Washington Odd Fellows Home
Inspection history, citations, penalties and survey trends for this long-term care facility in Walla Walla, Washington.
- Location
- 534 Boyer Avenue, Walla Walla, Washington 99362
- CMS Provider Number
- 505421
- Inspections on file
- 47
- Latest survey
- February 11, 2026
- Citations (last 12 mo.)
- 35
Citation history
Health deficiencies cited at Washington Odd Fellows Home during CMS and state inspections, most recent first.
The facility failed to meet professional standards of practice for insulin administration and documentation for a resident with diabetes. A physician order required insulin at 1 unit per 10 g of carbohydrates consumed after meals, with a maximum daily dose, but review of MARs over several months showed no documentation of carbohydrate intake or insulin units given. An LPN reported visually estimating carbs from the meal tray and administering insulin accordingly without recording the carb count or dose, and the Nurse Manager confirmed there was no established process to document these elements. The Medical Director and DON both indicated that documentation should include total carbs, insulin dose, and rationale, but acknowledged that consistent documentation of carb counts and insulin administration was not occurring, placing residents at risk for unstable blood sugars, duplicate dosing, and adverse outcomes.
The facility failed to implement proper infection control measures during a COVID-19 outbreak, with staff not using NIOSH-approved N95 masks and failing to clean face shields. Staff conducting COVID-19 tests did not wear appropriate PPE and allowed staff to return to work before test results were available. Interviews revealed a lack of understanding and training regarding PPE protocols.
The facility failed to provide timely and appropriate care for several residents, leading to significant harm and unmet care needs. A resident experienced a small bowel obstruction and urinary infection due to delayed assessments and lack of bowel protocol initiation. Two residents exceeded fluid restrictions due to inadequate monitoring and communication. Additionally, physician orders for lab work, medication changes, and wound care referrals were not completed, resulting in delayed treatment.
The facility failed to prevent and manage pressure ulcers for three residents, leading to harm and deterioration of their conditions. One resident developed a Stage 4 ulcer on their coccyx due to delayed treatment and inadequate pain management. Another resident's ulcers worsened due to tight shoes and insufficient pain relief, resulting in cellulitis and osteomyelitis. A third resident's pressure ulcers deteriorated due to ineffective interventions and non-compliance, with staff failing to advocate for increased measures.
A facility failed to provide adequate supervision for a resident at risk of falls, resulting in injury. Additionally, the facility did not properly identify and supervise residents who were active smokers, leading to violations of the smoke-free policy. Residents were found smoking on facility property without proper supervision or storage of smoking materials, highlighting a lack of communication and enforcement of the facility's smoking policy.
The facility failed to maintain a clean kitchen environment, with non-functional ventilation, dirty air conditioners, and fans, and unclean utensils and ice machines, risking foodborne illness.
The facility failed to provide necessary social services, including Medicare notifications and accurate PASARR assessments, affecting several residents. A resident did not receive a NOMNC or ABN, while others lacked ABNs. PASARR assessments for residents with mental health diagnoses were inaccurate. Additionally, discharge planning was inadequate for two residents, with one having no support network and another desiring to return home without facility assistance.
The facility failed to complete accurate PASARR assessments for four residents, leading to potential risks of not receiving appropriate mental health services. A resident with major depression and delusional disorder, another with dementia and agitation, and two others with various mental health diagnoses were not correctly identified in their PASARRs. The administrator cited the lack of a Social Services Director as a reason for these inaccuracies.
The facility failed to provide dignified care, as seen in delayed toileting assistance for a resident with dementia, inconsistent meal service times causing frustration among residents, and mishandled admissions leading to confusion and neglect. Staff acknowledged these lapses, which did not meet the expected standards of care.
The facility failed to issue required Medicare notices, including NOMNCs and SNF ABNs, for several residents, impacting their ability to make informed financial and care decisions. A resident with kidney failure did not receive a timely NOMNC, and there was no documentation of a SNF ABN. Another resident with pneumonia did not receive a SNF ABN when Medicare benefits began, and a third resident with a stroke received a SNF ABN on admission but not before the last covered day. Staff were unfamiliar with the ABN process.
The facility failed to provide written notice of discharge to two residents and their representatives, as well as the LTC Ombudsman. One resident was transferred to the hospital for issues related to clostridium difficile, while another was transferred due to unresponsiveness. The LTC Ombudsman was not informed of these discharges, and the facility's administrator was unaware of who was responsible for the notifications.
The facility failed to provide written bed-hold notices to residents or their representatives during hospital transfers, affecting two residents. Despite notifying representatives by phone, the facility did not include required written details about the bed-hold policy, such as duration, payment, and return conditions. Staff interviews indicated a lack of awareness of the requirement for written notices.
The facility failed to effectively plan discharges for two residents, neglecting to address their goals and needs or involve them and their representatives. One resident's representative had to independently arrange for an assisted living facility, while another resident's preference to return home was not facilitated. The discharge process lacked coordination and communication among staff, with the absence of a social services staff member exacerbating the issue.
Two residents with dementia on timed toileting programs did not receive timely assistance, leading to incontinence. Staff were unaware of the specific toileting schedules, resulting in unmet care needs. The Director of Nurses expected adherence to Kardex directives, which was not followed.
A resident with impaired vision did not receive necessary optometry services due to a missed referral order. Despite a physician's order for an eye evaluation, the appointment was not scheduled, leaving the resident without eyeglasses and unable to see properly. Staff responsible for scheduling were unaware of the order, indicating a lapse in procedure.
The facility failed to ensure medication storage rooms were free from expired medications, risking compromised or ineffective treatments for residents. Expired COVID-19 vaccinations and other medications were found in storage rooms, despite a policy requiring staff to check expiration dates. The night shift RN was responsible for this task, but expired items remained, indicating a lapse in procedure adherence.
A resident with a history of trauma and multiple diagnoses, including depression and dementia, did not receive adequate trauma-informed care at the facility. Despite recommendations for psychological evaluation and social worker assessment, these were not completed. The resident expressed ongoing distress, and staff interviews revealed a lack of trauma assessments and mental health services. The DON admitted to potentially conducting assessments incorrectly, leading to unmet care needs.
A facility failed to ensure an LPN had the necessary certification to administer IV medications, resulting in a missed dose for a resident with a PICC line. The LPN, who was not certified in Washington State, did not administer a scheduled antibiotic dose, and there was no record of completed competencies. Facility staff were unaware of the LPN's certification status, and expected communication protocols were not followed.
A resident with dementia and severely impaired cognition was found with significant bruising on their left hand and forearm, indicating possible abuse/neglect. The facility failed to report the incident to the State Agency within the required 24-hour timeframe, despite the severity of the injury and a possible non-displaced fracture identified in an x-ray. This was a repeat citation for the facility.
A resident with dementia and impaired cognition was found with significant bruising on their left hand and forearm. The facility failed to conduct a thorough investigation into the cause of the bruising, as required by their policy. The medical director speculated trauma as a cause, but this was not confirmed. The resident's Power of Attorney reported the bruise, but no explanation was provided. The Assistant Director of Nursing admitted that not all necessary interviews were conducted to rule out abuse.
The facility failed to thoroughly investigate allegations of potential neglect and unwitnessed falls, resulting in substantial injuries to three residents. Investigations were incomplete, lacking necessary interviews, assessments, and reviews, and failed to address critical issues such as the use of gait belts and medication side effects.
A resident with cellulitis and heart failure did not receive the increased dosage of furosemide as per hospital discharge orders upon returning to the facility. Staff believed the new orders would start the following day, leading to the resident missing the additional 40 mg dose on the day of return.
The facility failed to honor the bathing frequency preferences of two residents, providing only one shower per week despite requests for more. Staff limitations were cited as the reason for not accommodating these requests.
The facility failed to report an allegation of neglect to the State Agency involving a resident with a stroke, aphasia, and osteoporosis, who sustained a fracture and dislocated shoulder during a transfer. Despite logging the incident, it was not reported as required, placing residents at risk for further neglect.
