Washington Veteran Home-retsil
Inspection history, citations, penalties and survey trends for this long-term care facility in Pt Orchard, Washington.
- Location
- 1141 Beach Drive, Pt Orchard, Washington 98366
- CMS Provider Number
- 505517
- Inspections on file
- 40
- Latest survey
- July 29, 2025
- Citations (last 12 mo.)
- 4
Citation history
Health deficiencies cited at Washington Veteran Home-retsil during CMS and state inspections, most recent first.
The facility did not ensure that an area was free from accident hazards and failed to provide adequate supervision to prevent accidents. Surveyors observed environmental hazards and insufficient staff monitoring, leading to increased risk for residents.
The facility did not follow manufacturer instructions for mechanical lift sling use, resulting in a resident falling and sustaining injuries. Staff were trained incorrectly, and care plans lacked specific guidance. Additionally, fall investigations for several residents were incomplete, with missing assessments and interventions, and required monthly inspections of lift slings were not documented.
The facility did not accurately complete MDS assessments for five residents, including failing to conduct required BIMS interviews for residents who could participate and not properly documenting diagnoses such as dementia. Staff interviews and record reviews confirmed that assessments were either bypassed or incorrectly coded, and that written or alternative communication methods were not utilized when appropriate.
The facility did not ensure that PASRR Level I screenings were complete and accurate for several residents with mental health diagnoses, resulting in missing or incorrect documentation of conditions such as major depressive disorder, anxiety disorder, psychosis, PTSD, and schizoaffective disorder. Staff acknowledged errors in the PASRR forms and confirmed that necessary updates or referrals were not made when required.
The facility did not follow physician orders for medication administration and failed to ensure timely Covid vaccination with proper informed consent for several residents. Antihypertensive medications were given despite vital signs below ordered parameters, and multiple residents experienced delays or lacked documentation of risk/benefit discussions and VIS provision for Covid vaccination.
The facility did not consistently screen residents for influenza and pneumococcal vaccinations, failed to document the review of risks and benefits, and did not always provide the required Vaccine Information Sheet or obtain informed consent. In several cases, vaccines were not offered or administered as required, and staff confirmed these lapses in documentation and process.
Multiple deficiencies were identified, including a resident's urinary catheter bag being left uncovered and visible, mail privacy not being honored for a resident despite repeated requests, two residents missing medical appointments due to lack of available escorts, and a resident left waiting for an extended period in the dining area without being served a meal.
The facility did not transfer trust fund balances to the representatives or estates of two residents within the required 30-day period after discharge or death. Instead, the funds were sent more than two months later, as confirmed by review of account records and staff interviews.
A resident who used essential oils for insomnia was told by staff they could no longer use their diffuser due to complaints about the scent. Although the resident expressed discontent, social services did not offer to file a grievance and no grievance was documented, despite facility expectations that staff initiate grievances for resident concerns.
Two residents did not have accurate or complete care plans: one did not have the correct schedule for passive ROM restorative nursing, and another had a documented dementia diagnosis without a corresponding care plan. Staff confirmed discrepancies in both cases, including errors in the MDS and care plan documentation.
A resident who was dependent on staff for most ADLs, including oral care, did not consistently receive assistance with oral hygiene as required by their care plan. Staff reported that oral care was missed over several days due to time constraints and short staffing, despite facility expectations for care to be provided on both day and evening shifts.
Two residents did not receive care according to their orders and facility protocols: one experienced a six-day delay in bowel management interventions despite clear protocols, and another did not receive properly sized compression stockings for lymphedema, with staff unable to verify use or size despite documentation indicating otherwise.
Three residents received PRN opioid pain medications without documentation or provision of non-pharmacological interventions (NPIs) beforehand, despite facility policy and provider orders requiring this. Staff interviews confirmed that NPIs were not consistently offered or documented prior to administering pain medications, and pain medication records did not meet expectations.
A resident with moderate cognitive impairment was prescribed psychotropic medications, but the facility failed to complete and document required Gradual Dose Reductions (GDRs) as per regulatory standards. Only one GDR attempt was made for each medication over extended periods, and there was no supporting documentation for GDRs or contraindications. Staff were unclear on GDR requirements, and facility policy lacked specific time frames for GDR attempts.
Staff failed to lock medication carts when stepping away, leaving medications accessible while attending to residents or walking to the nurse's station. Multiple staff, including LPNs and nursing leadership, confirmed that carts should have been locked when unattended, but observations showed this was not consistently done.
The facility did not consistently record or verify dishwasher temperatures, failed to discard expired and moldy food items, and allowed staff to handle ready-to-eat food with gloved hands without changing gloves or using utensils. These actions resulted in multiple breaches of food service safety and sanitation standards.
Staff did not consistently follow infection control protocols, including failing to change N95 masks after exiting rooms of COVID-positive residents, improper use of hand sanitizer on gloved hands, and not adhering to Enhanced Barrier Precautions during urinary catheter care for two residents. These actions resulted in lapses in PPE use, hand hygiene, and catheter care standards.
Multiple incidents of resident-to-resident altercations and an allegation of theft by a staff member were not reported or logged to the state agency within the required timeframe. These events involved residents with varying cognitive impairments and resulted in injuries such as skin tears and bruising. Staff interviews revealed inconsistent reporting practices and a lack of awareness regarding proper procedures.
The facility did not investigate multiple incidents where two residents with severe cognitive impairment were involved in altercations with other residents, including physical and verbal threats. Despite facility policy requiring investigation of such events, no documentation or evidence of investigations was found.
A resident with severe cognitive impairment and multiple diagnoses experienced several falls due to the facility's failure to consistently implement and monitor fall prevention interventions. Despite a care plan requiring hourly toileting, staff documentation showed non-compliance, with only four out of 60 shifts meeting the requirement. The resident attempted to use the bathroom independently, leading to falls and injuries, while the facility failed to determine effective interventions for the resident's behavior.
A resident with severe cognitive impairment and urologic issues frequently disconnected their catheter, leading to falls and a urinary tract infection. The facility failed to provide adequate monitoring, follow-up with urology, or specific care plan interventions, resulting in the resident's hospitalization for septic shock.
A resident with severe cognitive impairment did not receive consistent oral care as required by their care plan. Despite being dependent on staff for all ADLs, the resident's oral care was not documented on multiple occasions, leading to poor oral hygiene. Staff interviews revealed time constraints and lack of awareness of refusals as contributing factors.
The facility failed to ensure sufficient qualified nursing staff were available to provide care and services, leading to long wait times for assistance, missed ADLs, and delays in meal tray delivery. The Restorative Nursing Program was also impacted due to staff being pulled to cover absences.
