Valley View Skilled Nursing And Rehabilitation
Inspection history, citations, penalties and survey trends for this long-term care facility in Renton, Washington.
- Location
- 4430 Talbot Road South, Renton, Washington 98055
- CMS Provider Number
- 505202
- Inspections on file
- 32
- Latest survey
- December 23, 2025
- Citations (last 12 mo.)
- 1
Citation history
Health deficiencies cited at Valley View Skilled Nursing And Rehabilitation during CMS and state inspections, most recent first.
A resident with severe pressure ulcers and limited mobility did not receive consistent monitoring of their air mattress, as required by their care plan. The air mattress was found deflated, and staff had no documentation or physician order to check its function prior to the incident, resulting in worsening skin condition.
Staff failed to cover ready-to-eat food items, left a dirty wash rag bin uncovered near a handwashing sink, and distributed uncovered meal trays without performing hand hygiene between residents. The meal cart used was also found to be dirty, and staff confirmed these practices were not isolated incidents. These actions violated the facility's food service policy and exposed residents to unsanitary conditions.
The facility's kitchen staff failed to maintain sanitary conditions, as observed during a survey. Staff neglected proper hand hygiene and glove use, leading to potential cross-contamination. Personal items were found in food preparation areas, and staff handled raw food and kitchen items without proper sanitation. Additionally, food temperatures were not adequately monitored, and soiled equipment was used during meal service, risking food-borne illnesses for residents.
The facility failed to provide newly admitted residents with timely information about their rights and services, as required. Three residents did not have their admission packets completed within the expected timeframe due to staffing changes, placing them at risk of not understanding their rights and services.
The facility failed to maintain a homelike environment in several areas, including resident rooms, the main dining room, and a shower room. Observations revealed issues such as non-latching doors, holes in floor tiles, missing window screens, exposed drywall, and a missing toilet. Cleanliness issues included dirty privacy curtains and strong urine odors. Staff acknowledged the importance of timely repairs, but limitations in authority to order supplies hindered prompt action, leaving residents at risk for a diminished quality of life.
The facility did not follow the dietician-approved menu and portion sizes during meal service, affecting three residents. All residents were served canned peach cobbler instead of fresh, and portion sizes were not adjusted for those on special diets. The Dietary Manager intervened to correct portion sizes, and the Regional Administrator stressed the importance of adhering to dietary guidelines.
The facility failed to prepare appetizing and palatable meals, leading to resident dissatisfaction and potential decreased nutritional intake. Observations showed food was placed on the steam table too early, resulting in poor quality meals. Residents expressed dissatisfaction, and staff confirmed the expectation for timely meal preparation was not met.
The facility failed to ensure arbitration agreements were explained to residents in a manner they understood, affecting three residents. Despite being alert and oriented, the residents were unaware of the agreements they signed, and staff interviews revealed a lack of proper communication. The admissions coordinator responsible for this process was no longer employed, leading to a disconnect in explaining the agreements' legal implications.
A resident reported a missing Grabber Reacher, an assistive device, to the nursing staff, but the facility failed to document and address the grievance promptly. Despite initial efforts to locate the item, the resident did not receive timely feedback or a suitable replacement, leading to frustration. Staff interviews revealed a lack of adherence to the grievance policy, which required formal documentation and investigation of grievances.
The facility did not report missing narcotics from the East 2 Narcotic Ledger to the SSA in a timely manner. Discrepancies included missing tablets and pages in the ledger. An LPN reported the issue to the Resident Care Manager and the DON, but the incident was not reported to the SSA. The DON later acknowledged the oversight and the importance of reporting to prevent further issues.
The facility failed to thoroughly investigate discrepancies in the East 2 narcotic ledger, including missing narcotics and torn-out pages. An LPN reported these issues to the DON, who conducted an incomplete audit and missed additional discrepancies. This oversight placed residents at risk for uncontrolled pain and potential misappropriation of medications.
The facility failed to provide timely written transfer/discharge notices to residents and their representatives, as required. Notices for two residents were left at the bedside, inaccessible during their hospital stay, and two other residents did not receive any documentation. Staff confirmed the lack of adherence to policy, risking uninformed transfers.
The facility failed to provide written bed-hold notices to residents or their representatives during hospital transfers, as required by policy. This affected multiple residents, with no documentation found to indicate that the notices were offered or provided. Interviews revealed confusion among staff about responsibility for issuing these notices.
The facility failed to update care plans for two residents, leading to inconsistent care and unmet needs. One resident's care plan was not updated to reflect a physician's order for fall prevention, while another's plan did not include requested vision services. Additionally, required care conferences were not conducted for two residents, limiting their participation in care planning.