Failure to Document Carbohydrate Counts and Insulin Doses per Sliding Order
Penalty
Summary
The facility failed to follow professional standards of practice for insulin administration and documentation for one resident with diabetes. The resident was admitted with diagnoses including breast and colon cancer, malnutrition, and diabetes, and had intact cognition and was largely independent with activities of daily living. A physician’s order dated 09/29/2025 directed that insulin be injected subcutaneously at 1 unit for every 10 grams of carbohydrates consumed after meals, with a total daily dose not to exceed 40 units. Review of the Medication Administration Records from September 2025 through 02/11/2026 showed no documentation of the amount of carbohydrates the resident consumed or the amount of insulin administered. During interviews, an LPN stated they visually assessed the resident’s meal tray to estimate carbohydrate intake and then administered 1 unit of insulin per 10 grams of carbohydrates but did not document either the carbohydrate amount or the insulin units given, and indicated there was no place on the MAR to record the units. The Nurse Manager explained that dietary staff documented the total carbohydrate count for each meal on the tray card and saved the tray for nursing to observe intake, but confirmed there was no process in place to document the carbohydrate count or corresponding insulin dose. The Medical Director stated that documentation for insulin administration should include the total carbohydrate count, the amount of insulin given each time, and the rationale for the dose. The DON similarly described a process in which dietary documented total carbohydrates and nursing calculated and administered insulin, with the expectation that nursing would document in progress notes, but acknowledged there was no process to consistently document the carbohydrate count and insulin administered. This failure was cited as not meeting professional standards of quality and placed residents at risk for unstable blood sugars, duplicate insulin administration, and adverse outcomes.
Inadequate PPE Use and COVID-19 Testing Protocols
Penalty
Summary
The facility failed to consistently implement infection control interventions during a COVID-19 outbreak, as observed in the use of personal protective equipment (PPE) by staff. Specifically, staff members did not wear the required NIOSH-approved N95 masks, face shields, gowns, and gloves when entering rooms of COVID-19 positive residents. Instead, some staff used KN95 masks, which are not NIOSH-approved, and were not properly fit-tested for N95 masks. Additionally, face shields were not cleaned and disinfected after use, contrary to CDC guidelines. The report highlights that staff members conducting COVID-19 testing did not adhere to proper PPE protocols. Staff G, who was responsible for performing nasal swab tests, wore only a surgical mask and gloves, rather than the required N95 mask, gown, and eye protection. Furthermore, staff members returned to work before receiving their COVID-19 test results, which is against the facility's policy and CDC guidance. Interviews with staff revealed a lack of understanding and training regarding the differences between KN95 and N95 masks, as well as the proper procedures for fit testing and PPE usage. Staff members, including those with facial hair, were improperly fit-tested, and there was confusion about the reuse and cleaning of face shields. The facility's administrator acknowledged these deficiencies and the need for retraining and proper fit testing.
Failure to Provide Timely and Appropriate Care
Penalty
Summary
The facility failed to provide treatment and care in accordance with professional standards and the comprehensive, person-centered care plan for several residents. Resident 54 experienced significant harm due to the facility's failure to conduct timely assessments and initiate bowel protocols. Despite receiving narcotic pain medication, the resident did not have a bowel movement for four days, leading to a small bowel obstruction and urinary bladder infection, which required hospitalization. Observations and interviews revealed that the resident was in pain, nauseated, and unable to eat, yet no thorough assessments or interventions were documented. Resident 11 and Resident 38 were both affected by the facility's failure to adhere to fluid restriction orders. Resident 11 had a water pitcher at their bedside, which was not accounted for in their fluid restriction, potentially leading to excessive fluid intake. Staff were unaware of the resident's fluid restriction status, and no monitoring was in place. Similarly, Resident 38 exceeded their fluid intake limits on multiple occasions, with no documentation of risk/benefit discussions or physician notifications, despite the resident's non-compliance with fluid restrictions. The facility also failed to implement physician orders for Residents 13 and 36. Resident 13's lab work and medication changes were not completed, with staff citing the resident's refusal as a reason, yet no further attempts or documentation were made. Resident 36 experienced a significant delay in receiving a referral to an outside wound care clinic for a pressure ulcer, with the first appointment occurring 50 days after the physician's order. Staff interviews indicated a lack of follow-up and communication regarding the scheduling delay, contributing to the deficiency.
Failure to Prevent and Manage Pressure Ulcers
Penalty
Summary
The facility failed to provide necessary treatment and services to prevent and manage pressure ulcers for three residents, leading to harm and deterioration of their conditions. Resident 48, who was admitted with Alzheimer's disease, CIDP, and diabetes, developed an avoidable Stage 4 pressure ulcer on their coccyx. The facility did not follow physician orders for a wound vac and surgical consult, resulting in delayed treatment. Additionally, Resident 48 experienced severe pain during wound care, which was not adequately managed with pain medication, as staff failed to administer appropriate analgesics before or after dressing changes. Resident 108, with a history of dementia, heart disease, and diabetes, developed pressure ulcers on their left heel and great toe due to tight shoes. The facility did not remove the shoes promptly, leading to the worsening of the ulcers. Despite the resident's complaints of significant pain, the facility did not pre-medicate before dressing changes, and the resident's condition deteriorated to the point of requiring a narcotic pain reliever. The resident's left foot developed cellulitis and osteomyelitis, and a physician recommended amputation due to the decline. Resident 13, with Alzheimer's disease and severe cognitive impairment, developed deep pressure ulcers on their right foot. The facility's interventions, such as floating feet on pillows and using padded boots, were ineffective as the resident was non-compliant. Despite requests for a specialized air mattress, the facility did not provide one, and the resident's wounds continued to deteriorate. Staff failed to report the non-compliance and advocate for increased interventions, leading to the worsening of the resident's condition.
Inadequate Supervision and Smoking Policy Violations
Penalty
Summary
The facility failed to provide the necessary supervision to prevent avoidable accidents for Resident 54, who was at a moderate risk for falls. Despite having a care plan that required assistance with transfers, hourly safety checks, and a scheduled toileting program, Resident 54 fell while attempting to use their walker unsupervised to go to the bathroom. This fall resulted in a laceration above the right eyebrow and fractured right ribs. The resident's cognitive impairment and physical unsteadiness, combined with inadequate supervision, contributed to the incident. Additionally, the facility did not adequately identify and supervise residents who were active smokers, as evidenced by the cases of Residents 214, 216, and 212. Resident 214 was observed smoking on facility property without proper supervision or storage of smoking materials, contrary to the facility's smoke-free policy. Staff were unaware of the resident's possession of cigarettes and a lighter, and the resident was not informed of the facility's smoking restrictions upon admission. Similarly, Resident 216 was observed attempting to smoke on facility property without supervision, and the facility failed to secure their smoking materials. Resident 212 also experienced issues related to smoking supervision. The resident's cigarettes and lighter were taken by staff, but the resident was not given access to them as promised. The facility's failure to properly assess and manage the smoking habits of these residents, along with inadequate communication of the smoke-free policy, resulted in unsafe conditions and non-compliance with the facility's smoking policy.
Kitchen Sanitation Deficiencies
Penalty
Summary
The facility failed to maintain a clean and sanitary kitchen environment, which is essential for ensuring food safety. During an observation, it was noted that the janitor's closet in the kitchen contained a mop and bucket filled with chemicals, and the ventilation fan in the closet was not operational, leading to a chemical odor. Additionally, two mounted portable air conditioners in the food preparation areas were found to be dirty, with dust and grime accumulation. The fans blowing air over food preparation areas were also covered in dust and grime. The floor in the dry goods room was dirty, with a black substance and dirt along the baseboards. Kitchen utensils were stored in trays and containers with food crumbs, and there was an open container of bene-protein powder with dirt and food crumbs on the serving tray. Furthermore, an ice machine in the East dining service area was observed to have a yellowish slime on the metal plate inside. Interviews revealed that maintenance and dietary staff shared the responsibility of cleaning the fans and air conditioners, but there was no specific task for cleaning them on the Daily Kitchen Form. The ice machines were on a cleaning schedule of every three months, but the last cleaning was completed over a month prior, and the ice machine was not clean. These deficiencies in maintaining cleanliness and sanitation in the kitchen and dining areas placed residents at risk for potential foodborne illness.