The facility failed to thoroughly investigate allegations of abuse, neglect, and misappropriation for two residents, leading to deficiencies in ensuring resident safety and proper documentation. Incidents involving threats and aggressive behavior were not properly documented or investigated, and care plans were incorrectly updated. Additionally, behavior monitoring was not implemented for a resident involved in an altercation.
The facility failed to offer and honor bathing choices for three residents, leading to a deficiency in promoting resident self-determination. Residents expressed preferences for more frequent showers, but their electronic health records lacked documentation of these preferences, and they were not provided showers as scheduled. The Director of Nursing confirmed the failure to adhere to care plans.
The facility failed to provide necessary restorative services to three residents, leading to a risk of avoidable decline in their ability to perform activities of daily living. Staffing issues were identified as the primary barrier, with restorative aides frequently reassigned from their duties.
The facility failed to follow bowel management protocols for five residents and did not adhere to a fluid restriction order for another resident. This led to extended periods without bowel movements and excessive fluid intake, placing residents at risk for various health complications. Staff interviews confirmed these deficiencies.
The facility failed to ensure resident safety from falls, particularly for a resident with dementia who experienced multiple falls. Despite care plan interventions, bedrails were not installed, and a recliner identified as a fall risk was not promptly removed or replaced. Staff acknowledged communication lapses and failure to conduct regular safety assessments.
The facility failed to ensure medications were properly dated when opened, discarded expired drugs, and secured medications in locked storage. Undated and expired medications were found in two medication carts and two medication rooms, and two residents had unsecured medications at their bedside.
The facility failed to serve food at appetizing temperatures, with observations showing that food temperatures were not taken before service and delays in delivering room trays led to cold meals for residents. Two residents reported consistently receiving cold breakfast, particularly eggs.
The facility failed to maintain a current hospice Plan of Care (POC) for four residents receiving hospice services. Staff were unable to locate the necessary documentation in both electronic health records and hospice binders, leading to a lack of proper documentation of hospice services provided.
The facility failed to provide dignified and respectful care for a resident with multiple diagnoses, leaving him in an unkempt state and neglecting essential care tasks such as oral care and feeding due to staffing constraints. Observations and staff interviews confirmed these deficiencies, which were contrary to the facility's stated standards.
The facility failed to accurately assess a resident for a significant change in condition. The resident, admitted with Parkinson's disease, Lewy Body Dementia, and a UTI, was not marked as receiving hospice care in the Significant Change in Status Assessment MDS, despite being admitted to hospice. Staff confirmed that the hospice care should have been marked in the MDS.
The facility failed to ensure care plans were reviewed, revised, and accurately reflected the care needs of four residents. Issues included missing care instructions for a PICC line, lack of a required PASRR Level II referral, outdated mobility and continence plans, and missing hospice care instructions. The Director of Nursing and MDS Coordinator acknowledged these deficiencies.
The facility failed to follow and clarify physician orders for four residents, leading to medication errors, incomplete BiPAP settings, and improper fluid restriction documentation. These deficiencies placed residents at risk for delays in treatment and potential negative outcomes.
The facility failed to ensure proper care and positioning of urinary catheter tubing and drainage bags for two residents, leading to potential health risks. One resident's catheter drainage bag was uncovered and positioned above the bladder level, while another's bag was lying directly on the floor without a cover. Staff did not address these issues, increasing the risk of infection.
The facility failed to properly maintain and monitor IV access devices for a resident, leading to incomplete PICC maintenance orders and improper use of dial-a-flow infusion sets. This resulted in significant delays in medication administration and placed the resident at risk for various complications.
The facility failed to provide consistent behavior monitoring for the use of psychotropic medications for two residents, leading to a deficiency. Both residents, diagnosed with dementia, were prescribed antipsychotic medications, but their medication administration records lacked documentation of behavior monitoring. Staff and the DNS confirmed the absence of required documentation, which did not meet the facility's expectations.
Facility staff failed to notify a provider of moderate and severe medication interactions for a resident, despite alerts from the EHR system. Interviews confirmed that staff did not follow up on these alerts, leading to a deficiency citation under WAC 388-97-1620 (2)(b)(ii).
Failure to Maintain Accident-Free Environment and Adequate Supervision
Penalty
Summary
The facility failed to ensure that an area was free from accident hazards and did not provide adequate supervision to prevent accidents. Surveyors observed that the environment contained hazards that could lead to resident accidents, and staff did not implement sufficient measures to monitor or protect residents from these risks. This deficiency was identified based on direct observations and findings during the survey, which indicated lapses in maintaining a safe environment and in providing necessary supervision to prevent accidents.
Failure to Follow Mechanical Lift Guidelines and Incomplete Fall Prevention Measures
Penalty
Summary
The facility failed to follow manufacturer guidelines during the use of a mechanical lift and sling for two residents who required assistance with transfers. In one incident, a resident who was dependent on staff for activities of daily living and had no recent history of falls was transferred using a red toileting sling. Staff did not crisscross the sling straps between the resident's legs as required by the manufacturer's instructions, resulting in the resident sliding through the sling and falling to the floor, sustaining a hip fracture and a head laceration. Staff interviews revealed that multiple nursing assistants were trained to use the sling in a manner inconsistent with manufacturer instructions, and neither the investigation nurse nor the director of nursing could state the correct method for using the sling. The care plan also lacked specific instructions on proper sling use. The facility also failed to conduct thorough fall investigations and implement individualized fall prevention interventions for several residents with a history of falls. For one resident with multiple falls, investigations were incomplete, often missing assessments of environmental factors, last toileting assistance, or staff interviews. Root causes were not consistently identified, and interventions were either not documented or not followed up. Another resident with a neurological condition and multiple falls did not have timely or adequate interventions, such as anti-roll back wheelchairs, and care plans were not updated to reflect new interventions or equipment provided. Additionally, the facility did not adhere to manufacturer requirements for routine inspection and documentation of mechanical lift slings. The operating manual specified that slings must be inspected monthly for damage and a permanent record kept, but the director of nursing confirmed that no such records were maintained. These failures in following equipment guidelines, conducting comprehensive fall investigations, and maintaining required documentation contributed to the deficiencies identified during the survey.