The facility failed to assist three residents with ADLs, leading to poor hygiene and grooming. A resident with a leg amputation was not shaved regularly, another with a stroke was found with greasy hair and no shoes, and a third resident received fewer baths than scheduled. Staff did not document refusals or follow care plans, as confirmed by the DON and Resident Care Manager.
The facility failed to follow provider orders and care plans for several residents, leading to deficiencies in care. A resident requiring bed rails for mobility was observed without them, and another resident's oxygen was set incorrectly. A resident with dementia frequently refused meals and medications, but the care plan lacked specific interventions for these refusals. Additionally, the facility did not monitor and document bruises for residents as required.
A resident with impaired vision did not receive necessary assistive devices or an eye exam due to the facility's failure to schedule the appointment, despite multiple requests from the resident's representative. The responsible social worker left the facility without documenting the communication or scheduling the exam, resulting in unmet care needs.
Two residents in an LTC facility did not receive necessary care for pressure ulcers. One resident had an open area on the coccyx that staff failed to document and report, while another resident's refusal of compression wraps was not communicated to the provider. Additionally, a delay in receiving a prescribed dressing was not reported, leading to inadequate care and risk of skin condition deterioration.
The facility failed to ensure a safe environment by not properly storing chemicals, placing residents at risk. Observations showed unsecured insect killer spray in a cabinet, an unlocked housekeeping closet with cleaning chemicals, and an open utility room with no rinse foam cleanser. Staff interviews confirmed the improper storage, with some staff unable to access locked closets, leading to chemicals being placed in unsecured areas. The Regional Administrator acknowledged the policy breach, emphasizing the importance of locking up chemicals to prevent resident exposure.
The facility failed to maintain an accurate narcotic ledger, with discrepancies such as missing tablets and torn pages. An LPN reported these issues to the Resident Care Manager and DON, who instructed corrections but did not verify their completion. A pharmacy audit found no further discrepancies.
The facility failed to remove expired medications from two medication carts and a storage room, risking resident safety. Observations revealed expired medications and unclean conditions in the West 1 and East 2 carts, and numerous expired IV supplies in the East 2 storage room. Staff acknowledged their responsibility to maintain cleanliness and remove expired items, but these actions were not completed.
A resident in a LTC facility did not receive prompt dental services despite being dependent on staff for oral care and having no teeth or dentures. The resident's representative repeatedly requested a dental exam for dentures, but the facility failed to schedule it. The previous social worker did not document the requests or add the resident to the dentist list, and the facility canceled dental visits due to an outbreak.
The facility failed to protect the privacy and confidentiality of resident information for four residents. PHI was left visible and unattended on electronic devices for three residents, and communication regarding another resident's care was not documented. Staff acknowledged the importance of confidentiality but did not secure the information.
The facility failed to maintain an effective infection prevention and control program, with deficiencies including lack of Enhanced Barrier Precautions for residents with indwelling devices, inadequate cleaning of the shower room and ice machine, and failure to adhere to hand hygiene and transmission-based precautions. These lapses were observed in multiple instances, such as a resident returning from the hospital with a catheter not being placed on EBP, and a provider entering a resident's room without PPE.
The facility's pest control program was ineffective, leading to insects in resident rooms and common areas. A resident reported bugs disturbing their sleep, and staff acknowledged the issue, noting ineffective pest control services. Fruit flies were observed in the kitchen and dining areas, with staff seeking pest control assistance. This failure compromised the facility's environment.
The facility failed to submit complete and accurate staffing data to CMS for Q1 2024, as required by PBJ guidelines. Interviews revealed a lack of oversight and potential technical issues as contributing factors. The DON acknowledged responsibility for staffing levels, while the CEO and Administrator recognized the need for improved compliance oversight.
The facility failed to assess and document wound characteristics, monitor, and implement interventions to mitigate worsening of non-pressure skin issues for four residents. This led to unidentified wounds, worsening conditions, and lack of proper medical notifications.
Failure to Monitor Air Mattress Results in Pressure Ulcer Care Deficiency
Penalty
Summary
The facility failed to ensure that a resident with multiple medical conditions, including heart disease, respiratory failure, systemic infections, unstable blood sugar, and bilateral leg amputations, received necessary treatment and services consistent with professional standards for pressure ulcer management. The resident, who was bedbound and had two Stage 4 pressure ulcers, was assessed to require an air mattress as a pressure-relieving intervention. However, there was no routine monitoring procedure established to ensure the air mattress was functioning properly. The care plan and safety device assessment indicated the need for the air mattress, but there was no physician order or documentation directing staff to monitor the device until after an incident occurred. On one occasion, the resident's representative found the air mattress deflated, with the resident lying on the metal bars of the bed. Staff who responded did not initially notice the malfunction. The following day, the wound nurse observed worsening redness on the resident's back, prompting the representative to request hospital evaluation. Interviews with staff confirmed the air mattress was unplugged and that there was no record of when it was last checked. The Director of Nursing acknowledged that staff were responsible for checking the air mattress each shift, but no monitoring order was in place prior to the incident.