Deficiencies in Medicare Notifications, PASARR Assessments, and Discharge Planning
Penalty
Summary
The facility failed to provide necessary medically related social services to residents, specifically in the areas of Medicare notifications and assessments. For Resident 215, the facility did not issue a Notice of Medicare Non-Coverage (NOMNC) within the required timeframe, nor did they provide an Advanced Beneficiary Notice (ABN) to inform the resident of potential out-of-pocket costs. Similarly, Residents 50 and 52 did not receive ABNs, leaving them uninformed about the financial implications of their continued care. The facility also neglected to ensure accurate Pre-Admission Screening and Resident Review (PASARR) assessments for several residents. Resident 6, who was admitted with major depression and delusional disorder, had a PASARR assessment that failed to accurately reflect these mental health diagnoses. Similarly, Residents 11, 210, and 43 had PASARR assessments that did not accurately identify their respective mental health conditions, such as dementia, depression, and anxiety. This lack of accurate assessment placed these residents at risk of not receiving appropriate mental health services. Additionally, the facility did not adequately plan for the discharge of residents. Resident 208, who had no family or support network, did not receive assistance from the facility in planning their discharge, leaving the responsibility to their representative. Resident 38 expressed a desire to return home, but the facility had not discussed discharge options with them or their representative. The facility's lack of social services staff contributed to these deficiencies in discharge planning, as acknowledged by the Director of Nursing Services.
Inaccurate PASARR Assessments for Residents
Penalty
Summary
The facility failed to ensure the Pre-Admission Screening and Resident Review (PASARR) was completed correctly for four residents, which placed them at risk for not receiving appropriate mental health services. Resident 6 was admitted with mental health diagnoses including major depression and delusional disorder, but their PASARR did not identify these conditions. Similarly, Resident 11, who had dementia with agitation and behavioral disturbances, was not accurately reflected in their PASARR. Resident 210's PASARR also failed to include their diagnoses of anxiety and depression. Resident 23 was admitted with multiple diagnoses, including stroke, depression, psychoactive substance abuse, and severe dementia with mood disturbance. However, their PASARR, completed at the hospital, did not reflect these mental health conditions. The facility's administrator attributed these inaccuracies to the absence of a Social Services Director, who would typically be responsible for ensuring the accuracy of PASARR assessments upon residents' admission.
Deficiencies in Resident Care and Admission Process
Penalty
Summary
The facility failed to provide dignified care and services to its residents, as evidenced by several incidents. One such incident involved a resident with dementia who required assistance with toileting. Despite the resident's repeated requests for help, staff delayed providing assistance, resulting in the resident experiencing an incontinent episode. This delay in care was observed over a period of 35 minutes, during which the resident expressed distress and embarrassment. In another instance, the facility did not serve meals simultaneously to all residents at a dining table, causing some residents to wait while others ate. This was observed on multiple occasions, with delays ranging from 17 to 21 minutes. Residents expressed frustration and hunger, yet staff did not address their concerns promptly. The facility's administrator acknowledged the expectation that all residents at a table should receive their meals at the same time, which was not met. Additionally, the admission process for two residents was mishandled, leading to feelings of neglect and confusion. One resident arrived at the facility without their representative, contrary to prearranged plans, and was left unattended in a room. Another resident's admission was marked by a lack of staff presence and guidance, resulting in confusion about room assignments and care preferences. The facility's staff admitted that the standard admission process was not followed for these residents.
Failure to Issue Required Medicare Notices
Penalty
Summary
The facility failed to issue a Notice of Medicare Non-Coverage (NOMNC) and a Skilled Nursing Facility (SNF) Advance Beneficiary Notice (ABN) as required for several residents, which placed them at risk for not being able to make informed financial and care decisions. Resident 215, who was admitted with diagnoses including kidney failure and weakness, did not receive a timely NOMNC, as it was issued on the first date of non-coverage instead of at least two days prior. Additionally, there was no documentation of a SNF ABN being provided. Staff C, the Assistant Director of Nursing Services, acknowledged the delay and unfamiliarity with the ABN process. Resident 50, admitted with conditions such as pneumonia and dysphagia, did not receive a SNF ABN when their Medicare A benefits began or when a NOMNC was issued. Similarly, Resident 52, who required maximum assistance due to a stroke and heart failure, received a SNF ABN on the day of admission but not prior to the last covered day of Medicare Part A benefits. Staff A, the Administrator, was unaware of the regulation for ABN issuance and considered the late NOMNC for Resident 215 an isolated incident.
Failure to Notify Residents and Ombudsman of Discharges
Penalty
Summary
The facility failed to provide a written notice to two residents and their representatives regarding the facility's intention and justification for their discharge. This deficiency was identified during a review of the medical records for two residents who were transferred to the hospital. Resident 39, who had diagnoses including clostridium difficile, kidney failure, and gastrointestinal hemorrhage, was transferred to the hospital for nausea, vomiting, diarrhea, dehydration, and possible C-diff. Similarly, Resident 55, with diagnoses including a urinary tract infection, atrial fibrillation, and diabetes, was transferred due to unresponsiveness. In both cases, there was no documentation indicating that a notice of transfer or discharge had been provided to the residents, their representatives, or the LTC Ombudsman. Interviews conducted during the investigation revealed that the LTC Ombudsman had not received any notifications of transfers or discharges from the facility. The facility's administrator acknowledged awareness of the regulation requiring notification to the Office of the State LTC Ombudsman but admitted to not knowing who was responsible for ensuring the notifications were completed. This lack of communication and documentation resulted in the residents and their representatives not being informed of their rights and the rationale for the discharges, as well as the LTC Ombudsman not being aware of the facility's practices related to transfers or discharges.
Failure to Provide Written Bed-Hold Notices During Hospital Transfers
Penalty
Summary
The facility failed to issue a written notice of bed-hold to residents or their representatives at the time of hospital transfer, as required by policy. This deficiency was identified for two residents who were transferred to the hospital. Resident 39, who had severe cognitive impairment and was dependent on staff for activities of daily living, was transferred to the hospital for nausea, vomiting, and diarrhea. Although the facility notified the resident's representative of the transfer via phone call, they did not provide the required written information about the bed-hold policy, including the duration of the bed-hold, payment details, and conditions for return. Similarly, Resident 55, who required maximum assistance for activities of daily living and had multiple diagnoses including a urinary tract infection and diabetes, was also transferred to the hospital. The facility issued a notice of bed-hold to the resident's representative, but it lacked the necessary written details. Interviews with facility staff revealed a lack of awareness and understanding of the requirement to provide written bed-hold notices before and upon transfers, contributing to the deficiency.
Inadequate Discharge Planning for Two Residents
Penalty
Summary
The facility failed to develop and implement an effective discharge planning process for two residents, which did not address their goals and needs, nor involved them or their representatives adequately. Resident 208, who was admitted with diagnoses including metabolic encephalopathy, high blood pressure, and depression, had no comprehensive discharge plan initiated. The resident's representative had to independently arrange for an assisted living facility and coordinate care, as the facility staff did not assist with the discharge planning. Interviews revealed that the facility's discharge process was not functioning effectively, with social services being spotty and no stand-up meetings occurring due to state surveyors' presence. Resident 38, admitted with congestive heart failure, high blood pressure, and anxiety, also experienced inadequate discharge planning. The resident expressed a desire to return home, but no discussions or plans were made to facilitate this option. The care plan indicated a potential long-term stay, but the resident was not involved in the care conference meeting. Interviews with staff revealed that the discharge process was supposed to start upon admission, but due to the absence of a social services person, the process was not properly executed. The therapy department had recommended discharge to an assisted living facility, but the resident's preference to return home was not adequately explored or facilitated. Overall, the facility's discharge planning process was inconsistent and lacked coordination among the interdisciplinary team. Staff interviews highlighted a lack of communication and involvement of the residents and their representatives in the discharge planning process. The absence of a social services staff member further complicated the situation, leading to a deficiency in meeting the residents' discharge goals and needs.