Failure to Accurately Complete MDS Assessments and Cognitive Status Interviews
Penalty
Summary
The facility failed to ensure accurate and complete Minimum Data Set (MDS) assessments for five residents, resulting in deficiencies related to cognitive status, diagnoses, and communication abilities. For several residents, the Brief Interview for Mental Status (BIMS) was not conducted as required, despite documentation and staff interviews indicating that the residents were able to understand, be understood, and participate in interviews. Instead, staff completed the Staff Assessment for Mental Status (SAMS) or incorrectly coded the MDS, bypassing the resident interview process without appropriate justification. In one case, a resident who was non-verbal but able to communicate via written means or technology was not given a written BIMS assessment, contrary to protocol. Additionally, there were discrepancies in the documentation of diagnoses. For one resident, the MDS did not reflect a diagnosis of dementia or Alzheimer's disease, despite multiple physician notes in the medical record indicating a diagnosis of dementia. Staff interviews confirmed that the provider's documentation should have been recognized and incorporated into the MDS, but this was not done, resulting in an inaccurate assessment. Another resident's MDS was not assessed for BIMS despite the resident being present and able to participate, as confirmed by staff. The Resident Assessment Instrument (RAI) Manual requires that staff attempt a BIMS on all residents unless specific criteria are met, such as the resident being rarely or never understood or unable to respond by any method. The facility's failure to follow these guidelines led to incomplete and inaccurate assessments regarding residents' cognitive status, communication, and diagnoses, as evidenced by the review of records and staff interviews.
Incomplete and Inaccurate PASRR Documentation for Multiple Residents
Penalty
Summary
The facility failed to ensure that Level I Preadmission Screening and Resident Reviews (PASRR) were complete and accurate for four out of seven sampled residents. For one resident with diagnoses including major depressive disorder, anxiety disorder, and unspecified psychosis, the PASRR Level I forms did not consistently reflect all current diagnoses, and a Level II evaluation was not completed despite changes in the resident's condition. Staff acknowledged that a new referral was not sent and that errors in the PASRR documentation were not corrected in a timely manner. Another resident with diagnoses of PTSD, major depressive disorder, anxiety disorder, and schizoaffective disorder had a PASRR Level I that failed to indicate any serious mental illness, which staff later confirmed was incorrect. Additional residents with diagnoses such as major depressive disorder, unspecified dementia, and anxiety disorder also had PASRR Level I forms that omitted relevant diagnoses. Staff interviews confirmed that these omissions were recognized but not addressed at the time, resulting in incomplete and inaccurate PASRR documentation for multiple residents.
Failure to Follow Physician Orders and Vaccination Protocols
Penalty
Summary
The facility failed to ensure that medications were administered according to physician orders and that vaccinations were provided in a timely manner with proper informed consent. For one resident, antihypertensive medications (amlodipine and metoprolol) were administered despite a diastolic blood pressure below the threshold specified in the physician's order, which required the medications to be held. Staff confirmed that the medications should have been withheld as per the order. Additionally, multiple residents experienced deficiencies related to the administration of Covid vaccinations. In several cases, there was a lack of timely administration following consent, missing documentation of risk/benefit discussions, and failure to provide or document the Vaccine Information Statement (VIS). Some residents did not receive the vaccine for months after consent, and in one case, a resident's refusal was not accompanied by documentation that risks and benefits were reviewed. Staff interviews confirmed that these actions did not meet facility expectations for timely vaccination and informed consent procedures.
Failure to Screen, Document, and Obtain Informed Consent for Vaccinations
Penalty
Summary
The facility failed to ensure that residents were properly screened and provided with informed consent for influenza and pneumococcal vaccinations. For five residents reviewed, there were multiple instances where either the risk and benefits of the vaccines were not documented, the required Vaccine Information Sheet (VIS) was not provided, or the vaccines were not offered or administered according to protocol. In several cases, consent for vaccination was obtained, but there was no documentation that the risks and benefits were reviewed with the resident or their representative. In one instance, a resident's refusal of the influenza vaccine was documented, but there was no evidence that the risks and benefits of refusal were discussed. Another resident had not been offered either the influenza or pneumococcal vaccine since admission, and their vaccination status had not been reviewed as part of the admission process. Staff interviews confirmed these deficiencies, with the Infection Preventionist and Director of Nursing Services acknowledging that the review of risks, benefits, and provision of VIS were not consistently documented or completed for every vaccine administration. The Director of Nursing Services also confirmed that it did not meet expectations for residents' vaccination status to go unreviewed or for vaccines not to be offered as required.
Failure to Honor Resident Dignity, Privacy, and Rights to Services
Penalty
Summary
The facility failed to maintain resident dignity and privacy in several instances. One resident with a neurogenic bladder and an indwelling urinary catheter was observed multiple times with their urinary drainage bag visible from the hallway and door side of the bed, without a dignity cover in place. Staff acknowledged that a dignity cover should have been used, but the issue persisted over several days. Another resident, dependent on staff for most activities of daily living and with a diagnosis of obstructive and reflux uropathy, reported ongoing issues with their roommate tampering with their mail. Despite repeated requests and documentation in the electronic health record for mail to be delivered directly to them or inside their room, mail continued to be left outside the room. Staff interviews revealed a lack of awareness of the resident's request and a breakdown in communication, resulting in the resident's mail privacy not being honored. The facility also failed to ensure residents' rights to attend medical appointments. Two residents missed important medical appointments because the facility was unable to provide an escort due to staff call outs. In one case, a resident's surgery consultation was canceled and not yet rescheduled, and in another, a resident who did not require an escort still had their appointment canceled. Additionally, a resident was left waiting for 24 minutes in the dining area without being served a meal, ultimately leaving the dining room without eating. Staff confirmed that meals should be served promptly upon seating, and the delay was not acceptable.
Delayed Transfer of Resident Trust Funds After Discharge or Death
Penalty
Summary
The facility failed to transfer resident trust fund balances to the appropriate resident representatives or estates within the required 30-day period following discharge or death. For one resident who was discharged on 11/25/2024, the trust account balance of $83 was not conveyed until 70 days later, as confirmed by the facility's fiscal analyst. Similarly, another resident discharged on 11/29/2024 had a trust account balance of $50, which was not sent to the representative or estate until 66 days after discharge. These delays were verified through review of trust account ledgers and staff interviews, demonstrating noncompliance with regulatory requirements for timely transfer of resident funds.
Failure to Initiate and Resolve Resident Grievance Regarding Aromatherapy Use
Penalty
Summary
The facility failed to initiate, investigate, and resolve a grievance for one resident who was admitted with a diagnosis including insomnia and was able to communicate their needs. The resident expressed being upset after being told by staff that they could no longer use their essential oils due to complaints about the strong smell. Documentation showed that the resident was informed by social services that the use of their diffuser was not allowed, and they were provided with a fragrance-free facility policy. Despite the resident expressing discontent, no grievance was filed or documented in the grievance log for the relevant period. Social services staff did not offer to file a grievance, stating the resident could initiate one independently, which was contrary to the administrator's stated expectation that staff should initiate grievances for resident concerns.