Failure to Maintain Sanitary Food Preparation and Service Conditions
Penalty
Summary
The facility failed to maintain sanitary conditions during food preparation and service on one nursing unit. Observations revealed that ready-to-eat salads and desserts were left uncovered on resident meal trays in the kitchen, with small black insects flying around the uncovered food. Staff interviews confirmed ongoing issues with insect infestation and acknowledged that food items were routinely left uncovered during transport to the units. Additionally, a bin of wet, dirty wash rags was left uncovered near a handwashing sink, also attracting insects. Staff admitted that bins should be kept covered to prevent contamination but failed to do so. Further observations showed that a CNA distributed uncovered food trays in the hallway, passing rooms on transmission-based precautions, and did not perform hand hygiene between serving different residents. The meal cart used for lunch service was found to be dirty, with dried liquid spills and brownish sediments lining the bottom. Staff interviews confirmed the lack of cleanliness and the expectation that the cart should be kept sanitary. These actions and inactions were in direct violation of the facility's food preparation and service policy, which requires adherence to safe food handling and hygiene practices.
Sanitation and Food Safety Deficiencies in Facility Kitchen
Penalty
Summary
The facility failed to maintain sanitary conditions in its kitchen, as observed during a survey. Staff CC, a dietary cook, repeatedly neglected proper hand hygiene and glove use while preparing food. On multiple occasions, Staff CC was seen removing gloves and putting on new ones without washing their hands with soap and water. Additionally, Staff CC was observed touching potentially contaminated surfaces, such as garbage cans and face masks, and then continuing food preparation without proper hand hygiene. These actions were contrary to the facility's policy, which required staff to wash hands for at least 20 seconds with soap and water between tasks and glove changes. Cross-contamination was another significant issue identified in the facility's kitchen. Staff members were observed engaging in practices that could lead to contamination of food. For instance, a staff member's personal phone was found in a bin of condiment packets, and Staff DD was seen placing fingers inside the cup ledge while filling juice cups. Staff CC handled raw chicken with gloved hands, then touched various kitchen items without changing gloves or sanitizing surfaces. Furthermore, during meal service, staff handled meal tray tickets and tongs in a manner that could lead to contamination of food items, such as rolls and cucumbers. The facility also failed to adequately monitor food cooking temperatures, as required by their policy. Staff CC did not check the final internal temperature of beef stroganoff before serving, which was supposed to reach 165 degrees Fahrenheit. The facility's food temperature logs showed no recorded temperatures for lunch items once cooking was completed. Additionally, the dish cart used for clean plates was found to be soiled with dried food and debris, yet it was still used during meal service. These lapses in maintaining sanitary conditions and monitoring food safety placed residents at risk of food-borne illnesses and compromised their quality of life.
Failure to Provide Timely Admission Information to Residents
Penalty
Summary
The facility failed to ensure that newly admitted residents were informed in a timely manner of their rights and responsibilities, as well as the services provided by the facility. This deficiency was identified for three residents (Residents 85, 139, and 339) out of five reviewed. The facility's admission packet, which includes information on resident rights, facility policies, and consent forms, was not completed for these residents within the expected timeframe. Resident 85 was admitted over 30 days prior to the review, Resident 139 over two weeks prior, and Resident 339 two weeks prior, yet none had their admission packets completed by staff upon admission. During an interview, Staff O, the Vice President for the Business Office, acknowledged the importance of having residents or their representatives review and sign the admission packet to ensure they are informed of their rights and the services they will receive. Staff O attributed the delay in completing the admission packets to staffing changes and stated that it was their expectation for the admission packet to be reviewed and signed within 72 hours of admission. This failure placed residents at risk of not understanding their rights and diminished their ability to self-advocate.
Facility Fails to Maintain Homelike Environment
Penalty
Summary
The facility failed to maintain a homelike environment in several areas, including 17 resident rooms, the main dining room, and a shower room. Observations revealed various deficiencies such as doors that did not latch, holes in floor tiles, missing window screens, exposed drywall, and a missing toilet in a bathroom. Additionally, there were issues with cleanliness, such as dirty privacy curtains, strong urine odors, and scattered personal belongings on the floor. These conditions were noted during observations and interviews with staff, who acknowledged the importance of timely repairs to maintain a homelike environment. In the main dining room, a cabinet was observed with peeling paint and warped wood surfaces, which was not cosmetically appealing. Staff interviews confirmed that the cabinet was not in good repair and emphasized the importance of maintaining an environment that is in good condition, as the facility serves as the residents' home. The West 2 Shower Room was found to have a broken door with dents and mold on the ceiling, further contributing to the failure to provide a homelike environment. Staff interviews revealed that while daily rounds were conducted to identify needed repairs, there were limitations in the authority to order supplies for repairs. The facility was aware of the issues, such as missing blinds and damaged tiles, and was considering different options for repairs. However, the lack of timely action to address these deficiencies left residents at risk for a diminished quality of life and a less than homelike environment.