Failure to Provide Timely Toileting Assistance
Penalty
Summary
The facility failed to provide timely assistance with toileting for two residents, both of whom were on timed toileting programs due to cognitive impairments. Resident 11, diagnosed with dementia and type 2 diabetes, was observed on multiple occasions not receiving assistance according to their scheduled toileting program. Despite being scheduled for assistance at specific times throughout the day, Resident 11 was left in their wheelchair for extended periods without being taken to the bathroom. Staff members were unaware of the resident's specific toileting program, leading to the resident experiencing incontinence and requiring a change of a saturated brief. Similarly, Resident 10, also diagnosed with dementia, was on a timed toileting program requiring assistance every two hours during the day and evening. However, the resident was observed waiting 35 minutes for assistance after requesting help, resulting in incontinence of stool. Staff interviews revealed a lack of adherence to the Kardex directives for toileting assistance, as expected by the Director of Nurses. These failures in providing timely toileting assistance placed both residents at risk for unmet care needs related to incontinence.
Failure to Provide Vision Services and Assistive Devices
Penalty
Summary
The facility failed to provide necessary vision services and assistive devices to Resident 23, who was admitted with diagnoses including stroke and depression. The comprehensive assessment indicated that the resident had moderately impaired vision and cognition and was dependent on two staff members for activities of daily living. Despite a physician's order dated 07/08/2024 for an optometry referral to evaluate the resident's vision, the appointment was not scheduled. This oversight left the resident without the necessary eyeglasses, impacting their ability to see the television remote and read. Interviews revealed a breakdown in the process for scheduling outside facility appointments. Staff K, responsible for obtaining optometry appointments, was unaware of the referral order for Resident 23, indicating a lapse in communication and procedure. The Director of Nursing Services outlined the process, which involved the charge nurse obtaining and submitting the signed order to Staff K. However, the order for Resident 23 was missed, resulting in the resident not receiving the required vision care.
Expired Medications Found in Storage Rooms
Penalty
Summary
The facility failed to ensure that medication storage rooms were free from expired medications, which placed residents at risk for receiving compromised or ineffective medications. During an observation and interview, it was found that the [NAME] Hall medication storage room refrigerator contained four expired COVID-19 vaccinations. A registered nurse acknowledged that nursing staff should be checking expiration dates on medications. Additionally, the East Hall medication storage room was found to contain several expired items, including povidone iodine swab sticks, saline enemas, a glucagon emergency kit, fecal collector bags, and medication cards of omeprazole and Methenamine Hippurate. The facility's policy on medication administration required staff to identify medication expiration dates and notify the nurse manager. However, during an interview, the facility administrator stated that the night shift RN was responsible for checking for expired medications and supplies, and expressed an expectation that nurses should remove expired medications. Despite this policy, expired medications were still present in the storage rooms, indicating a lapse in adherence to the facility's procedures.
Failure to Provide Trauma-Informed Care for a Resident
Penalty
Summary
The facility failed to provide trauma-informed and culturally competent care for Resident 23, who was identified as a trauma survivor. Resident 23 was admitted with diagnoses including stroke, depression, substance abuse, and severe dementia with mood disturbance. Despite the resident's history of trauma, including an abusive household and lifelong alcoholism, the facility did not complete a psychological evaluation or a social worker assessment as recommended. The Trauma Informed Care assessment noted trauma from a stroke, but the resident expressed ongoing distress related to their life experiences, which was not adequately addressed by the facility. Observations and interviews revealed that Resident 23 often stayed in a dark room, expressing feelings of hopelessness and a lack of motivation to engage with their environment. Staff interviews indicated a lack of trauma assessments and mental health services for residents, even those with known histories of depression or trauma. The Director of Nursing Services admitted to potentially conducting the Trauma Informed Care assessments incorrectly, as they did not thoroughly review or inquire about the resident's history. This oversight placed residents at risk for unidentified triggers, re-traumatization, and unmet care needs.
LPN Lacked Certification for IV Medication Administration
Penalty
Summary
The facility failed to ensure that a Licensed Practical Nurse (LPN), identified as Staff AA, possessed the necessary competencies and skill sets to safely administer intravenous (IV) medication to residents. Specifically, Staff AA was not certified to administer IV medications in Washington State, which was required for the care of Resident 208, who had a Peripherally Inserted Central Catheter (PICC) line for the administration of antibiotics. This deficiency was identified when the 6:00 AM dose of cefazolin sodium, an antibiotic prescribed for Resident 208, was not administered as scheduled. Staff AA documented that they were not certified to give IV medications, and there was no record of completed nursing competencies in their personnel file. Interviews with facility staff revealed a lack of awareness and communication regarding Staff AA's certification status. The Director of Nursing Services (DNS) was unaware of Staff AA's inability to administer IV medications, and the Staff Development/Staff Coordinator confirmed that LPNs without IV certification should not care for residents with IVs. The facility's Administrator expected LPN staff to inform the Registered Nurse (RN) on duty if they were unable to administer IV medication and to notify the Assistant Director of Nursing Services and the DNS if a medication was not administered. However, these protocols were not followed, leading to the deficiency.
Failure to Timely Report Abuse/Neglect Incident
Penalty
Summary
The facility failed to report an allegation of abuse/neglect to the State Agency within the required 24-hour timeframe for a resident who was found with significant bruising on their left hand and forearm. The resident, who had dementia, heart disease, and depression, was dependent on staff for activities of daily living and had severely impaired cognition. On observation, the resident's left hand and forearm were bruised and swollen, and the resident was unable to recall how the injury occurred. The facility's investigative report noted the bruising was identified on 07/14/2024, but the State Agency was not notified. The facility's investigation included an x-ray of the resident's left hand and wrist, which showed a possible non-displaced fracture. Despite the severity of the injury, the facility did not report the incident to the State Agency, as confirmed by the Assistant Director of Nursing Services during an interview. This failure to report in a timely manner was a repeat citation, indicating a pattern of non-compliance with the reporting requirements outlined in the Nursing Home Guidelines.
Failure to Investigate Alleged Abuse Resulting in Unexplained Bruising
Penalty
Summary
The facility failed to thoroughly investigate an allegation of abuse concerning a significant bruise of unknown origin on a resident, identified as Resident 28. The resident, who has dementia and other medical conditions, was observed with severe bruising and swelling on their left hand and forearm. Despite the visible injuries, the facility did not conduct a comprehensive investigation as required by their policy. The policy mandates immediate investigation upon suspicion of abuse, including interviewing all involved parties and documenting the investigation thoroughly. However, the Assistant Director of Nursing admitted that not all staff or resident interviews were completed to rule out abuse. The resident's medical records indicated dependency on staff for daily activities and impaired cognition, which could have contributed to the difficulty in identifying the cause of the bruising. The medical director speculated that the bruising might have been caused by the resident hitting their hand against a surface, but this was not confirmed. An x-ray revealed mild tissue swelling and a possible non-displaced fracture. The resident's Power of Attorney reported the bruise to the nursing staff but received no explanation. The incident follow-up report suggested possible causes like tight clothing or bumping against a table, but these were not substantiated by a thorough investigation.
