Vancouver Specialty And Rehab Care
Inspection history, citations, penalties and survey trends for this long-term care facility in Vancouver, Washington.
- Location
- 1015 North Garrison Road, Vancouver, Washington 98664
- CMS Provider Number
- 505269
- Inspections on file
- 38
- Latest survey
- February 24, 2026
- Citations (last 12 mo.)
- 29
Citation history
Health deficiencies cited at Vancouver Specialty And Rehab Care during CMS and state inspections, most recent first.
A resident with dementia sustained a new skin injury that was assessed and treated by staff, but there was no documentation that the resident's POA or physician were notified as required. Staff interviews confirmed the lack of notification documentation.
A resident dependent on staff for ADLs, including bathing, did not receive the scheduled number of baths or showers due to staffing shortages and missed assignments. Facility records and staff interviews confirmed that bathing was frequently delayed or missed, with responsibilities often passed between shifts and exacerbated by insufficient staffing.
The facility failed to implement bowel management protocols for three residents, resulting in prolonged constipation and discomfort. Despite the facility's policy requiring specific interventions and documentation, staff interviews revealed a lack of adherence, with no consistent initiation of the bowel protocol or documentation of interventions. This led to significant delays between bowel movements for the residents, impacting their well-being.
The facility failed to provide at least eight hours of RN coverage and supervision for three out of thirty days reviewed. Interviews and record reviews showed that the facility's daily nurse staff postings and the Staffing Coordinator's schedule did not reflect 24 hours of RN coverage on all reviewed days. The Administrator confirmed the lack of a waiver for RN coverage and mentioned recruitment efforts and incentives for staff retention.
The facility did not have procedures to assist a resident with completing advance directives (AD) or maintaining Power of Attorney documentation. A resident, moderately cognitively impaired, lacked an AD or documentation of AD review since March 2024. Despite having a POLST, there was no AD, Power of Attorney, or guardian documented. Staff indicated ADs were reviewed quarterly, but this was not done for the resident. The Administrator confirmed ADs should be reviewed upon admission and quarterly.
A facility failed to accurately complete the PASARR for a resident with anxiety and depression, as required by policy. The resident was admitted without a Level II evaluation, and the PASARR was not reviewed for accuracy until days later, despite the resident showing signs of distress and fear. This oversight risked unmet mental health needs.
The facility did not complete a performance evaluation for a nursing assistant hired in 2021, as required by policy. This oversight was identified through interviews and record reviews, revealing a lack of adherence to the facility's policy of conducting annual evaluations or additional training when needed. This failure posed a risk to residents by potentially exposing them to unskilled care.
The facility failed to monitor two residents on psychotropic medications for target behaviors and interventions. One resident, who was alert and oriented, had no behavior monitoring for depression symptoms in their EHR. Another resident was started on Trazadone for insomnia, but there was no monitoring for its psychotropic use. This lack of monitoring placed residents at risk for decreased mental health well-being.
A facility failed to obtain informed consent for a resident before administering Trazadone, a psychotropic medication. The resident, who was alert and oriented, was started on Trazadone for depression without documented consent. Staff interviews indicated that obtaining consent is usually the responsibility of Resident Care Managers or nurse managers, but no consent was found in the resident's records.
A facility failed to conduct quarterly care conferences for a resident, who was moderately cognitively impaired, resulting in an eight-month gap between meetings. This oversight was confirmed by staff, who acknowledged that care conferences should occur quarterly, potentially impacting the resident's involvement in their care decisions.
A facility failed to ensure a safe discharge for a resident with diabetes and moderate cognitive impairment. The discharge care conference did not address diabetic monitoring, and there was no documentation that the resident received a glucometer or training on its use. Staff acknowledged the oversight but could not provide evidence of proper discharge preparation.
The facility failed to initiate bowel interventions for a moderately cognitively impaired resident who had not had a bowel movement for over six days. The MAR did not show any interventions from 02/21/2024 until 5:52 PM on 02/27/2024, despite the bowel protocol requiring initiation after 72 hours.
The facility failed to conduct neurological checks for two residents who experienced unwitnessed falls. Both residents were moderately cognitively impaired, and staff confirmed that neurological checks should have been performed but were not documented. This lack of comprehensive investigation placed residents at risk.
Failure to Notify Representative and Physician of Change in Condition
Penalty
Summary
The facility failed to ensure timely notification of a resident's representative and physician following a significant change in the resident's condition. Specifically, a resident with dementia, who had a Power of Attorney (POA) responsible for health care decisions, sustained a new skin injury that was assessed and treated by staff. However, there was no documentation verifying that the resident's representative or physician were notified of the injury as required. Staff interviews confirmed that the required notifications were not documented.
Failure to Provide Scheduled Bathing Assistance Due to Staffing Shortages
Penalty
Summary
The facility failed to provide scheduled bathing assistance to a resident who was dependent on staff for activities of daily living (ADLs), specifically bathing. The resident, who had diagnoses including cerebral infarction, hemiplegia, and hemiparesis, required substantial or maximal assistance with bathing according to the Minimum Data Set and care plan, which specified bathing or showering twice per week and as necessary. However, facility records showed that the resident received only four out of eight scheduled baths or showers over a one-month period. Interviews with the resident and multiple nursing assistants revealed that staff were frequently unable to complete all assigned showers during their shifts, often passing the responsibility to the next shift. Staff cited staffing shortages, particularly on weekends, as a reason for missed showers. The Director of Nursing confirmed that the facility had experienced staffing difficulties during the relevant period due to nursing assistants quitting or not showing up for shifts.
