their wet, soiled clothing. The resident reported feeling humiliated and distressed by the incident, which occurred after breakfast and was not addressed until another aide found them and provided assistance. Interviews with staff revealed that the Social Services Director became aware of the incident the following day and collected a statement from the resident, who expressed significant distress over the situation. The Director of Nursing was notified of the incident on the same day it occurred and expressed concern over the resident being left in such a state. The nursing assistant involved was subsequently terminated after discussions about their capabilities. The incident was documented in the facility's investigation records, highlighting the failure to meet the resident's care needs and maintain their dignity.
Failure to Provide Adequate Supervision for High Fall Risk Resident
Penalty
Summary
The facility failed to provide necessary supervision to Resident 2, who was identified as a high fall risk and was confused. Despite being noted for unsafe behaviors and attempts to self-transfer, the resident was found multiple times trying to get out of bed and was not adequately monitored. On one occasion, the resident was found lying on the floor with bruising on their face, which was later identified as a small acute intracranial hemorrhage indicative of a fall. The resident's medical records and staff interviews indicate that the resident was given narcotic pain medication and was frequently moved to the nurses' station for closer monitoring, but these measures were insufficient to prevent the fall and subsequent injury. Staff interviews revealed that the resident was very confused, agitated, and unable to be redirected, which contributed to their attempts to self-transfer. Despite these observations, the facility did not implement effective measures to prevent the resident from falling. The Director of Nursing acknowledged that the resident must have hit their head while at the facility, leading to the observed injuries. The failure to provide adequate supervision and prevent the fall resulted in the resident being sent to the emergency room for further evaluation and treatment.
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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