Deficient Care Planning for Restorative and Dementia Care
Penalty
Summary
The facility failed to accurately complete and update care plans for two residents, resulting in deficiencies related to care planning. For one resident, the care plan for the restorative nursing program (RNP) was not consistent with the intended schedule. The resident was supposed to receive passive range of motion (ROM) exercises to both upper and lower extremities on alternating days, but the care plan listed both as occurring on the same days. The resident reported not receiving the RNP daily as expected, and the restorative nurse confirmed the care plan needed revision to reflect the correct alternating schedule. Another resident was admitted with a diagnosis of traumatic brain injury and was cognitively intact according to the Minimum Data Set (MDS), with no documented diagnosis of dementia or Alzheimer's disease. However, physician notes indicated a diagnosis of dementia, and staff confirmed this diagnosis was present in the electronic health record. Despite this, there was no dementia care plan in place for the resident, and staff acknowledged that the MDS was incorrect and a dementia care plan should have been developed based on the diagnosis.
Failure to Provide Consistent Oral Care Assistance
Penalty
Summary
Staff failed to provide consistent assistance with activities of daily living (ADLs), specifically oral care, for one resident who was dependent on staff for most ADLs. The resident, who had diagnoses including diabetes, obstructive and reflux uropathy, and depression, reported that staff were inconsistent in providing oral care. The resident's care plan required oral care in the morning, after meals, and at bedtime with substantial dependent assistance. A certified nursing assistant confirmed that oral care was not provided to the resident over the past few days due to lack of time and short staffing. The Director of Nursing Services stated that the expectation was for oral care to be provided on both day and evening shifts.
Failure to Follow Bowel and Edema Management Protocols
Penalty
Summary
The facility failed to provide appropriate treatment and care for two residents, resulting in deficiencies related to bowel management and edema management. For one resident with moderate cognitive impairment, the facility did not follow its bowel care protocol or the resident's medication orders when the resident experienced six consecutive days without a bowel movement. Although the facility's protocol required specific interventions and provider notification after three days without a bowel movement, documentation showed that bowel medications were not administered until the sixth day, and there was no record of the resident refusing medications or being monitored for refusal. In a separate incident, another resident with acute heart failure and lymphedema did not receive timely or appropriate compression stockings as ordered. Despite nurses documenting that the resident wore compression stockings on certain days, multiple observations confirmed that the resident was not wearing them, and the correct size could not be verified. The compression stockings were found in the resident's room, unlabelled and unused, and staff were unable to confirm the appropriate size. The DON acknowledged that documentation and adherence to provider orders for compression stockings did not meet expectations.
Failure to Document and Provide Non-Pharmacological Interventions Prior to PRN Pain Medication Administration
Penalty
Summary
The facility failed to ensure that non-pharmacological interventions (NPIs) were offered, provided, and documented prior to administering as-needed pain medications for three residents. For one resident with bipolar disorder, depression, and anxiety who required substantial assistance with daily living, hydrocodone-acetaminophen was administered eight times in April without any documentation that NPIs were offered or provided, contrary to facility expectations. The Director of Nursing Services confirmed that NPIs should have been documented in the Medication Administration Record (MAR) or progress notes before giving as-needed pain medication. Another resident with severe cognitive impairment had an order for oxycodone that specifically required documentation of NPIs prior to administration, but the MAR and TAR showed multiple instances where the opioid was given without such documentation. Additionally, a resident with chronic pain, depression, diabetes, and other conditions received oxycodone 20 times in April without NPIs being provided beforehand. Staff interviews confirmed that NPIs were not documented or available for these residents as required, and that pain medication records did not meet facility expectations.
Failure to Complete and Document Required Gradual Dose Reductions for Psychotropic Medications
Penalty
Summary
The facility failed to ensure that a Gradual Dose Reduction (GDR) was completed for one resident reviewed for unnecessary medications. The resident, who was moderately cognitively impaired, was prescribed Sertraline for depression and Zyprexa for dementia with psychotic disturbance. Documentation showed only one GDR attempt for Sertraline in over two years and only one GDR attempt for Zyprexa in the previous thirteen months. There was no supporting documentation in the electronic health record (EHR) for a GDR on the date indicated in the Minimum Data Set (MDS), nor was there documentation from the pharmacy or provider requesting a GDR or supporting contraindications for GDR. Staff interviews revealed confusion regarding the requirements for GDRs, with staff referencing facility policy and pharmacy guidelines but unable to provide documentation supporting their practices. The facility's policy did not specify time frame requirements for GDR attempts, and no further documentation was provided to support that appropriate GDRs or contraindications had been addressed for the resident's psychotropic medications.
Medication Carts Left Unlocked When Unattended
Penalty
Summary
Staff failed to ensure that medication carts were locked when unattended, as required by professional standards and facility policy. On multiple occasions, staff members left medication carts unlocked while stepping away or attending to residents, including on the dementia unit where an LPN left the cart unattended with residents nearby. The LPN acknowledged that the cart should have been locked, and other staff, including the Medicare Coordinator, Interim Assistant Director of Nursing Services, and Director of Nursing Services, confirmed that the expectation was for carts and computer screens to be locked when unattended. Additional observations revealed that another medication cart was left unlocked while an LPN was working with a resident and then walked away to the nurse's station. The LPN also acknowledged that the cart should have been locked. These incidents were directly observed and confirmed through staff interviews, demonstrating a failure to maintain secure storage of medications as required.
Failure to Maintain Food Service Safety and Sanitation Standards
Penalty
Summary
The facility failed to store, prepare, and serve food in accordance with professional standards, as evidenced by multiple deficiencies in food service safety. Review of dishwasher temperature logs over several months revealed that temperatures were not consistently recorded in any of the dining rooms, with most logs left blank and only sporadic entries in one area. Staff interviews confirmed that signatures on the logs were used in place of actual temperature recordings, and staff could not verify if dishwashers were operating at required temperatures. Direct observation of the dishwashing process showed that the thermometers on the dishwasher did not register any temperature changes during test cycles, and staff were unable to confirm if dishes were being properly sanitized. During a tour of the produce cooler, expired and moldy food items were found, including lime juice and mustard past their expiration dates and containers of strawberries with visible mold. Staff acknowledged that these items should have been discarded and stated that cooler clean-outs were supposed to occur regularly, but the presence of expired and spoiled food indicated this was not consistently done. The food services manager confirmed that expired and moldy food should not be present and should have been thrown out. Observations of meal preparation revealed that staff were handling ready-to-eat food with gloved hands instead of utensils, repeatedly touching food items and plates without changing gloves or performing hand hygiene. When questioned, staff admitted that this practice was not appropriate and did not meet expectations for food safety. The food services manager confirmed that staff should not touch food that is served to residents and should change gloves to prevent cross-contamination.