Failure to Implement Bowel Management Protocol
Penalty
Summary
The facility failed to consistently assess and implement interventions for bowel management for three residents, leading to prolonged periods without bowel movements and associated discomfort. Resident 76 experienced no documented bowel movements for seven days, despite reporting constipation and poor appetite to the staff. Similarly, Resident 332 had no documented bowel movements for 12 shifts, with no initiation of the bowel protocol, resulting in poor eating due to constipation. Resident 72 also faced significant delays between bowel movements, with no initiation of the bowel protocol for over 105 hours, 77 hours, and 86 hours during different periods. Despite being given Senna on multiple occasions, there was no progression to the next steps of the bowel protocol. Staff interviews revealed a lack of adherence to the facility's bowel management policy, which required specific actions and documentation when residents did not have bowel movements. Staff D, a Licensed Practical Nurse, and Staff E, the Assistant Director of Nursing Services, acknowledged the failure to follow the protocol and document interventions. The Director of Nursing Services, Staff B, confirmed the expectation for the bowel program to be initiated and documented, with medical director notification if no bowel movements occurred. However, the facility was unable to provide documentation showing that the bowel protocol was consistently initiated and followed for the affected residents.
Deficiency in RN Coverage and Supervision
Penalty
Summary
The facility failed to provide at least eight hours of Registered Nurse (RN) coverage and supervision for three out of thirty days reviewed. This deficiency was identified through interviews and record reviews, which revealed that the facility's daily nurse staff postings and the Staffing Coordinator's working schedule did not show 24 hours of RN coverage on all reviewed days. The Administrator, Staff A, confirmed that the facility did not have a waiver for RN coverage and mentioned efforts to recruit RNs and offer bonuses and incentives for staff retention.
Failure to Assist with Advance Directives
Penalty
Summary
The facility failed to have procedures in place to assist with completing advance directives (AD) and obtaining and maintaining Power of Attorney documentation for one of the twelve sampled residents reviewed for ADs. Resident 13, who was moderately cognitively impaired, was admitted to the facility and did not have an AD or documentation that ADs were reviewed since March 2024. Although the resident had a POLST, there was no AD, Power of Attorney, or guardian documented. Staff I, from Social Services, stated that ADs were reviewed quarterly during care conferences, and if a resident did not have an AD, they would assist in completing one. However, this was not done for Resident 13. The Administrator confirmed that ADs should be reviewed upon admission and quarterly if not already in place.
Failure to Ensure Accurate PASARR for Resident with Mental Health Needs
Penalty
Summary
The facility failed to ensure the Preadmission Screening and Resident Review (PASARR) was completed accurately for a resident with a history of anxiety and depression. The resident was admitted with diagnoses including anxiety and depression, and the initial Level I PASARR screening conducted by the discharging hospital indicated that a Level II evaluation was not required. However, the facility did not review the PASARR for accuracy upon admission, as per their policy, which mandates coordination with the PASARR program to ensure appropriate care for individuals with mental disorders or intellectual disabilities. The deficiency was identified when the resident exhibited signs of distress, including tearfulness and anxiety, and expressed fear of retaliation by staff after an incident involving a bag of knives. The Social Services Director acknowledged that the PASARR was not reviewed for accuracy until several days after admission, and the facility administrator could not provide documentation to support that the PASARR Level I had been reviewed for accuracy at the time of admission. This oversight placed the resident at risk for unmet mental health needs and a diminished quality of life.
Failure to Conduct Annual Performance Evaluation for Nursing Assistant
Penalty
Summary
The facility failed to complete performance evaluation reviews for a nursing assistant, identified as Staff J, who was hired on May 11, 2021. Staff J's personnel records lacked a performance evaluation for the previous year. This deficiency was identified through interviews and record reviews, indicating that the facility did not adhere to its policy of conducting annual performance evaluations or additional training when necessary. This oversight placed residents at risk of receiving care from unskilled staff, potentially affecting their quality of life.
Failure to Monitor Psychotropic Medication Use
Penalty
Summary
The facility failed to monitor residents on psychotropic medications for target behaviors and interventions, which led to a deficiency in the care of two residents. Resident 36, who was admitted to the facility, was noted to be alert and oriented with no symptoms of depression according to the Quarterly Minimum Data Set (MDS) assessment. However, a review of Resident 36's Electronic Health Records (EHR) revealed a lack of behavior monitoring for symptoms and/or signs of depression. Staff D, a Licensed Practical Nurse, indicated that behaviors should be recorded each shift, and new behaviors should be documented and monitored. Despite this, Staff E, the Assistant Director of Nursing Services, was unable to locate records of target behaviors and interventions for Resident 36 in the electronic Medication Administration Record (EMAR). Similarly, Resident 332, who was also alert and oriented with no signs of depression according to the 5-day MDS assessment, was started on Trazadone for depression. The EHR for Resident 332 did not show any monitoring of target behaviors or interventions related to the use of the psychotropic medication. Staff D and Staff E both acknowledged that Resident 332 was on Trazadone for insomnia, yet the January 2025 Medication Administration Record showed no monitoring for the psychotropic use of Trazadone. This lack of monitoring placed the residents at risk for decreased mental health well-being and a decreased quality of life.