Failure to Follow Dietician-Approved Menu and Portion Sizes
Penalty
Summary
The facility failed to adhere to the dietician-approved menu and portion sizes during meal service, affecting three residents. On the specified date, the lunch menu was supposed to include beef stroganoff over noodles, buttered brussel sprouts, peach cobbler made from fresh peaches, and a dinner roll. However, observations revealed that all residents were served a canned fruit version of peach cobbler instead of the fresh peach cobbler as directed. Additionally, the portion sizes for residents on a low concentrated sweets diet were not adjusted as required, with all residents receiving the same portion size. Specific issues were noted with the meal preparation for three residents. Resident 83 received a 3 oz serving of brussel sprouts instead of the required 4 oz. Residents 3 and 16 did not receive the large portions of food as indicated on their tray tickets. The Dietary Manager, Staff K, intervened multiple times to correct the portion sizes during the meal service. Staff K admitted that they were not usually present to oversee the tray line but were instructed to do so during the survey. The Regional Administrator, Staff C, emphasized the importance of following the dietician's recipes and portion sizes to meet dietary needs and restrictions.
Deficiency in Meal Preparation and Service
Penalty
Summary
The facility failed to prepare food in a manner that ensured meals were appetizing and palatable for four residents, leading to dissatisfaction and potential decreased nutritional intake. Observations revealed that the facility did not adhere to its own guidelines, which directed staff to place food on the tray line no more than 30 minutes prior to meal service. Instead, noodles were placed on the steam table an hour and a half before the tray line service began, resulting in brown crusted noodles stuck to the bottom of the bin. These noodles were then served to residents, along with mushy and tasteless brussel sprouts. Interviews with residents indicated widespread dissatisfaction with the food quality. One resident described the food as bland and overcooked, while another frequently ordered food from outside the facility due to dissatisfaction. Staff interviews confirmed that the expectation was for food to be on the steam table no more than 30 minutes before service, as prolonged exposure to heat could affect food quality and nutritional value. The failure to adhere to these guidelines contributed to the deficiency in meal preparation and service.
Failure to Explain Arbitration Agreements to Residents
Penalty
Summary
The facility failed to ensure that the arbitration agreement was explained in a form and manner that the residents and/or their representatives understood. This deficiency was identified for three residents who were reviewed for arbitration agreements. The facility's policy required that the arbitration agreement be explained to residents upon admission in a language and manner they understood, with the admissions coordinator responsible for addressing any questions. However, interviews with the residents revealed that they were not aware of the arbitration agreements they had signed, nor were they informed about the 30-day revocation period. Resident 49, who was alert and oriented, stated they were unaware of the arbitration agreement and its terms. Similarly, Resident 23 did not recall signing the agreement or being informed about it, and Resident 43, who had impaired vision, signed the agreement without understanding its purpose. The facility's staff interviews indicated a lack of proper communication and explanation regarding the arbitration agreements. The Director of Nursing stated that the admission coordinator was responsible for the arbitration agreement process, but the coordinator was no longer employed at the facility. The Vice President for the Business Office acknowledged that staff should have explained the arbitration agreement details to residents or their representatives before signing. This oversight placed residents at risk of not understanding the legal implications of the arbitration agreement, including the forfeiture of their right to a jury or court trial.
Failure to Implement Grievance Policy for Missing Assistive Device
Penalty
Summary
The facility failed to implement its grievance policy for a resident who reported a missing assistive device, specifically a Grabber Reacher. The resident, who was dependent on staff for various daily activities due to complex medical conditions, reported the missing item to the nursing staff. Despite the staff's initial efforts to locate the item, the resident did not receive timely feedback or a replacement, leading to frustration and a diminished quality of life. The facility's policy required grievances to be documented and investigated promptly, but this process was not followed. Interviews with staff revealed that the grievance was not formally documented, and the resident care manager admitted to not always using grievance forms, preferring to resolve issues informally. The Director of Nursing confirmed that staff were expected to document grievances using designated forms to ensure proper tracking and resolution. The failure to document and address the grievance promptly resulted in a delay in providing the resident with an appropriate replacement for the missing item.