Infection Control Deficiencies in PPE Use, Hand Hygiene, and Catheter Care
Penalty
Summary
Staff failed to maintain proper infection control practices in the COVID-positive unit, specifically regarding the donning and doffing of N95 masks. Multiple staff members, including a custodian and certified nursing assistants, were observed not changing their N95 masks after exiting rooms of residents on aerosol precautions for COVID-19. The N95 masks were located outside the unit, and staff reported changing masks only when entering or leaving the unit, rather than after each resident room as required. Signage on the unit doors instructed staff to change masks after exiting positive resident rooms, but this was not consistently followed. Hand hygiene practices were also deficient. A staff member was observed using hand sanitizer on gloved hands instead of removing gloves and performing hand hygiene as required. This practice was acknowledged by the infection preventionist and director of nursing as inappropriate and not in line with facility expectations. Urinary catheter care was not performed according to standards for two residents on Enhanced Barrier Precautions (EBP). One staff member donned PPE inside the resident's bathroom, which was identified as a potentially contaminated area, and another staff member failed to wear a gown during catheter care. Additionally, improper hand hygiene and glove changes were observed during catheter care, including touching multiple surfaces and resident items without changing gloves or performing hand hygiene between tasks. The staff also failed to use appropriate disinfectant techniques when disconnecting and reconnecting catheter tubing.
Failure to Timely Report and Log Allegations of Abuse, Neglect, and Theft
Penalty
Summary
The facility failed to report and log multiple allegations of abuse, neglect, and misappropriation of property to the state agency within the required five working days, as mandated by facility policy and state and federal regulations. Review of incident logs and progress notes revealed that several resident-to-resident altercations, as well as an allegation of theft by a staff member, were either not reported at all or were reported late. These incidents involved residents with varying levels of cognitive impairment, including those with severely impaired cognition, and included physical altercations resulting in injuries such as skin tears, bruising, and abrasions. Specific incidents included residents being struck, placed in headlocks, and sustaining injuries during altercations. In one case, a resident accused a nursing assistant of theft, but the allegation was not reported to the state agency in a timely manner. The incident logs did not reflect several of these events, and in some cases, there was no evidence that the incidents were reported to the appropriate authorities as required. Interviews with facility staff indicated a lack of awareness and inconsistent practices regarding the reporting and logging of such incidents. The investigation nurse acknowledged that some incidents were missed due to erroneous information and personal leave, and noted that direct care staff needed more support in reporting incidents. The DON and administrator were unaware of the reporting issues and expected that incidents would be investigated and reported promptly.
Failure to Investigate Resident-to-Resident Altercations
Penalty
Summary
The facility failed to thoroughly investigate allegations of resident-to-resident altercations involving two residents with severely impaired cognition. For one resident, progress notes documented two separate incidents: one where an unknown resident shouted at and nearly hit the resident, requiring staff intervention, and another involving a physical altercation with another resident over alleged theft, during which threats and physical contact occurred. For the second resident, progress notes described an incident where another resident leaned toward the resident's face, prompting the resident to push the other individual. In all cases, the facility was unable to provide evidence that investigations into these incidents were conducted. According to facility policy, all incidents of alleged or suspected abuse, neglect, or misappropriation of property are to be reported and investigated in accordance with state and federal regulations. However, interviews and record reviews confirmed that no investigations were completed for the incidents described, as acknowledged by the facility's investigation nurse. This lack of investigation was found to be inconsistent with the facility's own policies and regulatory requirements.
Failure to Implement and Monitor Fall Prevention Interventions
Penalty
Summary
The facility failed to consistently implement and monitor interventions for a resident at risk for falls, leading to multiple incidents. The resident, who has severe cognitive impairment, dementia, PTSD, and blindness, was admitted with a care plan that included hourly toileting, keeping items within reach, and maintaining room visibility. Despite these interventions, the resident experienced several falls, including incidents where they attempted to use the bathroom independently due to long wait times for assistance. The facility's documentation revealed that staff did not consistently assist the resident with toileting every hour as required, with only four out of 60 shifts showing compliance. The facility's incident reports and progress notes documented multiple falls and attempts by the resident to use the bathroom independently, resulting in injuries such as skin tears. The Director of Nursing acknowledged the lack of consistent documentation and the failure to determine effective interventions for the resident's behavior of disassembling their catheter. The facility's inability to ensure the effectiveness of fall interventions and the lack of consistent staff documentation contributed to the deficiency, placing the resident at risk for further accidents and injuries.
Failure to Monitor and Manage Indwelling Catheter Use
Penalty
Summary
The facility failed to adequately monitor and manage the use of an indwelling urinary catheter for a resident with severe cognitive impairment and multiple urologic issues, including an enlarged prostate and neurogenic bladder. The resident frequently disconnected their catheter, leading to urine spills and attempts to self-transfer to the toilet, which resulted in multiple falls and skin tears. Despite these ongoing issues, there was no follow-up with urology after the initial consultation, and no specific guidance or interventions were documented in the care plan to address the resident's behavior or the risk of infection. Staff interviews revealed a lack of communication and planning regarding the resident's catheter management and infection risk. Nursing staff were aware of the resident's frequent disassembly of the catheter but had not received specific instructions on how to manage the situation. The Director of Nursing confirmed the absence of a care plan addressing the catheter issues and infection control measures. The resident was hospitalized with septic shock due to a urinary tract infection, highlighting the facility's failure to prevent and manage catheter-associated complications.
Failure to Provide Consistent Oral Care for Dependent Resident
Penalty
Summary
The facility failed to consistently provide oral care for a resident who was dependent on staff for all activities of daily living (ADLs). The resident, who had severe cognitive impairment and was admitted with a care plan requiring oral care twice daily, did not receive documented oral care on multiple occasions across different shifts in April and May 2024. A dental hygienist noted severe oral hygiene issues, including dried mucus in the resident's mouth, indicating a lack of proper oral care. Photos taken in June 2024 further confirmed the poor condition of the resident's oral cavity. Interviews with staff revealed inconsistencies in the provision of oral care. A nursing assistant admitted to providing oral care every other day due to time constraints, while a registered nurse and unit care coordinator acknowledged the resident's resistance to oral care but did not report any refusals. The director of nursing was unaware of any issues with oral care refusals or staff challenges. The lack of adequate staffing and time was cited as a reason for the failure to provide the necessary oral care, particularly in a heavy care unit.