Failure to Obtain Informed Consent for Psychotropic Medication
Penalty
Summary
The facility failed to ensure that Resident 332 was informed about the risks and benefits of psychotropic medication and did not obtain informed consent prior to administering Trazadone. Resident 332, who was alert and oriented with no signs of depression, was admitted to the facility and started on Trazadone for depression shortly after admission. However, the electronic health record did not contain documentation of informed consent for the medication. Interviews with staff revealed that obtaining informed consent for psychotropic medications is typically the responsibility of Resident Care Managers or nurse managers, but in this case, no consent was documented for Resident 332's Trazadone prescription.
Failure to Conduct Quarterly Care Conferences
Penalty
Summary
The facility failed to ensure that residents and/or their representatives were offered the opportunity to participate in care conferences, as evidenced by the case of Resident 13. Resident 13, who was moderately cognitively impaired, was admitted to the facility and had a care conference documented on 04/16/2024. However, the next care conference was not conducted until 12/04/2024, which is almost eight months later, instead of the required quarterly schedule. Staff I from Social Services confirmed the dates of the care conferences, and Staff A, the Administrator, acknowledged that care conferences should be completed quarterly. This lapse in scheduling care conferences placed residents at risk of not being involved in decisions about their long-term care needs and a diminished quality of life.
Failure to Ensure Safe Discharge for Diabetic Resident
Penalty
Summary
The facility failed to ensure a safe and orderly discharge for Resident 186, who was admitted with a diagnosis of diabetes and had moderate cognitive impairment. During a discharge care conference, it was noted that Resident 186 would be discharging home with their spouse, who was also a resident at the facility. However, the documentation from this meeting did not include any discussion of diabetic monitoring or management, which is crucial for the resident's health given their condition. Upon review, it was found that there was no documentation to confirm that Resident 186 received a glucometer or training on its use prior to discharge. Staff I, the Social Services Director, and Staff E, the Assistant Director of Nursing Services, both acknowledged that the resident should have been provided with a glucometer and trained on its use, but neither could provide documentation to support that this occurred. Staff B, the Director of Nursing Services, also expected that such training would have been documented in the electronic health record, but was unable to find any evidence of it.
Failure to Initiate Bowel Interventions
Penalty
Summary
The facility failed to initiate bowel interventions for a resident who was moderately cognitively impaired and had not had a bowel movement for over six days. The resident was admitted to the facility and had a documented bowel movement on 02/21/2024. However, the next documented bowel movement was not until 02/28/2024, indicating a gap of over six days. The February 2024 Medication Administration Record (MAR) did not show any interventions from 02/21/2024 until 5:52 PM on 02/27/2024. According to the Director of Quality Assurance and Registered Nurse, the bowel protocol should have been initiated if a resident did not have a bowel movement after 72 hours, which should have been started on 02/25/2024.
Failure to Conduct Neurological Checks for Unwitnessed Falls
Penalty
Summary
The facility failed to ensure falls were comprehensively investigated, including obtaining neurological checks for two residents who experienced unwitnessed falls. Resident 53, who was moderately cognitively impaired, had multiple unwitnessed falls documented on various dates, but there was no documentation of neurological checks being completed for these incidents. Staff members, including a CNA, LPN, and the Risk Management Nurse, confirmed that neurological checks should be performed for unwitnessed falls, but these were not documented in the resident's fall investigations. The Director of Quality Assurance also confirmed that neurological checks should have been completed for all unwitnessed falls. Similarly, Resident 56, also moderately cognitively impaired, had unwitnessed falls on two separate occasions, but the facility did not document the completion of neurological checks. The Resident Care Manager and the Director of Quality Assurance both acknowledged that the Neurological Assessment Flowsheet was not completed for these incidents. This lack of comprehensive investigation placed residents at risk of inadequate interventions and a diminished quality of life.
Latest citations in Washington
A resident with cerebral palsy and a court-appointed guardian experienced multiple episodes of nausea, vomiting, loose stools, abdominal discomfort, fatigue, and later refusal of meals and medications, leading to changes in the care plan including close monitoring, lab testing, and IV fluid administration. Despite a facility policy recognizing court-appointed guardians as resident representatives with decision-making authority, staff did not document any notification to the guardian during these changes in condition or treatment decisions. The guardian reported not being contacted when the resident stopped eating or developed stomach issues and felt the facility did not respect the guardianship, while the DON acknowledged there were multiple missed opportunities to notify the guardian of the resident’s change from baseline.
A resident with depression, anxiety, moderate cognitive impairment, and urinary incontinence, care-planned for q2h checks and assistance with toileting, was found by a visitor to be soaking wet, unusually agitated, and reporting they had been told to wait to be changed and referred to with a derogatory remark. The visitor filed a written grievance alleging abuse/neglect related to delayed incontinence care and removal of the resident’s tablet as a consequence. Although an incident report noted that the matter was reported to the state and that the resident was not soaking wet, a CNA who actually changed the resident later reported the resident’s brief, pants, wheelchair, and socks were soaked and that the resident was acting timid and repeatedly saying they had to sit for five minutes, but this CNA was never interviewed. The DON acknowledged not investigating the resident’s behavior or interviewing this CNA, and the grievance official acknowledged the facility did not fully investigate or communicate findings and resolution to the complainant, resulting in a failure to follow the facility’s grievance policy.
