Washington Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Seattle, Washington.
- Location
- 2821 South Walden Street, Seattle, Washington 98144
- CMS Provider Number
- 505017
- Inspections on file
- 38
- Latest survey
- December 16, 2025
- Citations (last 12 mo.)
- 31
Citation history
Health deficiencies cited at Washington Care Center during CMS and state inspections, most recent first.
A resident who required total assistance for transfers, including the use of a mechanical lift with two-person support, was transferred by a CNA without a second staff member present. This failure to follow the care plan led to the resident falling from the lift and sustaining a traumatic brain injury, multiple brain bleeds, a neck fracture, and facial fractures. The incident was attributed to the CNA not reviewing or following the Kardex instructions, placing other residents needing similar assistance at risk.
A resident with significant mobility and medical needs was injured after being repositioned by a single CNA, despite care plan instructions requiring two-person assistance. The resident fell from bed and sustained multiple fractures, and records showed that not all CNAs had completed required training on care protocols.
The facility failed to maintain effective infection control practices, with inadequate PPE availability for staff caring for residents requiring Enhanced Barrier Precautions. Observations showed isolation carts were not stocked, and staff reported inconsistency in PPE supply and accessibility. Additionally, hand sanitizer dispensers were malfunctioning in several rooms, and residents noted staff did not consistently wear protective gear during care.
The facility failed to obtain informed consent for medications for three residents, including those with depression and anxiety. One resident received an antidepressant for insomnia without consent, another with depression and suicidal ideation received medications without consent, and a third had outdated and incomplete consent forms. The Regional Director of Clinical Operations confirmed these deficiencies.
The facility failed to maintain a homelike environment, with issues such as dirty and damaged walls, misaligned doors, hanging ceiling tiles, and dusty fans in resident rooms. Additionally, broken floor tiles, worn closets, and stained privacy curtains were observed. The facility entrance had broken cement tiles, posing a risk of injury. Staff X confirmed these issues and stated they should have been addressed promptly.
The facility failed to provide required written notices to residents and their representatives during transfers to hospitals. This deficiency affected five residents, as confirmed by interviews and record reviews. The Social Services Director admitted to not completing written notices for hospital transfers, citing a lack of awareness of the requirement.
The facility failed to complete PASRR Level II evaluations for three residents identified as needing them. A resident with anxiety disorder and mood swings was not referred for evaluation, while another with anxiety, depression, and bipolar disorder had no Level II evaluation completed. A third resident with complex conditions and on antipsychotic medications also lacked a necessary evaluation. Staff confirmed these oversights.
The facility failed to ensure accurate PASRR assessments for three residents, leading to potential risks in their care. A resident with depression and PTSD was not identified with SMI indicators, another resident's psychosis diagnosis was omitted, and a third resident's need for a Level II evaluation was not documented. The Social Services Director acknowledged these inaccuracies.
The facility failed to maintain accurate and updated care plans for several residents, leading to unmet care needs. A resident had conflicting care plans regarding bladder continence, while another's care plan included outdated interventions for discontinued medication. Observations showed a resident struggling with eating, yet their care plan lacked specific assistance instructions. Another resident's care plan did not include necessary tube feeding precautions. Significant weight loss in a resident was not documented in their care plan, and another's care plan lacked instructions for antibiotic use. Additionally, a resident's care plan did not include instructions for compression hose application despite a physician's order.
Several residents in a LTC facility were not provided adequate assistance with ADLs, leading to poor personal hygiene and grooming. Residents dependent on staff for tasks like bathing and dressing were observed with long fingernails, greasy hair, and strong odors. Staff interviews revealed a lack of assigned shower aides and inconsistent care practices, contributing to the deficiency.
A resident with decreased bed mobility developed pressure ulcers due to the facility's failure to conduct weekly skin assessments, adjust air mattress settings according to the resident's weight, and follow care plans. The resident refused certain interventions due to discomfort, and staff were unaware of how to adjust the air mattress. The resident's wounds deteriorated as a result.
The facility failed to ensure proper supervision and storage of smoking materials for several residents, contrary to its policy. Residents were found with cigarettes and lighters in their possession, and some refused safety measures like smoking aprons. Additionally, chemicals and sharps were left unsecured in utility rooms, posing safety risks. Staff interviews confirmed these lapses, highlighting a failure to maintain a hazard-free environment.