Failure to Investigate Allegations of Neglect and Falls
Penalty
Summary
The facility failed to thoroughly investigate an allegation of potential neglect and unwitnessed falls, resulting in substantial injuries to three residents. Resident 2, who had a stroke with right-sided weakness and osteoporosis, sustained a fracture and dislocation of the right arm and shoulder during a transfer without the use of a gait belt. The investigation did not include interviews with all relevant staff, the resident, or their representative, and failed to address the lack of gait belt usage during the transfer. Additionally, education on gait belt usage was delayed and incomplete. Resident 3, who had dementia and was at high risk for falls, was found on the bathroom floor with a large bump and bruise on the right side of their head after an unwitnessed fall. The investigation into this incident was not thorough, lacking interviews, a review of the resident's last toileting, type of footwear, medication review, and environmental observations. The investigation did not provide a conclusive statement regarding the fall, and corrective actions were insufficient. Resident 4, who had moderately impaired cognition and a history of falls, was found on the floor with a fractured left hip and a mildly displaced middle finger. The investigation into this incident was also inadequate, as it did not include interviews, an assessment of the environment, a medication review, or an evaluation of the resident's last observation by staff. The resident had recently been started on Namenda, which has side effects of sleepiness and dizziness, but this was not considered in the investigation.
Failure to Administer Prescribed Medication Dosage
Penalty
Summary
The facility failed to follow and/or clarify physician orders for a resident who was admitted with diagnoses including cellulitis and heart failure. Upon the resident's return from the hospital, the discharge orders indicated an increase in the dosage of furosemide to 80 mg every morning and an additional 40 mg at 1:00 PM for seven days. However, the staff did not administer the additional 40 mg dose on the day of the resident's return, as they believed the new orders would become effective the following day. This failure was confirmed through interviews with the resident and staff, as well as a review of the Medication Administration Record, which showed the increased dose was not given on the specified date. During interviews, the resident stated that staff refused to administer the additional dose of furosemide, and staff members confirmed they did not give the medication as per the new orders. Staff C entered the orders to begin the following day, and Staff D followed this instruction, resulting in the resident not receiving the prescribed medication on the day of their return from the hospital. This oversight placed the resident at risk for negative health outcomes and unmet care needs.
Failure to Honor Resident Choice in Bathing Frequency
Penalty
Summary
The facility failed to ensure residents had the ability to exercise self-determination related to the frequency of bathing. Resident 5, who was admitted with diagnoses including stroke, depression, and anxiety, expressed a desire to have more than one shower per week but was only receiving one shower on Thursdays. Despite multiple requests, Resident 5 did not receive additional showers. Similarly, Resident 6, who was readmitted with heart failure and kidney disease, also requested two showers per week but was only receiving one shower on Wednesdays. Resident 6 had been receiving two showers per week until a few months ago but this was no longer accommodated. Interviews with staff revealed that the facility had only one bath aide on duty, making it challenging to provide more than one shower per week per resident. Staff F, the Nursing Assistant Bath Aide, confirmed the limitation, while Staff E, the Staffing Coordinator, stated that the facility should be able to provide showers once or twice a week based on resident preferences. Review of the shower records for both residents showed they only received one shower per week with no refusals documented.
Failure to Report Allegation of Neglect
Penalty
Summary
The facility failed to report an allegation of neglect to the State Agency as required, involving a resident who had a stroke with right-sided weakness, aphasia, and osteoporosis. The resident, who required extensive assistance with transfers, was found with a bruise on their right arm, which was reported by a Nursing Assistant and assessed by a Licensed Nurse. The resident complained of pain and was sent for x-rays, which later revealed a fracture and dislocated shoulder. Despite logging the incident, the facility did not report it to the State Agency as mandated by regulations. The deficiency was identified during a review of the resident's medical records and progress notes, which documented the injury and subsequent diagnosis. The facility's Reporting Log confirmed that the incident was not reported to the State Agency, as required for allegations of neglect. This failure to report placed residents at risk for further neglect and was a repeat deficiency from a previous Statement of Deficiencies.
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A resident with cerebral palsy and a court-appointed guardian experienced multiple episodes of nausea, vomiting, loose stools, abdominal discomfort, fatigue, and later refusal of meals and medications, leading to changes in the care plan including close monitoring, lab testing, and IV fluid administration. Despite a facility policy recognizing court-appointed guardians as resident representatives with decision-making authority, staff did not document any notification to the guardian during these changes in condition or treatment decisions. The guardian reported not being contacted when the resident stopped eating or developed stomach issues and felt the facility did not respect the guardianship, while the DON acknowledged there were multiple missed opportunities to notify the guardian of the resident’s change from baseline.
A resident with depression, anxiety, moderate cognitive impairment, and urinary incontinence, care-planned for q2h checks and assistance with toileting, was found by a visitor to be soaking wet, unusually agitated, and reporting they had been told to wait to be changed and referred to with a derogatory remark. The visitor filed a written grievance alleging abuse/neglect related to delayed incontinence care and removal of the resident’s tablet as a consequence. Although an incident report noted that the matter was reported to the state and that the resident was not soaking wet, a CNA who actually changed the resident later reported the resident’s brief, pants, wheelchair, and socks were soaked and that the resident was acting timid and repeatedly saying they had to sit for five minutes, but this CNA was never interviewed. The DON acknowledged not investigating the resident’s behavior or interviewing this CNA, and the grievance official acknowledged the facility did not fully investigate or communicate findings and resolution to the complainant, resulting in a failure to follow the facility’s grievance policy.
A resident with dementia, respiratory failure, and heart failure developed new shortness of breath with an O2 sat of 90%, and a physician ordered transfer to the ED for tx and eval. An RN completed an SBAR, notified the MD and family, and reported to the oncoming nurse that the resident needed ED transfer and that paramedics should be contacted, then left the facility. Instead of calling 911 for this emergent respiratory distress, staff arranged non-emergent transport through a contracted ambulance service, resulting in the resident remaining at the facility for several hours without pickup until the dispatcher later instructed staff to call 911. The DON stated that 911 is expected to be used for emergent conditions and the contracted service only for non-emergent transport.
A resident with anoxic brain injury, dysarthria, and documented lack of decisional capacity alleged physical abuse and expressed fear of their identified representative, yet social services only reported the allegation to the state and did not complete an incident report, revise the care plan, or implement protective interventions. The same representative continued to be treated as the resident’s decision-maker and visited frequently, with staff noting suspicious odors of foreign substances and concerns about possible illicit substance use. Psychiatry later documented concern that the representative was providing illicit substances, and the resident was subsequently hospitalized for altered mental status and overdose, after which the representative was banned. Key staff, including the DON, unit manager, and administrator/abuse coordinator, were unaware of the initial abuse allegation, and social services did not timely explore or clarify legal decision-making authority or alternative representation for the resident.
A resident with severe cognitive impairment, osteoarthritis, and spinal spondylosis, care planned for 2-person Hoyer transfers, was being moved by two CNAs using a mechanical lift when one corner loop of the sling became disengaged, causing the resident to fall about four feet, strike the floor and the lift, and sustain head abrasion, multiple rib fractures, and lumbar vertebral fractures. Facility policy required staff to verify secure sling attachment, examine hooks, clips, fasteners, and strap stability, and ensure the sling bar was sound before lifting, but during this transfer the sling loop detached despite staff believing it was properly fastened and hearing it click into place; post-incident assessment showed the loop had come loose, the sling appeared in good condition, and a CNA later reported thinking one of the round metal disks on the lift might have been slightly loose, while maintenance logs documented no prior concerns with the lifts or slings.
The facility failed to revise and individualize care plans to reflect current needs and preferences for multiple residents, including one cognitively intact resident with hemiplegia, hemiparesis, and mononeuropathy who had bilateral shoulder surgery and could not tolerate BP measurements on the upper arms but preferred forearm readings. Despite repeatedly informing staff, this preference was not documented in the care plan or Kardex, and direct care staff and the RN/UM were unaware of it. Another cognitively intact resident with hemiplegia, contractures, and weakness reported they were supposed to get out of bed for two hours daily, but some NACs did not know this, even though the MAR/TAR contained an order to document times up and back to bed. The surveyors concluded that care plans were not accurately revised for several residents, placing them at risk for unidentified and unmet care needs and diminished quality of life.