Insufficient Qualified Nursing Staff
Penalty
Summary
The facility failed to ensure sufficient qualified nursing staff were available to provide care and services, as evidenced by multiple resident and staff interviews. Residents reported long wait times for assistance, with some waiting up to an hour for staff to respond to call lights. Several residents also mentioned that they were unable to receive daily shaves or showers due to staff being too busy. Staff interviews corroborated these claims, with many staff members stating that they were unable to complete all their assigned tasks due to being short-staffed. This included essential activities of daily living (ADLs) such as shaving, oral care, and feeding residents. The shortage of staff also affected the timely delivery of meal trays, with some residents receiving cold food due to delays in service. Additionally, the facility's Restorative Nursing Program (RNP) was impacted, as aides from the RNP department were frequently pulled to cover direct care staff absences. This resulted in residents not receiving their required restorative programs. Staff members confirmed that this was a common occurrence, particularly on weekends. The facility's Director of Nursing Services and Administrator acknowledged the staffing issues, citing challenges in hiring CNAs and the impact of the pandemic on their staffing levels. Despite efforts to recruit and train new staff, the facility continued to struggle with maintaining adequate staffing levels to meet the needs of its residents.
Failure to Investigate Allegations of Abuse and Implement Interventions
Penalty
Summary
The facility failed to thoroughly investigate three out of four allegations of abuse, neglect, and/or misappropriation for two residents, leading to deficiencies in ensuring resident safety and proper documentation. For Resident 97, there were multiple incidents involving threats and aggressive behavior from roommates. The investigations did not include interviews with all relevant staff members, failed to establish a clear timeline of events, and incorrectly updated Resident 97's care plan with information that should have been attributed to the roommate. This lack of thorough investigation and documentation detracted from the ability to ensure Resident 97's safety and address the incidents appropriately. In one incident, Resident 97 reported that his roommate threatened to kill him and smeared feces and urine in the bathroom. The investigation concluded that the roommate's delusions were exacerbated by the new environment, but there was no documentation of interviews with staff who were present during the incidents. Another incident involved Resident 97's roommate threatening to beat him, but the investigation was deemed unsubstantiated without interviewing direct care staff or providing a clear explanation for the conclusion. Additionally, Resident 97's care plan was incorrectly updated to reflect delusions and vivid dreams attributed to the roommate. For Resident 105, the facility failed to document and implement behavior monitoring after an altercation where Resident 105 was punched by another resident. Although the other resident was care planned for behavior monitoring, there was no documentation of this intervention being implemented. The Director of Nursing Services acknowledged that the expectation for immediate intervention and accurate care plan updates was not met, leading to a deficiency in ensuring resident safety and proper documentation.
Failure to Honor Resident Bathing Preferences
Penalty
Summary
The facility failed to offer and honor bathing choices for three residents, leading to a deficiency in promoting and facilitating resident self-determination. Resident 97, who had moderate cognitive impairment, expressed that he was not given a choice about his bathing frequency and preferred three showers a week. His electronic health record showed no documentation of his preferences, and he was only provided one shower per week instead of the scheduled two. Staff confirmed that residents scheduled for more than one shower a week were sometimes informed it would not be provided due to staffing issues. Resident 102, who was cognitively intact, also indicated he was not given a choice about his bathing frequency and preferred three showers a week. His electronic health record similarly lacked documentation of his preferences, and he was only provided one shower in a 20-day period instead of the scheduled one per week. Resident 125, who was cognitively intact, stated he was not allowed to choose his bathing frequency and preferred at least two showers a week. His care plan scheduled him for one shower a week, but he was not provided a shower on one of the scheduled days. The Director of Nursing confirmed that staff failed to provide bathing at the frequency care planned for these residents and was unsure who was responsible for identifying and documenting resident care preferences. This lack of adherence to resident preferences and care plans led to the deficiency in promoting resident self-determination and choice.
Failure to Provide Required Restorative Services
Penalty
Summary
The facility failed to provide the necessary care and services to ensure residents' ability to participate in activities of daily living did not diminish. This deficiency was observed in three residents who were assessed to require specific restorative programs. Resident 102, who was cognitively intact but had limited range of motion, did not receive the restorative ambulation program at the required frequency. The resident's restorative flowsheets showed the program was offered only 15 out of 25 times, with no documentation explaining the shortfall. Similarly, Resident 48, who had severe cognitive impairment and limited range of motion, did not receive the restorative transfer and standing exercise programs as frequently as required. The flowsheets indicated the transfer program was offered only 12 out of 25 times, again with no documentation explaining the discrepancy. Resident 97, who had moderate cognitive impairment and no limitations in functional range of motion, also did not receive the required frequency of restorative programs. The resident's lower extremity exercise program was offered only nine out of 12 times, and the ambulation program was offered only four out of 12 times. Staff interviews revealed that restorative aides were frequently pulled from their duties due to staffing issues, which was confirmed by both the Restorative Aide and the Restorative Nurse. This frequent reassignment of restorative aides was identified as the primary barrier preventing the provision of restorative programs at the assessed frequency.
Failure to Follow Bowel Management and Fluid Restriction Protocols
Penalty
Summary
The facility failed to provide necessary care and services to maintain the highest practicable level of well-being for several residents. Specifically, the facility did not follow the bowel management protocol for five residents, leading to extended periods without bowel movements and lack of administration of prescribed medications. For instance, Resident 239 went four days without a bowel movement, and no PRN bowel medication was administered despite the protocol requiring it after 72 hours. Similar failures were noted for Residents 91, 155, 175, and 82, where the bowel protocol was not followed, and necessary medications were not administered as per the orders. Additionally, the facility failed to adhere to a fluid restriction order for Resident 125, who was on a 1500 ml/day fluid restriction due to hyponatremia. The resident's fluid intake exceeded the prescribed limit on multiple occasions, and there was no documentation or calculation of the 24-hour total fluid intake by the nursing staff. The Medication Administration Records (MARs) did not provide a place for nurses to record the resident's fluid intake, and the staff failed to monitor and record the intake accurately. Interviews with staff confirmed these deficiencies. Staff H, a Charge Nurse, acknowledged that the fluid intake was not recorded or tallied, making it impossible to determine if the resident adhered to the fluid restriction. Staff B, the Director of Nursing, confirmed that the fluid restriction orders were incomplete and that the bowel protocol was not followed for the residents reviewed. These failures placed residents at risk for fluid and electrolyte imbalances, nausea, vomiting, pain, discomfort, and other health complications related to untreated constipation.