The facility failed to maintain infection control practices, including hand hygiene, use of PPE, and Enhanced Barrier Precautions. Staff did not perform hand hygiene during resident care and dining services, and failed to use PPE for residents under Transmission Based Precautions. Additionally, Enhanced Barrier Precautions were not initiated for residents with specific health conditions, and staff were observed wearing contaminated gloves in hallways.
The facility failed to provide written notification of its bed-hold policy to residents or their representatives during hospital transfers, affecting four residents. Interviews revealed inconsistencies in documentation processes, with staff providing conflicting accounts of departmental responsibilities. Records for the affected residents showed no documentation of bed-hold notifications, indicating a systemic issue in the facility's process.
The facility failed to follow Physician's Orders for several residents, including inconsistent flushing of a feeding tube, improper application and removal of a pain patch, and lack of compression stockings. Orders were not clarified for a resident on dialysis, leading to potential medication errors. Additionally, a resident received narcotic medication outside prescribed parameters, and tube feeding supplies were unlabeled.
Two residents in an LTC facility were not provided with individualized activity programs, leading to potential boredom and diminished quality of life. One resident, with anxiety and depression, had minimal documented activities and lacked control over their television. Another resident, with complex medical conditions, was observed not participating in activities despite having preferences for outdoor and religious activities. The facility's activity program policy was not adequately implemented for these residents.
The facility failed to provide adequate care for two residents, including pain management for a resident with a venous skin ulcer, proper monitoring and documentation of frequent diarrhea, and adherence to physician orders for compression stockings to manage edema. Despite recommendations and orders, the facility's records and observations showed lapses in care, with staff interviews revealing a breakdown in communication and execution of care plans.
The facility failed to provide adequate bowel and bladder care for two residents, leading to deficiencies. One resident, with impaired memory, was found in a room with a strong urine odor and wet clothes, with no completed bladder assessment or nighttime assistance. Another resident, requiring assistance for mobility, reported frustration due to lack of staff response to toileting requests, leading to the use of briefs. The facility did not complete necessary assessments to address the residents' incontinence needs.
The facility failed to properly store, label, and dispose of medications and supplies, with expired items found in medication carts and rooms. An opened vial of a Tuberculosis agent was over 30 days old, and a medication fridge's temperature log was incomplete. Staff confirmed these practices were against policy, risking resident safety.
The facility failed to protect a resident from sexual abuse, resulting in psychological harm. A resident with severe decision-making impairments and a history of trauma was found in a compromising situation with another resident who had a documented history of sexual behaviors. The facility's inadequate supervision and documentation allowed the incident to occur, leading to the resident being transferred to a hospital for evaluation.
Failure to Provide Required Two-Person Assistance During Mechanical Lift Transfer Resulting in Resident Injury
Penalty
Summary
A resident who required total assistance with all activities of daily living, including transfers using a mechanical lift with two-person assistance, experienced a fall resulting in significant injuries. The resident's care plan, as documented in the Kardex and Minimum Data Set (MDS), specified the need for two staff members to assist with all transfers due to the resident's high risk for falls and significant cognitive impairment. Despite these documented requirements, a Certified Nursing Assistant (CNA) provided care and attempted a transfer using the mechanical lift without a second staff member present. This action was contrary to the resident's assessed needs and the facility's established protocols. As a result of the CNA's failure to follow the care plan, the resident fell from the mechanical lift, landed on the floor, and sustained a traumatic brain injury, multiple areas of bleeding in the brain, an upper neck fracture, and facial fractures. Facility records and staff interviews confirmed that the CNA did not review or adhere to the Kardex instructions, which were designed to ensure resident safety and prevent such incidents. The incident placed not only the affected resident but also other residents requiring similar assistance at risk for harm.
Failure to Follow Care Plan Results in Resident Injury
Penalty
Summary
A deficiency occurred when a resident, who was assessed as requiring two staff members for repositioning and turning in bed due to paraplegia, seizure disorder, respiratory failure, and other comorbidities, was repositioned by a single CNA. The resident rolled off the bed during this process, resulting in three fractures to the hip, knee, and back, and required increased pain management, including narcotic medications. The resident's care plan and Kardex both specified the need for two-person assistance, but this was not followed. Facility records and interviews revealed that the CNA involved provided care independently, contrary to the resident's care plan. The facility's investigation confirmed that the fall and resulting injuries could have been prevented if the care plan had been followed. Additionally, review of staff training records showed that several CNAs had not completed required Kardex Protocol training prior to returning to work, with only 75% of CNA staff having completed the training. Staff interviews indicated issues with training reminders and access, contributing to inadequate education on following care plans.