Surveyors found that two residents with hemiplegia, hemiparesis, weakness, and contractures did not receive restorative nursing services, including ROM exercises and splint/brace or orthotic assistance, after therapy discharge. Although PT and OT discharge summaries documented established restorative ROM and transfer programs, recommended PROM to affected extremities, and recommended splint/brace use and assistance with orthotic wear, these recommendations were not entered as restorative referrals in the EHR. As a result, the residents’ care plans and records showed no restorative programs, and both residents reported that therapy and restorative exercises had stopped, while the DON, rehab director, and MDS coordinator confirmed they were unaware of and had not implemented the recommended restorative services.
A resident with cancer, cognitive impairment, and declining strength experienced multiple unwitnessed falls, most occurring while attempting to toilet or move toward the bathroom, culminating in a fractured ankle requiring ED treatment. Although assessments identified fall and incontinence risks and the facility’s policy required individualized interventions, the comprehensive care plan lacked a toileting plan and did not include several interventions that were discussed in incident investigations, such as consistent wheelchair placement and frequent rounding for bathroom assistance. Staff reported relying on verbal reminders and education to use the call light, despite acknowledging the resident’s impulsivity and failure to call for help, and the resident’s bed remained furthest from the bathroom while repeated bathroom-related falls occurred without the trend being recognized or addressed in the care plan.
A resident with a history of acute urinary retention and acute kidney injury had a Foley catheter deemed permanent by the hospital, with instructions that it not be removed in the SNF. At a later urology visit, the catheter was removed, and the resident returned with no new orders documented. Facility staff did not document bladder assessments, post-void residuals, or urine output, and CNA documentation showed the resident did not void that evening. Over the next day, the resident had vomiting, poor intake, altered level of consciousness, tachycardia, hypotension, and no documented wet briefs. A bladder scan eventually showed more than 2000–2500 mL of retained urine, and a new catheter drained a large volume. The resident and a roommate reported moaning, crying out in pain, and repeatedly alerting staff that the resident was not urinating and that the catheter was not draining, while nurses documented catheter care when no catheter was in place and later had to flush and replace the catheter due to continued complaints.
Surveyors found that nurses and nurse aides did not consistently administer medications according to professional standards and facility policy. Multiple residents reported that agency nurses were slow with medications, did not fully follow instructions, and often gave routine meds late. Observations showed an LPN administering expired Humalog/Lispro insulin well past the scheduled time, an LPN giving several scheduled meds (including Tizanidine) late and all at once, and an RN attempting to give sliding-scale insulin nearly two hours late, which a resident refused after already eating. Another resident received Methocarbamol two hours late after questioning the RN, and a resident on scheduled Tramadol had doses given without timely documentation, with a discrepancy between the narcotic count and pills remaining. These events demonstrated failures in timely administration, use of non-expired medications, and immediate, accurate MAR and narcotic documentation.
Failure to Notify Court-Appointed Guardian of Resident’s Clinical Changes
Penalty
Summary
The deficiency involves the facility’s failure to notify a resident’s court-appointed guardian of significant clinical changes and care decisions, contrary to its own policy and state requirements. The facility’s policy on Resident Representatives, revised 02/2021, states that a resident representative includes a court-appointed guardian or conservator and that the facility treats the representative’s decisions as those of the resident to the extent delegated or required by the court. Resident 1, admitted with cerebral palsy, had a Superior Court guardianship letter dated 02/07/2025 indicating a guardian of person and conservator of the estate with full authority, identifying Collateral Contact 1 (CC1) as the guardian. Despite this, multiple clinical events and changes in condition were documented without any corresponding documentation that CC1 was notified. Progress notes and provider notes show that Resident 1 experienced an episode of nausea and vomiting, frequent loose stools, abdominal discomfort, bloating, worsening fatigue, generalized weakness, and later refusal of meals and medications over at least a 24-hour period, with observations that the resident appeared frailer, more fatigued, and had no energy or interest to talk. The provider developed care plans including close monitoring for deterioration, sending stool to the lab, and later initiating IV fluids for rehydration, with a plan to call family/POA for discussion. However, there was no documentation that the guardian was notified at any of these points, including when IV fluids were started. CC1 reported that they were not contacted when the resident stopped eating or developed stomach issues, and expressed that the facility did not respect their guardianship and that involvement in care planning took too long. The DON confirmed on record review that there were many opportunities to notify the guardian when the resident’s condition changed from baseline and that there was no evidence staff did so.
Failure to Thoroughly Investigate and Resolve Resident Grievance Regarding Incontinence Care and Staff Conduct
Penalty
Summary
The deficiency involves the facility’s failure to thoroughly investigate and resolve a grievance alleging neglect and disrespect toward a resident, as required by its grievance policy. The resident had depression, anxiety, moderate cognitive impairment, occasional urinary incontinence, and required moderate assistance with toileting, with a care plan directing staff to check the resident every two hours, ask about toileting needs, and ensure they were clean and dry. A collateral contact reported arriving to visit the resident and finding them soaking wet and agitated, with behavior that was not typical for the resident. The collateral contact documented in a written grievance that the resident’s tablet was off, the resident appeared upset, and the resident reported being told they had to wait five minutes to be changed and that staff would change their “nasty *ss” in five minutes, leading the collateral contact to believe the resident had been given a consequence of no tablet and sitting in wet clothes, which they characterized as abuse/neglect and requested immediate removal of the responsible staff and a report filed. The facility documented receipt of the grievance and created an incident report indicating the matter was reported to the state agency, and that the unit manager interviewed the collateral contact and the resident, with the resident described as confused and denying being soaking wet. The incident report stated that a different nursing assistant was assigned to assist with the brief change and that the unit manager believed the resident was not soaking wet, and that the resident and collateral contact were satisfied when they left the room. However, a CNA who actually changed the resident reported that the resident’s brief was soaked through their pants onto the wheelchair and their socks were soaked, and that the resident was timid, repeatedly saying they had to sit for five minutes, and not acting like themselves; this CNA stated they were never interviewed or asked about the grievance or the resident’s condition. The DON acknowledged not interviewing this CNA or investigating the resident’s behavior and why they were upset, and the unit manager did not recall whether the collateral contact was present during follow-up and did not believe they followed up with the collateral contact regarding the grievance. The administrator, identified as the Grievance Official, stated the facility should have thoroughly investigated the grievance and discussed findings and resolution with the collateral contact, indicating the grievance process was not fully carried out in accordance with policy and WAC 388-97-0460.
Failure to Obtain Timely Emergency Transport for Resident in Respiratory Distress
Penalty
Summary
The deficiency involves the facility’s failure to obtain timely emergency medical services for a resident experiencing new-onset respiratory distress. The resident had dementia, respiratory failure, and heart failure, with severe cognitive impairment and a need for substantial assistance with activities of daily living. On the day the resident was sent to the hospital, a collateral contact observed the resident having difficulty breathing, appearing unable to get enough air, and looking as if they were sleeping or unconscious, and reported this to staff with a request to contact the doctor. An SBAR Communication Form documented that the resident was experiencing shortness of breath that had not occurred before, with an oxygen saturation of 90%. The physician was notified and ordered the resident sent to the emergency department for treatment and evaluation, and the collateral contact was notified shortly thereafter. Progress notes later documented that, despite the order for emergency department transfer, the resident was still awaiting pickup by Olympic transportation several hours later, with no estimated time of arrival. At approximately 3:30 AM, the dispatcher informed the facility that they could not provide transportation and instructed that 911 be called; only then was 911 contacted and the resident transported to the hospital via ambulance for respiratory distress. The RN caring for the resident stated they completed the SBAR, notified the physician and family, and at the end of their shift reported to the oncoming nurse that the resident needed to be sent to the emergency department for respiratory distress and that paramedics should be contacted, then left assuming 911 would be called. The DON stated that staff are expected to contact 911 for emergent conditions such as shortness of breath or respiratory distress, and that Olympic Ambulance is used only for non-emergent transport.