Failure to Ensure Resident Safety from Falls
Penalty
Summary
The facility failed to ensure residents were safe from falls, specifically for Resident 171, who had multiple falls documented. Resident 171, diagnosed with dementia, experienced falls on several occasions, including 11/22/2023, 11/23/2023, 03/29/2024, 04/09/2024, and 04/15/2024. Despite a care plan intervention dated 04/01/2024 to install bilateral assist bed handles for security and mobility, these were not observed to be installed. Additionally, a safety assessment for a recliner chair was conducted on 04/05/2023, but no further assessments were found, and the recliner was identified as a potential cause of falls without being removed or replaced promptly. On 04/15/2024, Resident 171 reported falling out of the recliner and hurting their left side and thigh. Staff confirmed the resident had slid out of the recliner a week prior. The Neighborhood Coordinator acknowledged a plan to replace the electric chair with a manual one, but this would take two weeks. The Director of Nursing Services stated that interventions like bedrails should have been implemented immediately and that the recliner should have been removed when identified as a root cause. The lack of communication between departments led to the bedrails not being installed, and safety assessments for the recliner were not conducted quarterly as expected.
Medication Management Deficiencies
Penalty
Summary
The facility failed to ensure medications were properly dated when opened and expired drugs and biologicals were discarded according to professional standards. During an audit, it was observed that two medication carts (G2 & G1) and two medication rooms (G2/H2 & A2/B2) contained undated and expired medications. Specifically, an opened and undated multiuse vial of tubersol was found in the G2/H2 medication room refrigerator, and an expired bottle of bismuth was found in the A2/B2 medication room. Additionally, the G2 medication cart contained undated bottles of fluticasone propionate nasal spray and Refresh eye drops, while the G1 cart had undated bottles of latanoprost and timolol maleate eye drops. Staff confirmed that these medications should have been dated upon opening and discarded after their respective expiration periods. Furthermore, the facility did not secure medications in locked storage for two residents. Resident 116 was observed with a bottle of TUMS on their bedside table on multiple occasions, and Resident 125 had a Dulera inhaler in a plastic bin on their bedside table. Staff confirmed that these medications should have been secured and not left at the bedside. These lapses in medication management placed residents at risk for accidentally taking another resident's medication and/or receiving expired or outdated medications and biologicals.
Failure to Serve Food at Appetizing Temperatures
Penalty
Summary
The facility failed to provide food at appetizing temperatures, which was observed during a review of kitchen services. During the lunch meal service, it was noted that none of the items on the steam table had their temperatures taken prior to being served. Additionally, plates were not being warmed within the plate holder, and only the top insulator was used for plating food. Staff EE admitted to not taking the food temperatures due to being in a rush and assuming another staff member had done it. The Dietary Manager, Staff FF, confirmed that temperatures should be taken before placing food on the steam table and thirty minutes into the meal service, and that both insulated plate bases and lids should be used to maintain food quality. The Administrator, Staff A, mentioned that new plate insulators had been ordered but had not yet arrived, and reiterated the expectation for staff to take food temperatures to ensure safe and palatable delivery to residents. Two residents who received meals in their rooms reported that their food, particularly breakfast, was often delivered cold. Resident 97 stated that the eggs were cold every morning, leading to them not eating breakfast. Resident 2 also complained about receiving cold breakfast. Observations showed that room trays were passed after the dining room service, causing delays. Staff H and Staff I confirmed that aides from certain halls were able to get in line for room trays first, resulting in delays for other residents. This process led to the food being cold by the time it was delivered to residents who ate in their rooms, particularly affecting the residents on G2 hall who had to wait longer for their meals.
Failure to Maintain Current Hospice Plan of Care
Penalty
Summary
The facility failed to develop and maintain a current hospice Plan of Care (POC) in collaboration with hospice for four residents receiving hospice services. This deficiency was identified through interviews and record reviews, revealing that the facility did not have documentation of hospice services being provided for the residents. For instance, Resident 137, who was admitted with diagnoses including Parkinson's disease and Lewy Body Dementia, had no documentation of hospice services in the electronic health record since the day after admission to hospice. Staff members, including the Resident Care Manager and Director of Nursing Services, were unaware of the hospice visits and could not locate the necessary documentation in the electronic medical record or hospice binder. Similarly, Residents 118, 37, and 87, all of whom had significant changes in condition and were receiving hospice services, had no hospice POC documented in their electronic health records. Staff members, including the Neighborhood Coordinator and Assistant Director of Nursing Services, were unable to locate the hospice POCs in both the electronic health records and the hospice binders. The Director of Nursing Services acknowledged the issue and indicated that the Neighborhood Coordinators and MDS Coordinator were responsible for obtaining the hospice POCs, but the necessary documentation was still missing for these residents.
Failure to Provide Dignified and Respectful Care
Penalty
Summary
The facility failed to ensure care and services were provided in a respectful and dignified manner for Resident 87, who was admitted with diagnoses including hemiplegia, depression, and polyneuropathy. Observations over several days revealed that Resident 87 was consistently left in an unkempt state, with unbrushed hair, stubble on his face and neck, discharge in his left eye, and food particles around his mouth. The resident was also observed wearing a dirty shirt protector for extended periods, and his Ensure drink was placed out of reach. Staff interviews confirmed that there was insufficient time to provide necessary care such as shaving, oral care, and feeding due to staffing constraints, leading to neglect of these essential tasks. The facility's admissions packet stated that residents have the right to be treated with respect and dignity, yet the observations and staff interviews indicated a failure to uphold this standard. Both the Assistant Director of Nursing Services and the Director of Nursing Services acknowledged that the expectation was for shirt protectors to be removed and oral care to be provided after meals, but this was not being consistently practiced. This deficiency placed residents at risk of being treated with a lack of dignity and respect, thereby diminishing their quality of life.
Failure to Accurately Assess Resident for Significant Change in Condition
Penalty
Summary
The facility failed to accurately assess Resident 137 for a significant change in condition. Resident 137, who was admitted with Parkinson's disease, Lewy Body Dementia, and a UTI, was noted to be cognitively intact and required supervision with ADLs according to the Quarterly Assessment MDS dated 02/28/2024. However, the resident was admitted to hospice care on 03/20/2024, which was not reflected in the Significant Change in Status Assessment MDS. Staff V, the MDS Coordinator, confirmed that hospice care should have been marked in the MDS, as it was the primary reason for the significant change. Staff B, the RN and Director of Nursing, acknowledged that the MDS had been corrected but confirmed that the hospice section should have been marked initially.