A resident with dementia, respiratory failure, and heart failure developed new shortness of breath with an O2 sat of 90%, and a physician ordered transfer to the ED for tx and eval. An RN completed an SBAR, notified the MD and family, and reported to the oncoming nurse that the resident needed ED transfer and that paramedics should be contacted, then left the facility. Instead of calling 911 for this emergent respiratory distress, staff arranged non-emergent transport through a contracted ambulance service, resulting in the resident remaining at the facility for several hours without pickup until the dispatcher later instructed staff to call 911. The DON stated that 911 is expected to be used for emergent conditions and the contracted service only for non-emergent transport.
A resident with anoxic brain injury, dysarthria, and documented lack of decisional capacity alleged physical abuse and expressed fear of their identified representative, yet social services only reported the allegation to the state and did not complete an incident report, revise the care plan, or implement protective interventions. The same representative continued to be treated as the resident’s decision-maker and visited frequently, with staff noting suspicious odors of foreign substances and concerns about possible illicit substance use. Psychiatry later documented concern that the representative was providing illicit substances, and the resident was subsequently hospitalized for altered mental status and overdose, after which the representative was banned. Key staff, including the DON, unit manager, and administrator/abuse coordinator, were unaware of the initial abuse allegation, and social services did not timely explore or clarify legal decision-making authority or alternative representation for the resident.
A resident with severe cognitive impairment, osteoarthritis, and spinal spondylosis, care planned for 2-person Hoyer transfers, was being moved by two CNAs using a mechanical lift when one corner loop of the sling became disengaged, causing the resident to fall about four feet, strike the floor and the lift, and sustain head abrasion, multiple rib fractures, and lumbar vertebral fractures. Facility policy required staff to verify secure sling attachment, examine hooks, clips, fasteners, and strap stability, and ensure the sling bar was sound before lifting, but during this transfer the sling loop detached despite staff believing it was properly fastened and hearing it click into place; post-incident assessment showed the loop had come loose, the sling appeared in good condition, and a CNA later reported thinking one of the round metal disks on the lift might have been slightly loose, while maintenance logs documented no prior concerns with the lifts or slings.
The facility failed to revise and individualize care plans to reflect current needs and preferences for multiple residents, including one cognitively intact resident with hemiplegia, hemiparesis, and mononeuropathy who had bilateral shoulder surgery and could not tolerate BP measurements on the upper arms but preferred forearm readings. Despite repeatedly informing staff, this preference was not documented in the care plan or Kardex, and direct care staff and the RN/UM were unaware of it. Another cognitively intact resident with hemiplegia, contractures, and weakness reported they were supposed to get out of bed for two hours daily, but some NACs did not know this, even though the MAR/TAR contained an order to document times up and back to bed. The surveyors concluded that care plans were not accurately revised for several residents, placing them at risk for unidentified and unmet care needs and diminished quality of life.
Surveyors found that two residents with hemiplegia, hemiparesis, weakness, and contractures did not receive restorative nursing services, including ROM exercises and splint/brace or orthotic assistance, after therapy discharge. Although PT and OT discharge summaries documented established restorative ROM and transfer programs, recommended PROM to affected extremities, and recommended splint/brace use and assistance with orthotic wear, these recommendations were not entered as restorative referrals in the EHR. As a result, the residents’ care plans and records showed no restorative programs, and both residents reported that therapy and restorative exercises had stopped, while the DON, rehab director, and MDS coordinator confirmed they were unaware of and had not implemented the recommended restorative services.
A resident with cancer, cognitive impairment, and declining strength experienced multiple unwitnessed falls, most occurring while attempting to toilet or move toward the bathroom, culminating in a fractured ankle requiring ED treatment. Although assessments identified fall and incontinence risks and the facility’s policy required individualized interventions, the comprehensive care plan lacked a toileting plan and did not include several interventions that were discussed in incident investigations, such as consistent wheelchair placement and frequent rounding for bathroom assistance. Staff reported relying on verbal reminders and education to use the call light, despite acknowledging the resident’s impulsivity and failure to call for help, and the resident’s bed remained furthest from the bathroom while repeated bathroom-related falls occurred without the trend being recognized or addressed in the care plan.
A resident with a history of acute urinary retention and acute kidney injury had a Foley catheter deemed permanent by the hospital, with instructions that it not be removed in the SNF. At a later urology visit, the catheter was removed, and the resident returned with no new orders documented. Facility staff did not document bladder assessments, post-void residuals, or urine output, and CNA documentation showed the resident did not void that evening. Over the next day, the resident had vomiting, poor intake, altered level of consciousness, tachycardia, hypotension, and no documented wet briefs. A bladder scan eventually showed more than 2000–2500 mL of retained urine, and a new catheter drained a large volume. The resident and a roommate reported moaning, crying out in pain, and repeatedly alerting staff that the resident was not urinating and that the catheter was not draining, while nurses documented catheter care when no catheter was in place and later had to flush and replace the catheter due to continued complaints.