Failure to Report Missing Narcotics to SSA
Penalty
Summary
The facility failed to report missing narcotics to the State Survey Agency (SSA) within the required timeframe, as observed in the East 2 Narcotic Ledger. The ledger showed discrepancies, including missing tablets and pages that were crossed off or ripped out. Specifically, one tablet was missing from a transferred count, and several pages had no corresponding medication cards in the lock box. Staff I, an LPN, reported the missing narcotics to the Resident Care Manager and the Director of Nursing (DON), Staff B, but the incident was not reported to the SSA as required. Staff B acknowledged being informed of the missing narcotics and ledger pages but did not report the incident to the SSA. During an interview, Staff B admitted to not knowing the requirement to report the missing narcotics and ledger pages at the time of the incident. However, after reviewing the guidelines, Staff B understood the importance of reporting such incidents to ensure a thorough investigation and prevent further misappropriation or diversion of controlled substances within the facility.
Failure to Investigate Missing Narcotics and Ledger Discrepancies
Penalty
Summary
The facility failed to conduct a thorough investigation into discrepancies found in the East 2 narcotic ledger, which included missing controlled substances and torn-out pages. Staff I, an LPN, reported these discrepancies to Staff B, the Director of Nursing (DON), who acknowledged the missing narcotics and ledger pages. Despite conducting a narcotic audit, Staff B did not reach a conclusion regarding the missing items and failed to ensure that corrective notations were made in the ledger by the RN Managers, Staff F and Staff H. Additionally, a pharmacy narcotic audit was ordered, but no further discrepancies were reported. Upon further review, it was discovered that Staff B missed additional discrepancies on several pages of the narcotic ledger. Staff B admitted to not performing a comprehensive page-to-page investigation during the initial audit, which should have been done. The failure to identify and reconcile these discrepancies during the initial investigation placed residents at risk for uncontrolled pain and potential misappropriation of narcotic medications.
Failure to Provide Timely Transfer/Discharge Notices
Penalty
Summary
The facility failed to ensure that residents and their representatives received the required written notices at the time of transfer or discharge, or as soon as practicable, for several residents. Specifically, for Residents 65 and 139, the facility did not provide the Nursing Home Transfer or Discharge Notice, which includes appeal rights, until after the residents returned to the facility from an acute care hospital. The notices were left at the bedside, rendering them inaccessible to the residents during their hospital stay. Staff E, responsible for completing these notices, confirmed that it was not their practice to provide the notice once a resident left the facility urgently and did not provide the notices to the residents' representatives unless requested. Additionally, for Residents 18 and 39, there was no documentation indicating that the required written transfer notifications were provided at the time of their discharge to an acute care hospital. Staff J and Staff B acknowledged the absence of documentation for Resident 18, while Staff E admitted that Resident 39 did not receive a written transfer notification. The facility's failure to follow its policy on providing timely written notifications placed residents at risk of being uninformed about their transfer or discharge, including their appeal rights.
Failure to Provide Bed-Hold Notices
Penalty
Summary
The facility failed to provide written notice of its bed-hold policy to residents or their representatives at the time of transfer to a hospital or within 24 hours, as required by their policy. This deficiency was identified for three sample residents and one supplemental resident who were transferred to acute care hospitals. The facility's policy, revised in December 2022, mandates that such notice be given to inform residents and their representatives of the duration of the bed hold and the conditions for the resident's return to the facility. However, records for Residents 65, 18, 39, and 139 showed no documentation of such notice being provided. Interviews with facility staff revealed a lack of clarity regarding responsibility for issuing bed-hold notices. Staff E, the Director of Social Services, expected the admissions department to handle bed holds, while Staff M, the Admissions Director, believed it was the responsibility of the social services department or nurses. Both Staff E and Staff M confirmed that no documentation was found in the records of the affected residents to indicate that bed-hold notices were offered or provided, as required by the facility's policy.
Failure to Update Care Plans and Conduct Care Conferences
Penalty
Summary
The facility failed to ensure that care plans were updated to reflect changes in residents' care needs, specifically for two residents. Resident 3's care plan was not updated to reflect a physician's order to change the placement of floor mats, which were intended to prevent fall-related injuries. Observations showed that no floor mats were placed as directed, and the Registered Nurse Manager confirmed that the care plan was not updated, leading to inconsistent and uncoordinated care. Resident 39's care plan did not reflect their need for vision services, despite requests from their representative for an eye exam to obtain glasses. The social worker who communicated with the representative left the facility, and there was no documentation of these communications in the resident's records. The Social Service Director acknowledged that the care plan should have been updated to include the resident's wishes for vision services. Additionally, the facility failed to conduct care conferences as required. Resident 39 was only offered one care conference since admission, and their representative confirmed that no further conferences were scheduled. Similarly, Resident 49 was not offered quarterly care conferences as expected, with only two conferences documented since admission. The Social Service Director stated that care conferences should be offered upon admission, quarterly, and as needed, to allow residents to participate in their care plans and address any concerns.