Care Plan Deficiencies
Penalty
Summary
The facility failed to ensure resident care plans were reviewed, revised, and accurately reflected residents' care needs for four residents. Resident 239's care plan did not include the type, location, and care instructions for a Peripherally Inserted Central Catheter (PICC) despite being readmitted with this device. The Director of Nursing acknowledged the omission and stated the care plan needed to be updated. Resident 97's care plan did not include a referral for a Level II Pre-Admission Screening and Resident Review (PASRR) assessment for serious mental illness (SMI) despite the assessment indicating the need. Additionally, the care plan included instructions for administering oxygen, but there was no corresponding order in the electronic health record. The Director of Nursing confirmed these discrepancies and stated the care plan needed revision. Resident 116's care plan required the use of sage boots at all times, but observations showed the resident without the boots while in bed. The Director of Nursing stated the boots were not required while the resident was in an Envella air fluidized bed but should be used when in a wheelchair. Resident 87's care plan was outdated and did not reflect the resident's current hospice care needs, including mobility and continence. The care plan also lacked specific instructions provided by hospice staff for skin care and positioning. The Director of Nursing and MDS Coordinator acknowledged the inaccuracies and the need for updates.
Failure to Follow and Clarify Physician Orders
Penalty
Summary
The facility failed to ensure services provided met professional standards of practice for four residents. For Resident 239, nurses administered metoprolol outside of the physician-ordered parameters on multiple occasions, despite specific instructions to hold the medication if certain blood pressure or pulse thresholds were not met. Similarly, Resident 116 received Glargine insulin outside of the ordered parameters and had their metoprolol held without documented assessment or physician's order. These actions indicate a failure to accurately follow and clarify physician's orders, leading to potential medication errors and unmet care needs. Resident 97's BiPAP orders were incomplete, lacking specific settings and instructions for checking and refilling the humidifier, which were not clarified by the nursing staff. Additionally, Resident 125's fluid restriction orders were incomplete, as there was no place for nurses to document fluid intake or calculate 24-hour totals. The Director of Nursing acknowledged these deficiencies, indicating that the facility nurses should have identified and clarified the incomplete orders to ensure proper care. These failures placed residents at risk for delays in treatment and potential negative outcomes.
Improper Catheter Care and Positioning
Penalty
Summary
The facility failed to ensure proper care and positioning of urinary catheter tubing and drainage bags for two residents, leading to potential health risks. Resident 164, who had severe cognitive impairment and an indwelling urinary catheter due to obstructive uropathy, was observed in a wheelchair with the catheter drainage bag uncovered and positioned above the level of the bladder. Despite multiple staff members passing by, none addressed the improper positioning or lack of a dignity cover for the drainage bag. The Director of Nursing confirmed that the drainage bag should have been covered and maintained below the bladder level to prevent backflow and potential urinary tract infections. Resident 116, who also had severe cognitive impairment and an indwelling urinary catheter due to a stage IV sacral pressure ulcer, was observed with the catheter drainage bag lying directly on the floor without a cover. The Administrator confirmed the improper positioning of the drainage bag, and the Director of Nursing acknowledged that the bag should have been secured to the bed frame to prevent contamination and reduce the risk of infection. These observations indicate a failure to adhere to proper catheter care protocols, placing residents at risk for catheter-associated urinary tract infections and other complications.
Failure to Properly Maintain and Monitor IV Access Devices
Penalty
Summary
The facility failed to ensure intravenous (IV) access devices were assessed, maintained, and monitored in accordance with professional standards of practice for Resident 239. The resident, who was readmitted with a double lumen Peripherally Inserted Central Catheter (PICC) for IV antibiotic therapy, had incomplete PICC maintenance and monitoring orders. These orders did not include directions for weekly PICC dressing changes, replacement of needleless injection caps, or measurement of the PICC's external length upon admission and weekly thereafter. Additionally, the nursing staff were not trained or competent in the use of dial-a-flow infusion sets, leading to improper administration of IV medications. Specifically, the dial-a-flow infusion set was not validated for the correct infusion rate, resulting in the IV ceftriaxone infusing at an incorrect rate over an extended period of time. On multiple occasions, the nursing staff failed to manually verify the infusion rate of the dial-a-flow infusion set, leading to significant delays in medication administration. For instance, during an observation, the IV ceftriaxone infusion, which was supposed to be completed in 30 minutes, was still infusing after 1 hour and 29 minutes. The charge nurse admitted to not being aware of the need to manually check the infusion rate. The Director of Nursing Services (DNS) confirmed that the PICC line maintenance and monitoring orders were incomplete and acknowledged the failure to manually verify the infusion rate. These deficiencies placed the resident at risk for loss of vascular access, infection, and IV medication errors.
Failure to Monitor Psychotropic Medication Use
Penalty
Summary
The facility failed to provide consistent behavior monitoring for the use of psychotropic medications for two residents, leading to a deficiency. Resident 175, diagnosed with a neurocognitive disorder, was prescribed an antipsychotic medication for delusions related to dementia. However, the medication administration records (MAR) for March and April 2024 showed no documentation of behavior monitoring for the use of the antipsychotic medication. Staff CC and the Director of Nursing Services (DNS) confirmed the lack of documentation, which did not meet the facility's expectations. Similarly, Resident 82, also diagnosed with dementia, was prescribed Zyprexa, an antipsychotic medication. The MAR for March and April 2024 also lacked documentation of behavior monitoring for this resident. Staff CC and the DNS acknowledged the absence of required behavior monitoring documentation. This failure to develop target behaviors, adequately monitor the behaviors and interventions for effectiveness, and monitor changes in orthostatic blood pressures placed the residents at risk for incorrect dose and duration of psychotropic medications, unwanted side effects, medical complications, and decreased quality of life.
Failure to Notify Provider of Medication Interactions
Penalty
Summary
The facility staff failed to notify a provider when moderate and severe medication interactions were alerted on new medication orders for a resident. This failure was identified through interviews and record reviews. Specifically, a severe drug interaction between omeprazole and clopidogrel was noted on 02/21/2024, but there was no documentation that a physician was notified. Additionally, a moderate drug interaction involving an antibiotic and two other medications was noted on 02/22/2024, but again, there was no documentation of physician notification. The resident involved was cognitively intact and required supervision to maximum assistance for activities of daily living. Interviews with facility staff revealed that the Electronic Health Record (EHR) system alerts staff to medication interactions, but the alerts were not being properly followed up with provider notifications and documentation. Staff members, including a Registered Nurse and the Resident Care Manager, confirmed that they would expect providers to be notified of moderate and severe interactions and for this to be documented in the resident's medical record. The facility administrator also confirmed this expectation. The deficiency was cited under WAC 388-97-1620 (2)(b)(ii).
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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