Inadequate Infection Control Practices and PPE Availability
Penalty
Summary
The facility failed to establish and maintain effective infection control practices, as evidenced by the lack of Personal Protective Equipment (PPE) availability for staff caring for 12 out of 19 residents requiring Enhanced Barrier Precautions (EBP) due to specific diagnoses such as wounds and indwelling medical devices. Observations revealed that isolation carts outside resident rooms were not stocked with the necessary PPE, and staff interviews indicated inconsistency in PPE supply and accessibility. Staff members reported not knowing where to obtain PPE supplies and disregarded isolation signs when providing care, highlighting a lack of guidance and resources following the departure of the Infection Preventionist Nurse. Additionally, the facility failed to ensure that alcohol-based hand sanitizer dispensers were functioning properly in 25 out of 46 rooms, both inside and along the hallway outside occupied resident rooms. Interviews with residents confirmed that staff did not consistently wear gowns and gloves during care, and malfunctioning hand sanitizer dispensers were reported but not addressed. The Director of Nursing acknowledged the expectation for accurate isolation signs and PPE restocking, while the Regional Administrator emphasized the importance of functioning hand sanitizer dispensers and staff knowledge of supply locations.
Failure to Obtain Informed Consent for Medications
Penalty
Summary
The facility failed to ensure that residents were provided informed consent for treatments, specifically regarding the explanation of risks and benefits of medications. This deficiency was identified for three residents whose medication regimens were reviewed. Resident 113, diagnosed with depression and anxiety, was prescribed an antidepressant for insomnia without evidence of informed consent. Staff C, the Regional Director of Clinical Operations, confirmed the absence of informed consent documentation for this resident. Similarly, Resident 17, who had a diagnosis of depression with suicidal ideation, received antidepressant and antipsychotic medications without documented informed consent. Staff C acknowledged the lack of consent for this resident as well. Additionally, Resident 21, with diagnoses including depression, anxiety, and a psychotic disorder, had outdated and incomplete consent forms for antipsychotic and antidepressant medications. Staff C noted that the reasons and diagnoses for these medications were not explained to the resident or their representative prior to administration.
Facility Fails to Maintain Homelike Environment
Penalty
Summary
The facility failed to maintain a homelike environment in two of its units and the entryway, as observed by surveyors. On the 100 Unit, the first-floor shower room door had multiple tan smears visible from the hallway, and a shared bathroom had dried brown debris on the walls and floor, which remained uncleaned for several days. The supply closet doors were misaligned and could not be closed, and ceiling tiles in a resident's room were hanging down precariously. A box fan in another room was covered in dust debris, which was being blown around the room. Staff X, the Maintenance Director, confirmed these issues and stated that they should have been addressed promptly. On the 200 East Unit, a room had a wheelchair with a dirty commode bucket parked in the bathroom, and deep scratches were observed on the wall behind a resident's bed. The closet had missing wood chunks and exposed metal hardware. Another room had a broken floor tile, and closets in two rooms were worn with missing wood, with one supported by adhesive tape. A privacy curtain in a room was stained, and Staff X acknowledged the unclean conditions and broken fixtures, noting that the facility was awaiting an order for backing behind the beds. Additionally, the facility entrance had broken and missing cement tiles, posing a risk of injury, as confirmed by Staff X.
Failure to Provide Written Notification for Hospital Transfers
Penalty
Summary
The facility failed to provide required written notices to residents and their representatives at the time of transfer or discharge to an acute care hospital. This deficiency was identified for five residents who were reviewed for hospitalizations. The lack of written notification was confirmed through interviews and record reviews, which showed no documentation of such notices being provided. Specifically, Residents 127, 34, 113, 55, and 96 were transferred to hospitals without receiving the necessary written communication regarding their discharge. Staff E, the Social Services Director, acknowledged during an interview that they did not complete written notices of transfer when residents were sent to the hospital. Staff E stated that they were unaware of the requirement to provide written notifications for hospital transfers and only completed notices when residents were discharged from the facility. This oversight placed residents at risk of being discharged without alignment with their care goals and preferences, as there was no documentation of the reasons for their discharge in a language and manner they understood.