Failure to Assist Residents with ADLs and Maintain Hygiene
Penalty
Summary
The facility failed to provide adequate assistance with Activities of Daily Living (ADL) for three residents, leading to issues with cleanliness and grooming. Resident 18, who was cognitively intact and required assistance with personal hygiene due to a left leg amputation, was observed multiple times with long facial hair and fingernails. Despite expressing a desire to be shaved every other day, Resident 18 reported that staff only provided shaving assistance on shower days. The Director of Nursing acknowledged that the facility did not document Resident 18's preferences or provide the necessary assistance. Resident 22, who was dependent on staff for bathing, dressing, and personal hygiene due to a stroke and delusional disorder, was observed with greasy hair, long eyebrows, and facial hair. The resident's room smelled of urine, and they were wearing a hospital gown without shoes. Although staff claimed that Resident 22 refused showers, there was no documentation of such refusals. The Director of Nursing was unaware of the shoe issue and stated that refusals should be documented and reported to a supervisor. Resident 3, who required assistance with bathing due to altered mental status and limited range of motion, was scheduled for two showers per week. However, documentation showed that Resident 3 only received one shower per week over a 32-day period, despite the Health Care Power of Attorney's preference for two baths per week. The Resident Care Manager confirmed that the facility failed to follow the care plan and document refusals properly.
Deficiencies in Following Provider Orders and Resident Care Plans
Penalty
Summary
The facility failed to follow provider orders for several residents, leading to deficiencies in care. Resident 35, who was assessed to require bilateral bed rails for mobility and safety, was observed without them on multiple occasions. Despite having a care plan and physician's orders for bed rails, staff did not install them, and the Treatment Administration Records (TARs) were inaccurately signed, indicating compliance. Interviews with staff confirmed the oversight and the expectation to follow provider orders. Resident 27, who required continuous supplemental oxygen at 2 liters per minute due to chronic respiratory failure, was observed with the oxygen setting at 2.5 liters per minute. This discrepancy was noted over several days, despite the Medication Administration Record (MAR) indicating the correct setting. Staff interviews revealed a lack of adherence to the physician's order and the need for proper monitoring and adjustment of oxygen settings. Resident 71, who had multiple health issues including dementia and depression, frequently refused meals and medications. The care plan lacked specific interventions for handling these refusals, and there was no documentation of actions taken when refusals occurred. The resident experienced significant weight loss, and staff interviews highlighted the absence of a coordinated response to the resident's nutritional and care refusals. Additionally, the facility failed to monitor and document bruises for Residents 139, 15, and 45, as required by their care plans and physician's orders.
Failure to Provide Vision Services
Penalty
Summary
The facility failed to ensure that residents with vision deficits were assessed and provided with necessary assistive devices, specifically impacting one resident who was reviewed for vision needs. Resident 39, who was readmitted to the facility with moderately impaired vision without corrective lenses, was unable to see their television and did not have any visual assistive devices available. Despite the resident's representative requesting an eye exam multiple times, the facility did not schedule the exam, leaving the resident without the necessary corrective lenses. The facility's policy required the social worker to assist residents in accessing vision services, but the social worker responsible for Resident 39's case left the facility without documenting the communication or scheduling the necessary eye exam. The social worker had assured the resident's representative that the resident would be added to the list for the eye doctor, but this did not occur. The lack of documentation and follow-through resulted in the resident not receiving the needed vision services, as the previous social worker had cleared their data before leaving the facility.
Failure to Provide Adequate Pressure Ulcer Care
Penalty
Summary
The facility failed to provide necessary care and services for two residents, Resident 71 and Resident 1, to promote healing and prevent new pressure ulcers. Resident 71, who had non-Alzheimer's dementia, diabetes, depression, and muscle weakness, was at risk for pressure ulcers. Despite the care plan's instructions to monitor and report skin breakdown, staff failed to document and notify the nurse about a new open area on Resident 71's coccyx. The area was observed without a dressing, and staff did not follow the facility's policy to report skin changes promptly. Resident 1, who had morbid obesity, back pain, severe nerve pain, and osteoporosis, was dependent on staff for personal hygiene and had recurring moisture-associated skin damage. The care plan required staff to keep the skin clean and dry and follow wound care recommendations. However, staff did not notify the provider or social services about Resident 1's refusal of compression wrap treatments, nor did they document discussions with the resident about the refusals. Additionally, there was a delay in applying the prescribed skin graft dressing due to unavailability, and staff failed to notify the physician about the missing dressing. The facility's failure to adhere to its pressure injury prevention and management policy resulted in inadequate monitoring, assessment, and reporting of skin conditions for both residents. This lack of timely intervention and communication with healthcare providers placed the residents at risk for deterioration in their skin conditions, as evidenced by the observations and interviews conducted during the survey.
