Wesley Homes Des Moines Health Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Des Moines, Washington.
- Location
- 826 South 218th Street, Des Moines, Washington 98198
- CMS Provider Number
- 505475
- Inspections on file
- 29
- Latest survey
- February 12, 2026
- Citations (last 12 mo.)
- 24
Citation history
Health deficiencies cited at Wesley Homes Des Moines Health Center during CMS and state inspections, most recent first.
The facility failed to ensure that nurses and nurse aides had the necessary competencies to provide adequate care, as there was no system to evaluate staff skills. This deficiency was identified through interviews and record reviews, revealing that essential training and competency evaluations were not documented or implemented, placing residents at risk.
The facility failed to implement a comprehensive Antibiotic Stewardship program, as outlined in their policy. Key deficiencies included the lack of an accurate surveillance method to track infections, incomplete data collection, and failure to provide necessary reports. The Director of Nursing and Infection Control Preventionist were unable to provide complete documentation, and the Administrator acknowledged the program was not intact, placing residents at risk for adverse outcomes.
The facility failed to assist five residents with ADLs, resulting in poor hygiene and grooming. Residents dependent on staff for personal hygiene were observed with long fingernails, greasy hair, and unshaven facial hair. Despite being scheduled for showers, documentation showed that these residents did not receive the necessary care, and staff interviews confirmed the lack of adherence to care plans.
The facility failed to implement an effective infection prevention and control program, lacking a system for infection surveillance and failing to apply Enhanced Barrier Precautions (EBP) for two residents with specific medical needs. Additionally, a CNA improperly used PPE, wearing two masks due to an allergy and not being fit-tested for a new N-95 respirator. These deficiencies highlight significant lapses in infection control and PPE protocols.
The facility failed to ensure nurse aides completed required training, including dementia care and special needs management, as outlined in the facility assessment. Interviews revealed a lack of a structured system for verifying competency and tracking training completion, with missing documentation for required training. This deficiency placed residents at risk for less than competent care.
The facility failed to obtain informed consent for psychotropic medications for three residents, violating their policy and residents' rights. A resident with severe cognitive impairment received antianxiety medications without consent from their representative. Another resident's consent forms lacked signatures, and verbal consents were improperly documented. A third resident's consent forms were incomplete and lacked witness signatures. Staff acknowledged the failure to follow proper consent procedures, placing residents at risk for unwanted treatment.
The facility failed to provide required written transfer notifications to residents or their representatives during hospital transfers. Despite a policy mandating such notices, staff interviews revealed a lack of awareness and adherence, affecting three residents. This oversight risked misalignment with residents' care goals.
A facility failed to complete the PASRR process for a resident with psychiatric mood disorder and confusion. The PASRR form was incomplete, lacking indicators for mood or anxiety disorders and a decision on the need for a Level II evaluation. The Social Services Director confirmed the oversight, noting the resident's increased antidepressant medication and nighttime wandering, indicating a potential need for further assessment.
A facility failed to conduct an accurate PASRR assessment for a resident with multiple mental health diagnoses, including psychotic and delusional disorders. Despite receiving antipsychotic medications, the resident's Level I PASRR did not indicate the need for a Level II evaluation, which was acknowledged as necessary by the Social Service Director.
The facility failed to develop comprehensive care plans for two residents, leading to unmet care needs. A resident with severe cognitive impairment and chronic pain lacked a pain management care plan, while another resident with a contracted hand due to a stroke had no care plan instructions for nail care. Staff interviews confirmed the absence of these essential care plans.
The facility failed to update care plans for three residents, leading to unmet care needs. A resident with a pressure ulcer was not repositioned as required, another resident at risk for wandering had an incomplete care plan, and a third resident had a transfer pole installed without proper assessment. Staff interviews confirmed these oversights.
A resident with a urinary catheter did not have their catheter care documented in their Care Plan, leading to a lack of awareness among staff and potential risks. The CP incorrectly noted bladder incontinence without mentioning the catheter, and the Kardex lacked care instructions. Interviews revealed staff were unaware of the catheter, highlighting a failure in communication and documentation.
A resident with multiple sclerosis and pressure ulcers experienced inadequate pain management during wound care, leading to treatment refusals. Pain medications were not administered as ordered, and the resident reported significant pain during treatments. Staff interviews highlighted the importance of pre-medicating for comfort and documenting treatment effectiveness.
The facility failed to ensure that two staff members, hired as Nursing Assistant Registered (NAR), completed the Certified Nursing Assistant (CNA) class and passed the state license exam within four months of hire. Both staff members continued to work with residents without obtaining their CNA licenses, as confirmed by the Washington State Provider Credential Search website. The facility's administrator acknowledged this oversight.
The facility failed to implement non-pharmacological interventions before administering psychotropic medications to three residents, as required by their policy. A resident with schizophrenia and depression received daily antidepressant and antipsychotic medications without prior non-pharmacological interventions. Another resident received antidepressant medication without documented interventions, despite no behavioral issues. A third resident, admitted with depression and anxiety, received antidepressant and narcotic pain medications without non-pharmacological pain interventions. Staff acknowledged the lack of documentation and the importance of these interventions.
A significant medication error rate of 68% was observed in an LTC facility due to late administration of medications to several residents. A registered nurse administered morning medications hours after the scheduled time without consulting providers, violating the facility's policy. Staff interviews revealed a lack of awareness of the policy, and the Director of Nursing highlighted the need for timely reporting and monitoring of residents.
The facility failed to follow dietary orders for three residents, leading to inappropriate food textures being served. A resident with dysphagia was given bread products, another with chewing difficulties received sandwiches, and a third on a mechanically altered diet was served the wrong meat texture. These errors occurred despite clear meal ticket instructions.