Failure to Complete PASRR Level II Evaluations
Penalty
Summary
The facility failed to ensure that Pre-admission Screening and Resident Review (PASRR) Level II comprehensive evaluations were obtained for three residents who were identified as needing them. Resident 134, who had diagnoses of anxiety disorder and a chronic mental illness, was not referred for a Level II PASRR evaluation despite indicators of a serious mental illness (SMI) being present. Staff E, the Social Services Director, confirmed that a referral should have been made but was not. Similarly, Resident 85, who had diagnoses including anxiety, depression, and bipolar disorder, was identified as needing a Level II PASRR evaluation due to SMI indicators. However, no Level II evaluation was completed, as confirmed by Staff E. Resident 113, with complex medical conditions and taking antipsychotic and antidepressant medications, also required a Level II PASRR evaluation, which was not in place. Staff E acknowledged that Level II services should have been followed up on but were not.
Inaccurate PASRR Assessments for Residents
Penalty
Summary
The facility failed to ensure accurate Pre-Admission Screening and Resident Review (PASRR) assessments for three residents, which is crucial for determining their mental health needs and appropriate care. Resident 34, who had diagnoses of depression and PTSD, was not identified with Serious Mental Illness (SMI) indicators in their Level I PASRR, despite requiring antidepressant and antianxiety medications. Staff E, the Social Services Director, acknowledged the inaccuracy of Resident 34's PASRR Level I, which needed updating to reflect the resident's mental health conditions accurately. Resident 113's Level I PASRR did not reflect their psychosis diagnosis or auditory hallucinations, despite the resident taking antipsychotic and antidepressant medications for these conditions. Staff E confirmed that the PASRR should have included this information. Additionally, Resident 17, who had schizophrenia and depression, was inaccurately documented in their Level I PASRR as not requiring a Level II evaluation, and there was no documentation of an invalidation report. Staff E noted the inaccuracies in Resident 17's PASRR, including the language used and the need for a Level II evaluation.
Deficiencies in Care Plan Updates and Accuracy
Penalty
Summary
The facility failed to ensure that care plans (CPs) were accurate, regularly reviewed, and revised to reflect the current status and needs of seven residents. For Resident 48, there were conflicting CPs regarding bladder continence, with one indicating continence and another indicating incontinence. Staff acknowledged that CPs should be updated to reflect the resident's current condition. Resident 113's CP still included interventions for antipsychotic medication use, despite the medication being discontinued, indicating a lack of timely updates to the CP. Resident 10's CP did not specify the level of assistance required for eating, despite observations showing the resident struggled with eating independently. Resident 150's CP and Kardex lacked specific instructions for tube feeding precautions, such as keeping the head of the bed elevated to prevent aspiration. Staff confirmed that these instructions were necessary but not included in the CP. Resident 55 experienced significant weight loss, yet their CP did not document this or provide any interventions for staff to follow. Resident 99's CP did not include instructions related to the use of an antibiotic for a bladder infection, and Resident 85's CP lacked instructions for applying compression hose for edema, despite a physician's order. Staff interviews confirmed that these omissions were contrary to the facility's requirements for maintaining accurate and up-to-date CPs. These deficiencies left residents at risk for unmet care needs and a diminished quality of life.
Inadequate Assistance with ADLs in LTC Facility
Penalty
Summary
The facility failed to provide adequate assistance with Activities of Daily Living (ADLs) for several residents, leading to issues with personal hygiene and grooming. Residents 21, 55, 99, 134, 10, 150, and 71 were observed with long, broken fingernails, greasy hair, and in some cases, strong odors due to infrequent showers and inadequate personal care. These residents were dependent on staff for assistance with tasks such as bathing, dressing, and oral hygiene, yet the facility did not meet these needs consistently. For instance, Resident 21 was noted to have received only three showers in the past 30 days, despite requiring assistance due to physical weakness. Staff interviews revealed systemic issues in the facility's approach to providing care. Staff I, a registered nurse, confirmed the lack of adequate personal hygiene care for Resident 21, citing a urine odor in the resident's room due to nighttime incontinence. Similarly, Staff L, a CNA, indicated that the facility did not have an assigned shower aide, and CNAs were responsible for providing showers, which were often limited to residents who could walk to the shower rooms. This practice left residents like 55 and 99, who required maximal assistance, without proper bathing and grooming care. The facility's failure to adhere to its own policies and care plans was evident in the lack of documentation and follow-up on residents' ADL needs. Staff S, a unit manager, acknowledged that staff should provide all necessary ADL care, including oral care, dressing, and showers, and document any refusals. However, the observations and interviews indicated that these practices were not consistently followed, resulting in diminished quality of life for the affected residents.