Failure to Provide Social Service Advocacy After Abuse Allegation and Questionable Representative
Penalty
Summary
The deficiency involves the facility’s failure to provide appropriate medically-related social services and advocacy for a resident following an allegation of abuse and concerns about the resident’s representative. The resident had an anoxic brain injury, dysarthria, moderate cognitive impairment, and was dependent on staff for activities of daily living. A hospital palliative care note documented that the resident lacked decisional capacity, had no DPOA, that the legal next of kin (CC4) did not want to be part of care decisions, and that care decisions were being deferred to another contact (CC5). CC5 accompanied the resident on admission, signed admission forms, and was listed as the primary contact in the medical record profile. On a date in February, during communication therapy, the resident reported that CC5 had done something to them, pounded their hands on their chest, recalled being hit in the back of the head by an unknown person, and stated they were sometimes afraid of CC5. A social services staff member reported this allegation to the state agency but did not complete a facility incident report, did not initiate care plan changes or interventions, and took no further action. CC5 continued to be treated as the resident’s representative, and progress notes documented CC5 at the bedside on multiple dates, including an entry noting the room smelled like foreign substances and that CC5 was seen waking the resident and then asking the nurse to administer pain medications. A psychiatry note later documented concern that CC5 was providing the resident with illicit substances and stated it would be prudent for the resident to identify a POA. Subsequently, the resident was found unresponsive, transported to the hospital, and later readmitted after altered mental status and overdose, with a provider note stating that CC5 posed a significant danger to the resident and was banned from visiting. After readmission, staff attempted to contact CC4 for consent to treat but initially reached someone who stated they were not CC4. The social service director acknowledged that, beyond reporting the initial allegation, no additional interventions were implemented, that CC5 continued to be used as the resident’s representative after the allegation, and that they had not explored legal authority for decision making following the abuse allegation or concerns about substances. The social service assistant reported they did not speak with the resident about the hospital stay or CC5 and did not complete an incident report or care plan changes after the allegation. The unit manager and DON were unaware of the initial abuse allegation, and the administrator, who served as abuse coordinator, also stated they were unaware of the allegation and that an investigation should have been initiated and a representative for the resident investigated at a minimum.
Injury from Mechanical Lift Sling Detachment During Transfer
Penalty
Summary
The facility failed to ensure a safe mechanical lift transfer when a resident was being moved with a Hoyer lift and sling, resulting in a fall and injury. Facility policy for using a mechanical lifting machine required staff to securely attach sling straps to the sling bar according to manufacturer’s instructions, double-check the security of the sling attachment before lifting, examine all hooks, clips, or fasteners, check strap stability, and ensure the sling bar was securely attached and sound. Despite these requirements, during a transfer for dinner, two CNAs placed the sling under the resident, attached the loops at each corner of the sling to the lift, and raised the resident off the bed into the space between the bed and wheelchair when the bottom left corner of the sling became disengaged from the lift. The resident involved had multiple diagnoses including osteoarthritis, cervical and thoracic spondylosis, and Alzheimer’s disease, with the Minimum Data Set documenting severely impaired cognitive skills for daily decision-making. The resident’s care plan required the assistance of two staff during Hoyer lift transfers. During the transfer, the resident fell approximately four feet, landing on her buttocks, bouncing, and then falling backward and striking her head on the leg of the Hoyer lift. Hospital records documented that the resident sustained an abrasion to the back of the head, fractures of the 6th, 7th, 8th, and 10th ribs, and fractures of the 1st and 2nd lumbar vertebra. Staff interviews and observations showed that staff believed the sling loops had been securely fastened and reported hearing the loops click into place before lifting. One CNA stated that they had barely lifted the resident off the bed when the bottom left loop became disconnected and the resident fell. Another CNA reported being shocked and unable to figure out what had happened. A nurse who assessed the resident and then examined the equipment after the fall noted that one of the loops of the sling had become disengaged but stated the sling appeared to be in good condition. During a later demonstration, a CNA indicated she thought one of the round metal disks on the lift might have been a little loose. Maintenance logs for Hoyer slings and lifts for the preceding months documented no concerns with the slings or lifts, and the DON acknowledged expecting a citation due to the resident’s injury from the fall.
Failure to Revise Care Plans to Reflect Resident Needs and Preferences
Penalty
Summary
The deficiency involves the facility’s failure to revise and individualize comprehensive care plans to reflect residents’ current needs and preferences, as required by its own care planning policy. For one resident with hemiplegia, hemiparesis following cerebrovascular disease, and mononeuropathy of the upper limb, the admission MDS showed intact cognition and upper extremity impairment. This resident reported having bilateral shoulder surgery and an inability to tolerate blood pressure measurements on the upper arms due to pain, and stated a preference for BP measurements on the forearms. The resident reported having informed multiple nursing staff of this preference, but staff continued to place the cuff on the upper arms. Review of the resident’s care plan and Kardex showed no interventions or instructions regarding forearm BP cuff placement. A NAC confirmed they were unaware of the preference until the resident told them directly and that this instruction was not documented in the Kardex. The RN/Unit Manager, who stated they were responsible for revising and reviewing care plans when there were changes, also confirmed they were not aware of the resident’s preference and that it should have been updated in the care plan. Another resident, readmitted with hemiplegia and hemiparesis following a nontraumatic subarachnoid hemorrhage, contracture of the left hand, and weakness, was cognitively intact and required maximum assistance for bed mobility per a quarterly MDS. This resident stated they were supposed to get out of bed for two hours every day, but some NACs were not aware of this care requirement. Review of the resident’s March 2026 MAR/TAR showed an order to document the time the resident got up and the time they returned to bed daily. The report states that, overall, the facility failed to revise care plans accurately to reflect residents’ needs for three of four residents reviewed for care plan revision, placing them at risk for unidentified and unmet care needs and a diminished quality of life.
Failure to Implement Restorative Nursing and Splint/Brace Programs After Therapy Discharge
Penalty
Summary
The deficiency involves the facility’s failure to provide restorative nursing services, including range of motion (ROM) exercises and splint/brace assistance, to maintain or prevent decline in mobility and contractures for two residents with significant motor impairments. The facility’s undated Restorative Nursing Services policy stated that residents would receive restorative care as needed to achieve and maintain optimal functioning and that residents may initiate a restorative program upon discharge from rehabilitative care. Despite this, surveyors found that residents with documented hemiplegia, hemiparesis, weakness, and contractures were not placed on restorative programs and had no restorative interventions documented in their electronic health records (EHRs). Resident 1 was admitted with hemiplegia and hemiparesis following cerebrovascular disease, a left lower leg fracture, and weakness, and the admission MDS showed intact cognition, moderate assistance needs for bed mobility and transfers, and one-sided upper and lower extremity impairment. During observation, the resident was seen lying in bed with a bent inward left forearm and hand and reported no longer receiving therapy or nursing-assisted exercises. The care plan initiated in January showed no restorative services, and the care plan history and EHR contained no restorative nursing interventions. However, the PT discharge summary from February documented that restorative ROM and transfer programs had been established and trained, including PROM to the left upper and lower extremities and stand-by assist with transfers, and the OT discharge summary recommended a splint/brace to prevent contracture. The OT stated that the splint/brace was not tried due to lack of time before insurance was discontinued, and both the Director of Rehab and the MDS coordinator confirmed there was no restorative referral in the EHR and they were unaware of the recommendations. Resident 2 was readmitted with hemiplegia and hemiparesis following a nontraumatic subarachnoid hemorrhage, a left-hand contracture, and weakness, and the quarterly MDS showed intact cognition, maximum assistance needs for bed mobility, total assistance for transfers, bilateral upper and lower extremity impairment, and no therapy or restorative programs. The resident reported that therapy had been discontinued months earlier and that no restorative staff were assisting with exercises. The care plan and EHR showed no restorative services. OT evaluation documented left upper extremity ROM impairment, a left-hand contracture, and prior use of a left orthotic to manage flexion tone, and the OT discharge summary recommended restorative care and assistance with donning/doffing the orthotic. The PT discharge summary recommended restorative programs if Medicaid Part B services did not continue. The Director of Rehab confirmed therapy was discontinued and that restorative nursing programs were recommended, but both the Director of Rehab and the MDS coordinator stated there were no restorative referrals in the EHR after readmission, and the MDS coordinator confirmed the resident had no restorative programs since readmission.