Surveyors found that nurses and nurse aides did not consistently administer medications according to professional standards and facility policy. Multiple residents reported that agency nurses were slow with medications, did not fully follow instructions, and often gave routine meds late. Observations showed an LPN administering expired Humalog/Lispro insulin well past the scheduled time, an LPN giving several scheduled meds (including Tizanidine) late and all at once, and an RN attempting to give sliding-scale insulin nearly two hours late, which a resident refused after already eating. Another resident received Methocarbamol two hours late after questioning the RN, and a resident on scheduled Tramadol had doses given without timely documentation, with a discrepancy between the narcotic count and pills remaining. These events demonstrated failures in timely administration, use of non-expired medications, and immediate, accurate MAR and narcotic documentation.
Failure to Notify Court-Appointed Guardian of Resident’s Clinical Changes
Penalty
Summary
The deficiency involves the facility’s failure to notify a resident’s court-appointed guardian of significant clinical changes and care decisions, contrary to its own policy and state requirements. The facility’s policy on Resident Representatives, revised 02/2021, states that a resident representative includes a court-appointed guardian or conservator and that the facility treats the representative’s decisions as those of the resident to the extent delegated or required by the court. Resident 1, admitted with cerebral palsy, had a Superior Court guardianship letter dated 02/07/2025 indicating a guardian of person and conservator of the estate with full authority, identifying Collateral Contact 1 (CC1) as the guardian. Despite this, multiple clinical events and changes in condition were documented without any corresponding documentation that CC1 was notified. Progress notes and provider notes show that Resident 1 experienced an episode of nausea and vomiting, frequent loose stools, abdominal discomfort, bloating, worsening fatigue, generalized weakness, and later refusal of meals and medications over at least a 24-hour period, with observations that the resident appeared frailer, more fatigued, and had no energy or interest to talk. The provider developed care plans including close monitoring for deterioration, sending stool to the lab, and later initiating IV fluids for rehydration, with a plan to call family/POA for discussion. However, there was no documentation that the guardian was notified at any of these points, including when IV fluids were started. CC1 reported that they were not contacted when the resident stopped eating or developed stomach issues, and expressed that the facility did not respect their guardianship and that involvement in care planning took too long. The DON confirmed on record review that there were many opportunities to notify the guardian when the resident’s condition changed from baseline and that there was no evidence staff did so.
Failure to Thoroughly Investigate and Resolve Resident Grievance Regarding Incontinence Care and Staff Conduct
Penalty
Summary
The deficiency involves the facility’s failure to thoroughly investigate and resolve a grievance alleging neglect and disrespect toward a resident, as required by its grievance policy. The resident had depression, anxiety, moderate cognitive impairment, occasional urinary incontinence, and required moderate assistance with toileting, with a care plan directing staff to check the resident every two hours, ask about toileting needs, and ensure they were clean and dry. A collateral contact reported arriving to visit the resident and finding them soaking wet and agitated, with behavior that was not typical for the resident. The collateral contact documented in a written grievance that the resident’s tablet was off, the resident appeared upset, and the resident reported being told they had to wait five minutes to be changed and that staff would change their “nasty *ss” in five minutes, leading the collateral contact to believe the resident had been given a consequence of no tablet and sitting in wet clothes, which they characterized as abuse/neglect and requested immediate removal of the responsible staff and a report filed. The facility documented receipt of the grievance and created an incident report indicating the matter was reported to the state agency, and that the unit manager interviewed the collateral contact and the resident, with the resident described as confused and denying being soaking wet. The incident report stated that a different nursing assistant was assigned to assist with the brief change and that the unit manager believed the resident was not soaking wet, and that the resident and collateral contact were satisfied when they left the room. However, a CNA who actually changed the resident reported that the resident’s brief was soaked through their pants onto the wheelchair and their socks were soaked, and that the resident was timid, repeatedly saying they had to sit for five minutes, and not acting like themselves; this CNA stated they were never interviewed or asked about the grievance or the resident’s condition. The DON acknowledged not interviewing this CNA or investigating the resident’s behavior and why they were upset, and the unit manager did not recall whether the collateral contact was present during follow-up and did not believe they followed up with the collateral contact regarding the grievance. The administrator, identified as the Grievance Official, stated the facility should have thoroughly investigated the grievance and discussed findings and resolution with the collateral contact, indicating the grievance process was not fully carried out in accordance with policy and WAC 388-97-0460.
Failure to Obtain Timely Emergency Transport for Resident in Respiratory Distress
Penalty
Summary
The deficiency involves the facility’s failure to obtain timely emergency medical services for a resident experiencing new-onset respiratory distress. The resident had dementia, respiratory failure, and heart failure, with severe cognitive impairment and a need for substantial assistance with activities of daily living. On the day the resident was sent to the hospital, a collateral contact observed the resident having difficulty breathing, appearing unable to get enough air, and looking as if they were sleeping or unconscious, and reported this to staff with a request to contact the doctor. An SBAR Communication Form documented that the resident was experiencing shortness of breath that had not occurred before, with an oxygen saturation of 90%. The physician was notified and ordered the resident sent to the emergency department for treatment and evaluation, and the collateral contact was notified shortly thereafter. Progress notes later documented that, despite the order for emergency department transfer, the resident was still awaiting pickup by Olympic transportation several hours later, with no estimated time of arrival. At approximately 3:30 AM, the dispatcher informed the facility that they could not provide transportation and instructed that 911 be called; only then was 911 contacted and the resident transported to the hospital via ambulance for respiratory distress. The RN caring for the resident stated they completed the SBAR, notified the physician and family, and at the end of their shift reported to the oncoming nurse that the resident needed to be sent to the emergency department for respiratory distress and that paramedics should be contacted, then left assuming 911 would be called. The DON stated that staff are expected to contact 911 for emergent conditions such as shortness of breath or respiratory distress, and that Olympic Ambulance is used only for non-emergent transport.