Failure to Provide Adequate Pressure Ulcer Care
Penalty
Summary
The facility failed to provide necessary treatment and services to a resident with pressure ulcers, consistent with professional standards of practice. The resident, who was admitted with weakness on the left side of their body, developed pressure ulcers in the facility and was at risk for more due to decreased bed mobility. The facility did not complete weekly skin assessments as required, with only one skin check documented in July and none in August. Observations showed the resident lying on their back without heel/elbow protectors, and the air mattress settings were not adjusted according to the resident's weight, which was significantly lower than the settings indicated. Interviews revealed that the resident refused certain interventions like heel floaters and pillows under their heels due to discomfort, and staff were unaware of how to adjust the air mattress settings. The resident expressed that they stayed in bed due to wounds on their back and buttocks, and lying on their side was painful. A contracted wound care provider noted that all of the resident's wounds had deteriorated. The facility's failure to follow physician orders, care plans, and facility policies contributed to the resident's condition worsening.
Failure to Secure Smoking Materials and Hazardous Items
Penalty
Summary
The facility failed to maintain an environment free from accident hazards, particularly concerning the supervision and storage of smoking materials for several residents. Residents 135, 117, 54, 43, and 22 were observed with smoking materials in their possession, contrary to the facility's smoking policy, which mandates that all smoking materials be stored with the activities or nursing departments. Resident 135, who had balance problems, was seen with cigarettes and a lighter in their room and during a smoke break, refused to wear a smoking apron, and was not supervised adequately as per the policy. Similarly, Resident 117, who also had balance issues, was found with cigarettes in their lap, and Resident 54, who had limited range of motion, was observed with cigarettes in their room. Resident 43 and Resident 22 were also found with smoking materials on their person, violating the facility's policy. The facility also failed to secure chemicals and sharps in designated areas, posing additional safety risks. Observations revealed that the janitor room on the first floor and the Second Floor-West clean utility room were left unlocked, with various hazardous chemicals accessible. These included disinfectants, glass cleaners, and a bottle of Super Blue Mild Acid Bowl Cleaner, all labeled with cautionary warnings. Additionally, the clean utility room on the first floor contained unsecured shaving razors, which were accessible due to a malfunctioning door lock that had not been addressed for nearly two months. Interviews with staff confirmed these lapses in safety protocols. Staff A, the Administrator, acknowledged that smoking supplies should be kept with the smoking aid, while Staff S, the Unit Manager, and Staff C, the Regional Director of Clinical Operations, confirmed that chemicals and razors should not be left unsecured. These failures in supervision and securing hazardous materials placed residents at risk for smoking-related injuries and other accident hazards, compromising their safety.
Infection Control Deficiencies
Penalty
Summary
The facility failed to maintain proper infection control practices, as evidenced by multiple observations and interviews. Staff members did not perform hand hygiene (HH) during resident care and dining services, despite the facility's policy requiring HH before and after resident contact and room entry or exit. For instance, a Certified Nursing Assistant (CNA) was observed delivering meal trays to multiple residents without washing or sanitizing their hands, citing being too busy as the reason for non-compliance. This lack of adherence to HH protocols was confirmed by the Infection Control staff, who stated that HH was expected before and after resident interactions. Additionally, the facility did not ensure the use of Personal Protective Equipment (PPE) for residents under Transmission Based Precautions (TBP). Staff members were observed entering rooms with posted contact enteric precautions without wearing the required gowns and gloves. In one case, a CNA entered a resident's room, who was on contact enteric precautions for a contagious bacterial infection, without donning PPE and only used hand sanitizer upon exiting, contrary to the posted instructions to wash hands with soap and water. The facility also failed to identify and initiate Enhanced Barrier Precautions (EBP) for residents who required them. Observations revealed that residents with urinary catheters, pressure ulcers, and feeding tubes did not have EBP signs posted on their doors, which are necessary to instruct staff on the required precautions. Furthermore, staff were seen wearing contaminated gloves in the hallways after providing care, which is against the facility's expectations. These lapses in infection control practices were acknowledged by the Infection Control staff, who admitted that EBP signs should have been placed and gloves should not be worn in hallways.