Improper Chemical Storage Poses Risk to Residents
Penalty
Summary
The facility failed to ensure a safe environment free from accident hazards by not properly storing chemicals, which placed residents at risk of exposure to unsafe substances. Observations revealed that on the second-floor central hall, a bottle of insect killer spray was found in an unsecured and unlocked drawer within a facility cabinet. Additionally, the housekeeping supply closet on the same floor did not have a lock, and contained bottles of enzymatic cleaner and spray polish and cleanser on a shelf. Furthermore, the utility room near the stairwell was found open, with several bottles of no rinse foam cleanser conditioning for hair and skin, which had a warning label for external use only. Interviews with staff members confirmed the improper storage of chemicals. Staff P, a Housekeeping Aid, acknowledged that chemicals should not be in the utility room or housekeeping closet and noted that some staff might have placed chemicals in the unlocked closet due to difficulty accessing other locked closets. Staff C, the Regional Administrator, reiterated that all chemicals should be locked up according to facility policy to prevent residents from ingesting them. The facility's failure to adhere to its policy on chemical storage was evident, as not all housekeeping closets were equipped with locks, compromising resident safety.
Inaccurate Narcotic Ledger Management
Penalty
Summary
The facility failed to ensure the accuracy of the East 2 Narcotic Ledger, which was one of the two narcotic ledgers reviewed for accuracy. During an observation and record review, discrepancies were found in the narcotic ledger, including missing tablets and pages that were crossed off without proper documentation. Specifically, page 83 showed a discrepancy of one missing tablet when transferred to page 101, and pages 96, 99, and 103 had crossed-off entries with no corresponding medication cards in the lock box. Additionally, pages 111 and 112 were missing, having been ripped out of the ledger. Staff I, an LPN, reported the missing narcotics and torn pages to Staff F, the Resident Care Manager, and Staff B, the Director of Nursing, after first noticing the discrepancies during a count with the night nurse. Staff B acknowledged being informed of the issue and instructed Staff F and Staff H, both Registered Nurse Managers, to make notations on the incorrect pages. However, Staff B did not verify if these corrections were made. A pharmacy narcotic audit was ordered and completed, but no further discrepancies were reported by the pharmacist at that time.
Expired Medications and Unclean Storage in Facility
Penalty
Summary
The facility failed to ensure that expired medications were removed in a timely manner from two medication carts and one medication storage room. During observations and interviews, it was found that the West 1 and East 2 medication carts contained expired medications, including a bottle of laboratory testing solution, laxatives, and pain medication with an illegible expiration date. Additionally, the East 2 medication cart had expired medication cards with remaining tablets and loose pills in the drawers. Staff members acknowledged that they were expected to clean the carts and remove expired medications before handing them off to the next shift, but this was not done. In the East 2 medication storage room, numerous expired intravenous (IV) supplies, including IV start kits, IV sets, IV lock caps, IV flushes, and syringes, were found. Staff members admitted that they were responsible for keeping the storage room free of expired medications and supplies, but these items were not disposed of by their expiration dates. The Director of Nursing confirmed the expectation for nursing staff to dispose of expired medications and maintain cleanliness in medication carts and storage rooms.
Failure to Provide Prompt Dental Services
Penalty
Summary
The facility failed to ensure prompt dental services for Resident 39, who was dependent on staff for oral care and had no teeth or dentures available. Despite the resident's ability to communicate and understand others, and the resident representative's repeated requests for a dental exam to be fitted for dentures, the facility did not schedule the necessary dental appointment. The resident had been waiting for months without being offered an exam since their admission to the facility. The social services department was responsible for scheduling the dental exam, but the previous social worker, who had communicated with the resident's representative, left the facility without documenting the requests or adding the resident to the dentist list. The Social Service Director acknowledged the oversight and mentioned that the facility had canceled dental visits due to an infectious outbreak, and the dentist had also canceled due to illness. However, there was no documentation of the communication with the resident's representative, and the resident was never placed on the list to be seen by the dentist.
Failure to Protect Resident Privacy and Confidentiality
Penalty
Summary
The facility failed to maintain the confidentiality of Protected Health Information (PHI) for four residents, leading to a violation of their right to privacy. For Resident 340, an electronic wall device displayed their full name and care information in a hallway, unattended, allowing a visitor to view the PHI. Staff Q admitted to leaving the device open due to being in a rush. Similarly, Staff S left a medication cart with a computer open to Resident 80's medical records, and Staff I did the same with Resident 10's records. Both staff members acknowledged the importance of keeping resident information confidential and admitted to not securing the computers. For Resident 39, a representative showed text message communications with a facility social worker, which were not documented in the resident's records. The social worker involved had left the facility and cleared their data before leaving, resulting in a lack of documentation. Staff E, the Social Service Director, confirmed the absence of documentation, and Staff B, the Director of Nursing, emphasized the expectation for staff to maintain confidentiality and ensure accurate documentation of resident records.