Failure to Provide Social Service Advocacy After Abuse Allegation and Questionable Representative
Penalty
Summary
The deficiency involves the facility’s failure to provide appropriate medically-related social services and advocacy for a resident following an allegation of abuse and concerns about the resident’s representative. The resident had an anoxic brain injury, dysarthria, moderate cognitive impairment, and was dependent on staff for activities of daily living. A hospital palliative care note documented that the resident lacked decisional capacity, had no DPOA, that the legal next of kin (CC4) did not want to be part of care decisions, and that care decisions were being deferred to another contact (CC5). CC5 accompanied the resident on admission, signed admission forms, and was listed as the primary contact in the medical record profile. On a date in February, during communication therapy, the resident reported that CC5 had done something to them, pounded their hands on their chest, recalled being hit in the back of the head by an unknown person, and stated they were sometimes afraid of CC5. A social services staff member reported this allegation to the state agency but did not complete a facility incident report, did not initiate care plan changes or interventions, and took no further action. CC5 continued to be treated as the resident’s representative, and progress notes documented CC5 at the bedside on multiple dates, including an entry noting the room smelled like foreign substances and that CC5 was seen waking the resident and then asking the nurse to administer pain medications. A psychiatry note later documented concern that CC5 was providing the resident with illicit substances and stated it would be prudent for the resident to identify a POA. Subsequently, the resident was found unresponsive, transported to the hospital, and later readmitted after altered mental status and overdose, with a provider note stating that CC5 posed a significant danger to the resident and was banned from visiting. After readmission, staff attempted to contact CC4 for consent to treat but initially reached someone who stated they were not CC4. The social service director acknowledged that, beyond reporting the initial allegation, no additional interventions were implemented, that CC5 continued to be used as the resident’s representative after the allegation, and that they had not explored legal authority for decision making following the abuse allegation or concerns about substances. The social service assistant reported they did not speak with the resident about the hospital stay or CC5 and did not complete an incident report or care plan changes after the allegation. The unit manager and DON were unaware of the initial abuse allegation, and the administrator, who served as abuse coordinator, also stated they were unaware of the allegation and that an investigation should have been initiated and a representative for the resident investigated at a minimum.
Injury from Mechanical Lift Sling Detachment During Transfer
Penalty
Summary
The facility failed to ensure a safe mechanical lift transfer when a resident was being moved with a Hoyer lift and sling, resulting in a fall and injury. Facility policy for using a mechanical lifting machine required staff to securely attach sling straps to the sling bar according to manufacturer’s instructions, double-check the security of the sling attachment before lifting, examine all hooks, clips, or fasteners, check strap stability, and ensure the sling bar was securely attached and sound. Despite these requirements, during a transfer for dinner, two CNAs placed the sling under the resident, attached the loops at each corner of the sling to the lift, and raised the resident off the bed into the space between the bed and wheelchair when the bottom left corner of the sling became disengaged from the lift. The resident involved had multiple diagnoses including osteoarthritis, cervical and thoracic spondylosis, and Alzheimer’s disease, with the Minimum Data Set documenting severely impaired cognitive skills for daily decision-making. The resident’s care plan required the assistance of two staff during Hoyer lift transfers. During the transfer, the resident fell approximately four feet, landing on her buttocks, bouncing, and then falling backward and striking her head on the leg of the Hoyer lift. Hospital records documented that the resident sustained an abrasion to the back of the head, fractures of the 6th, 7th, 8th, and 10th ribs, and fractures of the 1st and 2nd lumbar vertebra. Staff interviews and observations showed that staff believed the sling loops had been securely fastened and reported hearing the loops click into place before lifting. One CNA stated that they had barely lifted the resident off the bed when the bottom left loop became disconnected and the resident fell. Another CNA reported being shocked and unable to figure out what had happened. A nurse who assessed the resident and then examined the equipment after the fall noted that one of the loops of the sling had become disengaged but stated the sling appeared to be in good condition. During a later demonstration, a CNA indicated she thought one of the round metal disks on the lift might have been a little loose. Maintenance logs for Hoyer slings and lifts for the preceding months documented no concerns with the slings or lifts, and the DON acknowledged expecting a citation due to the resident’s injury from the fall.
Failure to Revise Care Plans to Reflect Resident Needs and Preferences
Penalty
Summary
The deficiency involves the facility’s failure to revise and individualize comprehensive care plans to reflect residents’ current needs and preferences, as required by its own care planning policy. For one resident with hemiplegia, hemiparesis following cerebrovascular disease, and mononeuropathy of the upper limb, the admission MDS showed intact cognition and upper extremity impairment. This resident reported having bilateral shoulder surgery and an inability to tolerate blood pressure measurements on the upper arms due to pain, and stated a preference for BP measurements on the forearms. The resident reported having informed multiple nursing staff of this preference, but staff continued to place the cuff on the upper arms. Review of the resident’s care plan and Kardex showed no interventions or instructions regarding forearm BP cuff placement. A NAC confirmed they were unaware of the preference until the resident told them directly and that this instruction was not documented in the Kardex. The RN/Unit Manager, who stated they were responsible for revising and reviewing care plans when there were changes, also confirmed they were not aware of the resident’s preference and that it should have been updated in the care plan. Another resident, readmitted with hemiplegia and hemiparesis following a nontraumatic subarachnoid hemorrhage, contracture of the left hand, and weakness, was cognitively intact and required maximum assistance for bed mobility per a quarterly MDS. This resident stated they were supposed to get out of bed for two hours every day, but some NACs were not aware of this care requirement. Review of the resident’s March 2026 MAR/TAR showed an order to document the time the resident got up and the time they returned to bed daily. The report states that, overall, the facility failed to revise care plans accurately to reflect residents’ needs for three of four residents reviewed for care plan revision, placing them at risk for unidentified and unmet care needs and a diminished quality of life.