Failure to Provide Bed-Hold Policy Notification
Penalty
Summary
The facility failed to provide written notification of its bed-hold policy to residents or their representatives at the time of transfer to a hospital or within 24 hours, as required. This deficiency was identified for four residents who were transferred to acute care hospitals with the anticipation of return. For Resident 127, there was no documentation indicating that the facility provided the required written information regarding the bed-hold policy when the resident was transferred to the hospital for stomach issues and blood loss. Similarly, Resident 34's records lacked documentation of the bed-hold policy being communicated, despite the resident being transferred to a hospital. Interviews with facility staff revealed inconsistencies in the process of documenting and communicating bed-hold information. Staff E, the Social Services Director, and Staff W, the Admissions Coordinator, provided conflicting accounts of which department was responsible for completing bed-hold documentation. Additionally, Staff C, the Regional Director of Clinical Operations, noted that the eINTERACT Transfer Form, which should include bed-hold information, was not completed for Residents 127 and 34. The records for Residents 55 and 96 also showed no documentation of bed-hold notifications, indicating a systemic issue in the facility's process for informing residents and their representatives of their rights regarding bed-hold policies during hospital transfers.
Deficiencies in Following Physician's Orders and Documentation
Penalty
Summary
The facility failed to ensure that Physician's Orders (POs) were followed for several residents, leading to unmet care needs and potential negative health outcomes. For Resident 1, the facility did not consistently flush the feeding tube with the prescribed amount of water, as documented in the Medication Administration Record (MAR). Despite observations showing the tube feeding pump was set correctly, the actual amounts recorded varied significantly from the ordered 640 CC daily. This inconsistency in following POs was acknowledged by the Regional Director of Clinical Operations. Additionally, the facility did not ensure that nurses signed only for tasks completed, as evidenced by the cases of Residents 10 and 85. Resident 10 had a pain medication patch that was not removed as scheduled, despite documentation indicating otherwise. Similarly, Resident 85 was supposed to have compression stockings applied daily, but observations showed they were not wearing them, and the resident confirmed they were never provided. Staff interviews revealed awareness of the orders but a failure to execute them properly. The facility also failed to clarify POs for Residents 10 and 107, leading to confusion and potential medication errors. Resident 10's pain patch order lacked specific instructions on placement and frequency, while Resident 107's dialysis schedule conflicted with their medication times, with no orders to hold or adjust medications. Furthermore, Resident 34 received a narcotic pain medication outside the prescribed parameters, and Resident 150's tube feeding supplies were not labeled as required. These deficiencies highlight significant lapses in following and clarifying POs, as well as in medication administration and documentation practices.
Failure to Provide Individualized Activities for Residents
Penalty
Summary
The facility failed to provide individualized activity programs for two residents, leading to a risk of boredom and diminished quality of life. Resident 95, who was assessed with a slightly impaired mood and diagnosed with anxiety and depression, had a care plan that included goals for engaging in independent activities and attending group activities weekly. However, from the time of admission until mid-August 2024, there was minimal documentation of activities offered or participated in by Resident 95. The resident expressed that staff did not provide them with things to do, and observations confirmed the lack of available activity materials and control over their television. Resident 150, with complex medical diagnoses including stroke and paralysis, was also not provided with meaningful activities as per their care plan. Despite the resident's preferences for outdoor activities, religious services, and crafts, observations showed the resident lying in bed without engaging in any activities. The activity documentation for the previous 30 days showed no recorded activities, and the staff admitted to difficulties in understanding the resident's communication, relying on family input for activity preferences. The facility's activity program policy aimed to support residents' well-being through independent and group activities, but the implementation for Residents 95 and 150 was inadequate. The Activity Director acknowledged the importance of activities for residents' mental well-being but failed to ensure that the residents' preferences and needs were met, as evidenced by the lack of documented activities and the residents' reports of insufficient engagement.