Infection Control Deficiencies in LTC Facility
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by multiple deficiencies observed during the survey. Resident 18, who returned from the hospital with an indwelling catheter, was not placed on Enhanced Barrier Precautions (EBP) as required by the physician's order. The absence of isolation signage and the lack of implementation of EBP for Resident 18 were confirmed by the Infection Control Preventionist, Staff D, who acknowledged the oversight. In the shower room on the West-1 unit, the facility failed to maintain cleanliness, as evidenced by the presence of debris and dried hair on the shower drain cover. The cleaning log indicated that the last cleaning was documented several months prior, and observations showed that the drain remained uncleaned even after resident use. Staff J, a Registered Nurse Manager, admitted the need for staff training and a cleaning schedule to address the buildup of debris. The facility also failed to adhere to proper hand hygiene and transmission-based precautions. Staff J was observed performing wound care for Resident 80 without changing gloves or performing hand hygiene, leading to potential cross-contamination. Additionally, a provider entered Resident 339's room without the required personal protective equipment (PPE) despite the presence of a contact precautions sign. The provider continued to visit other residents' rooms without donning PPE, contrary to the facility's infection control policies. Furthermore, the ice machine was found to be inadequately cleaned, with visible debris and slime, indicating a lapse in regular maintenance and cleaning protocols.
Ineffective Pest Control Program in Facility
Penalty
Summary
The facility failed to maintain an effective pest control program, resulting in the presence of insects in resident rooms and common areas. Resident 49 reported bugs in their room, which disturbed their sleep, and despite multiple reports to staff, no resolution was communicated. Staff N, the Regional Plant Operation Manager, acknowledged the issue, noting that the monthly pest control services were ineffective, possibly due to open windows with missing screens. This situation was observed in multiple areas, including the West Central Hallway Sink, where ants were previously present, and fruit flies were noted in the Second Floor Hallway, Resident 43's room, Resident 22's room, and the West Central Office. In the kitchen and dining room, fruit flies were observed in the dry food storage area, with a trap and a bowl containing fruit flies. Flies were also seen in the dining room and above food in the tray line assembly area during food service. Staff K, the Dietary Manager, confirmed that fruit flies had been a persistent problem, and assistance from pest control was being sought. These observations indicate a failure to provide a safe, clean, comfortable, and homelike environment for residents, as required by the facility's pest control policy.
Incomplete PBJ Staffing Data Submission
Penalty
Summary
The facility failed to submit complete and accurate direct care staffing information to the Centers for Medicare and Medicaid Services (CMS) for the first quarter of 2024, as required by the Payroll Based Journal (PBJ) guidelines. The PBJ system mandates that long-term care facilities electronically submit staffing data, including hours worked by all employees and contract workers, in a uniform format. The facility's submission was found to be incomplete, with missing Total Employee Link Records, which are essential for accurate reporting of staffing levels. Interviews with facility staff revealed a lack of oversight and potential technical issues as contributing factors to the incomplete submission. The Director of Nursing acknowledged responsibility for ensuring daily staffing levels but indicated that PBJ data submission was managed at the corporate level. The Regional Operations Manager speculated that a technical issue with payroll might have caused the incomplete data submission, and both the CEO and Administrator recognized the need for more oversight to ensure compliance with the PBJ guidelines.
Failure to Assess and Document Skin Conditions
Penalty
Summary
The facility failed to assess and document wound characteristics, monitor, and implement interventions to mitigate worsening of non-pressure skin issues for four residents. Resident 1 was admitted to the facility and was dependent on staff for toileting hygiene, bathing, and bed mobility. Despite being at risk for skin impairments, no new skin issues were documented in the weekly skin checks. However, a new open area was identified by nursing assistants, but no documented assessment by a licensed nurse was found. Upon discharge, the receiving facility identified multiple open areas and extensive moisture-associated skin damage (MASD) that were not documented by the facility staff prior to discharge. Resident 2 was also dependent on staff for toileting hygiene and bed mobility and had ongoing MASD. Despite this, the facility's documentation did not reflect consistent monitoring or assessment of the skin condition. Nursing assistants documented red and open areas on multiple occasions, but these were not followed up with proper assessments or notifications to the medical doctor. The resident's condition worsened without appropriate documentation or intervention. Resident 3 had an open area on the right great toe that was noted to have become infected but was not consistently monitored or documented. Additionally, the resident had crusted and peeling skin on the face and scalp, which was not reported to the nurse or documented in the medical record. Resident 4 had a rash under the left breast that spread to the underarm, but the facility failed to document the spread or notify the medical doctor. The facility acknowledged concerns regarding skin care and was in the process of implementing changes, but these deficiencies highlight significant lapses in the assessment, documentation, and monitoring of skin conditions for multiple residents.
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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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