Failure to Implement Restorative Nursing and Splint/Brace Programs After Therapy Discharge
Penalty
Summary
The deficiency involves the facility’s failure to provide restorative nursing services, including range of motion (ROM) exercises and splint/brace assistance, to maintain or prevent decline in mobility and contractures for two residents with significant motor impairments. The facility’s undated Restorative Nursing Services policy stated that residents would receive restorative care as needed to achieve and maintain optimal functioning and that residents may initiate a restorative program upon discharge from rehabilitative care. Despite this, surveyors found that residents with documented hemiplegia, hemiparesis, weakness, and contractures were not placed on restorative programs and had no restorative interventions documented in their electronic health records (EHRs). Resident 1 was admitted with hemiplegia and hemiparesis following cerebrovascular disease, a left lower leg fracture, and weakness, and the admission MDS showed intact cognition, moderate assistance needs for bed mobility and transfers, and one-sided upper and lower extremity impairment. During observation, the resident was seen lying in bed with a bent inward left forearm and hand and reported no longer receiving therapy or nursing-assisted exercises. The care plan initiated in January showed no restorative services, and the care plan history and EHR contained no restorative nursing interventions. However, the PT discharge summary from February documented that restorative ROM and transfer programs had been established and trained, including PROM to the left upper and lower extremities and stand-by assist with transfers, and the OT discharge summary recommended a splint/brace to prevent contracture. The OT stated that the splint/brace was not tried due to lack of time before insurance was discontinued, and both the Director of Rehab and the MDS coordinator confirmed there was no restorative referral in the EHR and they were unaware of the recommendations. Resident 2 was readmitted with hemiplegia and hemiparesis following a nontraumatic subarachnoid hemorrhage, a left-hand contracture, and weakness, and the quarterly MDS showed intact cognition, maximum assistance needs for bed mobility, total assistance for transfers, bilateral upper and lower extremity impairment, and no therapy or restorative programs. The resident reported that therapy had been discontinued months earlier and that no restorative staff were assisting with exercises. The care plan and EHR showed no restorative services. OT evaluation documented left upper extremity ROM impairment, a left-hand contracture, and prior use of a left orthotic to manage flexion tone, and the OT discharge summary recommended restorative care and assistance with donning/doffing the orthotic. The PT discharge summary recommended restorative programs if Medicaid Part B services did not continue. The Director of Rehab confirmed therapy was discontinued and that restorative nursing programs were recommended, but both the Director of Rehab and the MDS coordinator stated there were no restorative referrals in the EHR after readmission, and the MDS coordinator confirmed the resident had no restorative programs since readmission.
Failure to Implement Effective Fall and Toileting Interventions for High-Risk Resident
Penalty
Summary
The deficiency involves the facility’s failure to provide adequate supervision, identify fall trends, and implement progressive, resident-centered interventions for a resident with multiple falls and declining strength. The facility’s own Falls and Fall Risk Management policy required staff to identify interventions related to residents’ specific risks and causes to prevent falls and minimize complications. The resident’s Care Area Assessment identified cancer-related risks for pain, falls, and ADL decline, and stated that falls and urinary incontinence would be addressed in the care plan with an objective of improvement and risk minimization. However, the comprehensive care plan did not include a urinary or ADL care plan and contained no toileting plan, despite the resident’s identified risks and prior fall history. Over a series of falls, the resident repeatedly fell while attempting to toilet or move toward the bathroom, yet the facility did not recognize or address this pattern in its investigations or care planning. The resident had multiple unwitnessed falls: next to the bed while getting up to use the restroom, in the bathroom while standing to use the toilet, and near or in the bathroom on several occasions. Incident investigations and post-fall assessments documented environmental factors such as clutter, items on the floor, water on the floor, and issues with footwear, as well as the resident’s increasing weakness, impulsivity, poor safety awareness, and poor insight into limitations. Interventions documented in investigations and risk reviews included encouraging use of the front-wheeled walker, keeping the wheelchair and walker accessible, ensuring proper footwear and non-skid socks, and providing resident education on safe transfers, ambulation, and assistive device use. However, several of these planned interventions, including placement of the wheelchair and frequent rounding/toileting assistance, were not added to or reflected in the care plan as stated. Staff interviews further showed that the resident frequently fell while trying to go to the bathroom and that staff relied on verbal education and reminders to use the call light, even though the resident often did not use it. Staff acknowledged the resident’s impulsivity and tendency to get up independently despite instructions, and one staff member stated that nursing assistants were verbally instructed to offer bathroom assistance, but this intervention was not documented in the care plan. The resident’s bed remained the one furthest from the bathroom throughout the stay, and none of the facility’s investigations identified the trend of bathroom-related falls or addressed toileting options in the care plan. Ultimately, the resident sustained a left ankle fracture after another bathroom-related fall, requiring transfer to the emergency department for evaluation and treatment, and later records documented additional fractures and a decline in condition. The surveyors concluded that the facility’s failures placed residents at risk of repeated falls and injuries.