Deficiencies in Pain Management, Diarrhea Monitoring, and Edema Care
Penalty
Summary
The facility failed to provide adequate pain management and care for Resident 60, who was suffering from multiple chronic conditions including a venous skin ulcer. Despite a recommendation from an outside wound team to administer pain medication 30 minutes prior to wound treatment, the facility's records showed no pain medication was given to Resident 60 from the beginning to the middle of August 2024. Interviews with Resident 60 revealed complaints of pain, and observations confirmed the resident experienced pain during wound care, contradicting staff claims that pain medication had been administered. Additionally, the facility did not properly monitor or document Resident 60's episodes of diarrhea, which were frequent and severe enough to cause incontinence issues. The care plan did not address the risk of diarrhea, and staff failed to notify the provider of these episodes, indicating a breakdown in the facility's diarrhea management system. Interviews with staff revealed an expectation for care staff to inform nurses of such issues, which did not occur, potentially missing serious health concerns. For Resident 85, the facility neglected to follow physician orders for the application of compression stockings to manage edema. Despite documentation indicating that compression stockings were applied daily, observations showed Resident 85 was not wearing them, and staff interviews confirmed the absence of compression stockings. The care plan lacked instructions for this essential treatment, and staff were unable to locate the necessary compression stockings, highlighting a failure in executing prescribed care for edema management.
Deficiency in Bowel and Bladder Care for Two Residents
Penalty
Summary
The facility failed to provide adequate care for two residents, leading to deficiencies in managing bowel and bladder incontinence. Resident 21, who had impaired memory and required assistance with personal hygiene, was observed in a room with a strong urine odor and was found with wet clothes due to urine. Despite being able to use the bathroom independently during the day, Resident 21 was incontinent at night and used briefs. The facility did not complete a bowel and bladder assessment for Resident 21, and there was no documentation of staff offering assistance at night or assessing the resident's bladder needs, which could have made Resident 21 a candidate for bladder training. Resident 71, who required moderate assistance for mobility and was dependent on staff for toileting, reported frustration due to staff not providing a bedpan when requested, leading them to use briefs instead. The facility's care plan directed staff to assist Resident 71 with toileting, but no bladder assessment was completed to evaluate the resident's incontinence needs. Interviews with staff revealed a lack of completed assessments for Resident 71, despite expectations for such assessments to be conducted on admission, quarterly, and as needed. This oversight in assessing and addressing the residents' incontinence needs contributed to the deficiency.
Medication Storage and Labeling Deficiencies
Penalty
Summary
The facility failed to ensure proper storage, labeling, and disposal of medications and medical supplies across multiple medication carts and rooms. Observations revealed expired medications and supplies, such as nicotine gum, needles, and ointments, were not removed from the medication carts. Additionally, some medications were not labeled with resident names, and opened medications were not dated, which is against the facility's policy. For instance, a loose green pill was found in a drawer, and several expired needles and medications were present in the carts. In the medication rooms, an opened vial of a Tuberculosis skin testing agent was found to be over 30 days old, and the temperature log for a medication fridge was not maintained for seven consecutive days. Interviews with staff, including the Assistant Director of Nursing, confirmed that expired medications and supplies should be removed, and refrigerator temperatures should be monitored nightly. These lapses in medication management placed residents at risk for ineffective treatment and exposure to expired or contaminated medications.
Failure to Protect Resident from Sexual Abuse
Penalty
Summary
The facility failed to protect a resident's right to be free from sexual abuse, resulting in psychological harm to Resident 1. Resident 1, who had severe impairments to their decision-making ability and a history of trauma, was found in a compromising situation with Resident 2. Staff observed Resident 2 with their pants down on top of Resident 1, who was exposed from the waist down. Despite Resident 1's initial statements to the police and hospital staff that the interaction was consensual, the facility's failure to prevent the incident led to Resident 1 being transferred to a hospital for evaluation. Resident 2 had a documented history of sexual behaviors and fluctuating levels of confusion due to dementia and other mental health conditions. Despite this, the facility did not maintain adequate supervision or documentation of Resident 2's behaviors. Staff were unaware of Resident 2's sexual inappropriateness, and previous incidents involving Resident 2 were not properly documented or followed up with consistent monitoring. This lack of oversight allowed Resident 2 to engage in inappropriate behavior with Resident 1. Interviews with staff revealed that there was no consistent monitoring of Resident 2's sexually inappropriate behaviors, and the one-on-one caregiver assigned to Resident 2 was discontinued without clear documentation or rationale. The facility's failure to adhere to its own policies and protocols regarding abuse and neglect, as well as inadequate supervision and documentation, placed all residents at risk for potential sexual abuse and psychological harm.
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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