Failure to Implement Effective Fall and Toileting Interventions for High-Risk Resident
Penalty
Summary
The deficiency involves the facility’s failure to provide adequate supervision, identify fall trends, and implement progressive, resident-centered interventions for a resident with multiple falls and declining strength. The facility’s own Falls and Fall Risk Management policy required staff to identify interventions related to residents’ specific risks and causes to prevent falls and minimize complications. The resident’s Care Area Assessment identified cancer-related risks for pain, falls, and ADL decline, and stated that falls and urinary incontinence would be addressed in the care plan with an objective of improvement and risk minimization. However, the comprehensive care plan did not include a urinary or ADL care plan and contained no toileting plan, despite the resident’s identified risks and prior fall history. Over a series of falls, the resident repeatedly fell while attempting to toilet or move toward the bathroom, yet the facility did not recognize or address this pattern in its investigations or care planning. The resident had multiple unwitnessed falls: next to the bed while getting up to use the restroom, in the bathroom while standing to use the toilet, and near or in the bathroom on several occasions. Incident investigations and post-fall assessments documented environmental factors such as clutter, items on the floor, water on the floor, and issues with footwear, as well as the resident’s increasing weakness, impulsivity, poor safety awareness, and poor insight into limitations. Interventions documented in investigations and risk reviews included encouraging use of the front-wheeled walker, keeping the wheelchair and walker accessible, ensuring proper footwear and non-skid socks, and providing resident education on safe transfers, ambulation, and assistive device use. However, several of these planned interventions, including placement of the wheelchair and frequent rounding/toileting assistance, were not added to or reflected in the care plan as stated. Staff interviews further showed that the resident frequently fell while trying to go to the bathroom and that staff relied on verbal education and reminders to use the call light, even though the resident often did not use it. Staff acknowledged the resident’s impulsivity and tendency to get up independently despite instructions, and one staff member stated that nursing assistants were verbally instructed to offer bathroom assistance, but this intervention was not documented in the care plan. The resident’s bed remained the one furthest from the bathroom throughout the stay, and none of the facility’s investigations identified the trend of bathroom-related falls or addressed toileting options in the care plan. Ultimately, the resident sustained a left ankle fracture after another bathroom-related fall, requiring transfer to the emergency department for evaluation and treatment, and later records documented additional fractures and a decline in condition. The surveyors concluded that the facility’s failures placed residents at risk of repeated falls and injuries.
Failure to Monitor Urinary Retention After Foley Removal Leading to Prolonged Pain
Penalty
Summary
The deficiency involves the facility’s failure to adequately assess and monitor a resident for complications associated with an indwelling urinary catheter and urinary retention, particularly after catheter removal. The resident had a history of acute kidney injury due to urinary retention, which improved after Foley catheter placement in the hospital. Hospital discharge documentation indicated the catheter was placed for acute urinary retention, was deemed permanent, and included instructions that, given the resident’s significant retention and acute renal failure, staff at the skilled nursing facility should not attempt Foley removal. The facility’s catheter care plan directed staff to empty the catheter as needed and record output in milliliters, but review of the last 30 days of documentation showed continence was not rated due to the indwelling catheter and there was no documented urinary output in milliliters on the treatment administration records. The resident had a scheduled urology appointment at which the urinary catheter was discontinued. Upon return from this appointment, nursing documentation initially indicated no new orders, and an alert note later stated the catheter was discontinued and staff were monitoring for retention or pain. However, there was no documented bladder assessment or urinary output following catheter removal. Nursing assistant documentation showed that the resident did not void on the evening shift that same day. Despite the catheter having been removed, the treatment administration record showed staff continued to document provision of catheter care on subsequent shifts when no catheter was in place. Over the next day, the resident experienced vomiting, decreased oral intake, and an altered level of consciousness, with vital signs showing tachycardia and low blood pressure, and staff documented decreased urine output. A bladder scan performed later revealed more than 2000–2500 milliliters of urine in the bladder, and an indwelling catheter was reinserted, initially draining a large volume of urine. The provider note indicated the resident had not eaten since the prior night, was unable to hold down fluids, and staff were unsure whether the resident had urinated in incontinence briefs, with no wet briefs reported since the resident’s return from the hospital after catheter removal. The provider expressed concern that the documented early-morning wet brief might not be accurate given the large bladder volume on scan and stated this should require further investigation. Subsequent notes described the resident moaning and complaining of pain, with limited urine output in the catheter bag and staff flushing and then replacing the catheter due to continued complaints. Interviews with the resident, the roommate, and staff indicated the resident was crying out and moaning in pain, the roommate repeatedly alerted staff that the resident was not urinating and that the catheter was not draining, and staff had to seek assistance to replace the catheter. Facility leadership and clinical staff later acknowledged that typical practice after catheter removal would include contacting the provider, placing the resident on alert, performing post-void residuals with bladder scans, and documenting monitoring, which was not done in this case.
Medication Administration Delays, Documentation Errors, and Use of Expired Insulin
Penalty
Summary
The deficiency involves the facility’s failure to ensure sufficient nursing staff with appropriate competencies and skill sets to administer medications according to professional standards of practice, facility policy, and prescriber orders. The facility’s medication administration policy required medications to be given as prescribed, in accordance with manufacturers’ specifications and good nursing principles, with no expired medications used, and doses administered within 60 minutes of the scheduled time and documented immediately after administration. Multiple residents reported that agency nurses often gave medications late, did not read full instructions, or were slow in bringing medications, and that routinely scheduled medications were not consistently provided without residents having to ask. Surveyors observed several specific medication administration failures. For a resident with diabetes, an LPN drew up and administered Humalog/Lispro insulin from a multi-dose vial that had been opened and dated “02/16” with no year, making it expired per policy, and administered the dose nearly 1 hour and 45 minutes after it was due. Another resident with care plan instructions to receive medications as ordered had multiple scheduled medications (Gabapentin, Oxybutynin, Baclofen, and Tizanidine) that were ordered at specific times throughout the day; the LPN was observed administering all four together and acknowledged that at least one (Tizanidine) was late, while the resident reported that receiving them together at that time was typical and not at their request. For another diabetic resident, an RN checked blood sugar and prepared sliding scale Humalog/Lispro insulin almost two hours after the scheduled time; the resident refused the insulin, stating they had already finished lunch. Additional deficiencies were identified with other residents’ pain and scheduled medications. One resident with a pain care plan and an order for Methocarbamol four times daily at set times approached the cart requesting Methocarbamol and Tylenol; the RN initially stated the Methocarbamol had already been given, but then administered it two hours after it was due when the resident pointed out the scheduled timing. For another resident with a risk for pain care plan and Tramadol ordered three times daily at specific times, an LPN retrieved a PRN pain medication while the electronic record showed no 8:00 AM medications documented; the LPN stated they had given them but had not yet documented. Later, an RN prepared the 2:00 PM Tramadol dose, and review of the narcotic count showed a discrepancy between the number of pills documented and the number remaining in the card. The RN stated they had given the 8:00 AM Tramadol but had not signed it out, then signed out both the 8:00 AM and 2:00 PM doses at that time. Residents interviewed consistently reported that medications were sometimes or frequently late, that agency nurses did not always follow instructions, and that they often had to request medications that were routinely scheduled.
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