Failure to Monitor Urinary Retention After Foley Removal Leading to Prolonged Pain
Penalty
Summary
The deficiency involves the facility’s failure to adequately assess and monitor a resident for complications associated with an indwelling urinary catheter and urinary retention, particularly after catheter removal. The resident had a history of acute kidney injury due to urinary retention, which improved after Foley catheter placement in the hospital. Hospital discharge documentation indicated the catheter was placed for acute urinary retention, was deemed permanent, and included instructions that, given the resident’s significant retention and acute renal failure, staff at the skilled nursing facility should not attempt Foley removal. The facility’s catheter care plan directed staff to empty the catheter as needed and record output in milliliters, but review of the last 30 days of documentation showed continence was not rated due to the indwelling catheter and there was no documented urinary output in milliliters on the treatment administration records. The resident had a scheduled urology appointment at which the urinary catheter was discontinued. Upon return from this appointment, nursing documentation initially indicated no new orders, and an alert note later stated the catheter was discontinued and staff were monitoring for retention or pain. However, there was no documented bladder assessment or urinary output following catheter removal. Nursing assistant documentation showed that the resident did not void on the evening shift that same day. Despite the catheter having been removed, the treatment administration record showed staff continued to document provision of catheter care on subsequent shifts when no catheter was in place. Over the next day, the resident experienced vomiting, decreased oral intake, and an altered level of consciousness, with vital signs showing tachycardia and low blood pressure, and staff documented decreased urine output. A bladder scan performed later revealed more than 2000–2500 milliliters of urine in the bladder, and an indwelling catheter was reinserted, initially draining a large volume of urine. The provider note indicated the resident had not eaten since the prior night, was unable to hold down fluids, and staff were unsure whether the resident had urinated in incontinence briefs, with no wet briefs reported since the resident’s return from the hospital after catheter removal. The provider expressed concern that the documented early-morning wet brief might not be accurate given the large bladder volume on scan and stated this should require further investigation. Subsequent notes described the resident moaning and complaining of pain, with limited urine output in the catheter bag and staff flushing and then replacing the catheter due to continued complaints. Interviews with the resident, the roommate, and staff indicated the resident was crying out and moaning in pain, the roommate repeatedly alerted staff that the resident was not urinating and that the catheter was not draining, and staff had to seek assistance to replace the catheter. Facility leadership and clinical staff later acknowledged that typical practice after catheter removal would include contacting the provider, placing the resident on alert, performing post-void residuals with bladder scans, and documenting monitoring, which was not done in this case.
Medication Administration Delays, Documentation Errors, and Use of Expired Insulin
Penalty
Summary
The deficiency involves the facility’s failure to ensure sufficient nursing staff with appropriate competencies and skill sets to administer medications according to professional standards of practice, facility policy, and prescriber orders. The facility’s medication administration policy required medications to be given as prescribed, in accordance with manufacturers’ specifications and good nursing principles, with no expired medications used, and doses administered within 60 minutes of the scheduled time and documented immediately after administration. Multiple residents reported that agency nurses often gave medications late, did not read full instructions, or were slow in bringing medications, and that routinely scheduled medications were not consistently provided without residents having to ask. Surveyors observed several specific medication administration failures. For a resident with diabetes, an LPN drew up and administered Humalog/Lispro insulin from a multi-dose vial that had been opened and dated “02/16” with no year, making it expired per policy, and administered the dose nearly 1 hour and 45 minutes after it was due. Another resident with care plan instructions to receive medications as ordered had multiple scheduled medications (Gabapentin, Oxybutynin, Baclofen, and Tizanidine) that were ordered at specific times throughout the day; the LPN was observed administering all four together and acknowledged that at least one (Tizanidine) was late, while the resident reported that receiving them together at that time was typical and not at their request. For another diabetic resident, an RN checked blood sugar and prepared sliding scale Humalog/Lispro insulin almost two hours after the scheduled time; the resident refused the insulin, stating they had already finished lunch. Additional deficiencies were identified with other residents’ pain and scheduled medications. One resident with a pain care plan and an order for Methocarbamol four times daily at set times approached the cart requesting Methocarbamol and Tylenol; the RN initially stated the Methocarbamol had already been given, but then administered it two hours after it was due when the resident pointed out the scheduled timing. For another resident with a risk for pain care plan and Tramadol ordered three times daily at specific times, an LPN retrieved a PRN pain medication while the electronic record showed no 8:00 AM medications documented; the LPN stated they had given them but had not yet documented. Later, an RN prepared the 2:00 PM Tramadol dose, and review of the narcotic count showed a discrepancy between the number of pills documented and the number remaining in the card. The RN stated they had given the 8:00 AM Tramadol but had not signed it out, then signed out both the 8:00 AM and 2:00 PM doses at that time. Residents interviewed consistently reported that medications were sometimes or frequently late, that agency nurses did not always follow instructions, and that they often had to request medications that were routinely scheduled.
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