The facility failed to maintain food safety and sanitation standards. A cook improperly handled raw chicken without changing gloves or washing hands, leading to potential cross-contamination. Additionally, expired and undated food items were found in storage, and kitchen vents were observed with debris. Staff confirmed these practices were against policy.
The facility failed to maintain proper disposal and cleanliness of garbage and recycling dumpsters, leaving them uncovered and surrounded by debris. This was observed over several days, with sea gulls accessing the garbage. The Director of Environmental Services confirmed the need for covered dumpsters and a clean area to prevent pest attraction.
A resident with complex medical conditions reported two incidents of another resident entering their room at night, causing distress due to a history of domestic violence. Despite notifying staff and the Administrator, no grievance reports were filed, and the resident received no follow-up, violating the facility's policy on abuse and neglect.
The facility failed to maintain a safe environment for two residents, leading to potential accident risks. A resident with wandering behavior was not adequately monitored, and their care plan did not reflect their tendencies, resulting in frequent unsupervised wandering. Another resident had a transfer pole installed without proper assessment or consent, posing a risk of harm due to the lack of evaluation for safe usage.
Lack of Staff Competency Evaluation in LTC Facility
Penalty
Summary
The facility failed to ensure that nurses and nurse aides possessed the necessary competencies and skills to provide adequate care and services to residents. This deficiency was identified during interviews and record reviews, which revealed that the facility did not have a process in place to evaluate the competency of its staff, including medication pass evaluations. The lack of a structured evaluation system for Registered Nurses (RNs), Licensed Practical Nurses (LPNs), and Nurse Aides (NAs) meant that staff were not assessed for their ability to perform essential job functions, such as medication management, emergency response, and personal care skills. The facility's 2024 Facility Assessment outlined the training and education needs for RNs, LPNs, and NAs, but these were not implemented or documented for the staff reviewed. During an interview, the Human Resources Director and Administrator admitted that the Administrator, Director of Nursing, and Staff Development Specialist were new to their roles and acknowledged the absence of a system to evaluate staff competencies. This oversight placed residents at risk for medication errors, accidents, injuries, infections, and a diminished quality of life and care.
Deficiency in Antibiotic Stewardship Program Implementation
Penalty
Summary
The facility failed to implement a comprehensive Antibiotic (ABO) Stewardship program, which is essential for optimizing infection treatment and reducing adverse events associated with antibiotic use. The facility's policy outlined a detailed ABO Stewardship program, including the use of national standard surveillance tools, monthly antibiotic reviews by the pharmacist, and documentation of assessments and ABO use protocols. However, the facility did not adhere to these guidelines. Interviews and record reviews revealed that the facility lacked an accurate surveillance method to track resident infections, identify infection sources, and ensure correct ABO treatment. Additionally, there was no data collection analysis or summary for resident infections for August and September 2024, and the facility was unable to provide necessary data reports as per the ABO stewardship policy. The Director of Nursing and the Infection Control Preventionist were unable to provide complete surveillance logs or documentation of analysis for resident ABO use. The ABO Stewardship binder for September and October 2024 contained incomplete data, with many blanks in critical columns such as infection etiology, evaluation, laboratory results, and whether the infection met the criteria for ABO treatment. The Administrator acknowledged the deficiencies, noting that the ABO stewardship program was not intact and did not meet policy requirements. This lack of implementation placed residents at risk for potential adverse outcomes associated with inappropriate or unnecessary ABO use and increased the risk for ABO-resistant organisms.
Failure to Provide ADL Assistance
Penalty
Summary
The facility failed to provide necessary assistance with Activities of Daily Living (ADL) for five residents, leading to issues with cleanliness and grooming. Resident 2, who had weakness on the right side due to a stroke, required maximal assistance with personal hygiene but was observed with long facial hair and fingernails. Staff interviews confirmed that Resident 2 did not refuse care, and staff were expected to provide the necessary grooming assistance. Resident 3, dependent on staff for personal hygiene due to poor balance and vision impairment, was observed with long fingernails and greasy hair. Despite being scheduled for showers twice a week, no showers were documented for Resident 3 in the past 30 days. Resident 24, who required total assistance with personal hygiene, was observed with long fingernails and greasy hair, and no showers were documented for the past 30 days. Resident 35, who needed one-person assistance, reported not receiving a shower for a month. Resident 37, totally dependent on staff for personal hygiene, was observed with greasy hair and had not received scheduled showers. Staff interviews confirmed that these residents did not refuse care, and the facility's policy required staff to provide ADL assistance according to residents' needs and preferences. The failure to adhere to these policies resulted in poor hygiene and diminished quality of life for the affected residents.
Inadequate Infection Control and PPE Use
Penalty
Summary
The facility failed to implement an effective infection prevention and control program, as evidenced by the lack of a system for surveillance to identify and control infections and communicable diseases. The facility's policy outlined a comprehensive infection surveillance system, but during interviews, the Director of Nursing and the Infection Control Preventionist were unable to provide data for infection tracking and monitoring for several months. The Administrator confirmed that the infection control systems were not intact, indicating a significant gap in the facility's infection prevention efforts. Enhanced Barrier Precautions (EBP) were not implemented for two residents who required them. One resident had open pressure ulcers and an indwelling catheter, while another had an indwelling urinary catheter. Observations revealed that neither resident's room had EBP signage or readily available supplies for staff use. The Infection Control Preventionist acknowledged that residents with certain conditions should be on EBP precautions, but this was not executed for the residents in question. The facility also failed to ensure proper use of Personal Protective Equipment (PPE). A Certified Nursing Assistant was observed wearing two masks due to an allergy to the N-95 respirator and did not clean their face shield after exiting an isolation room. The CNA later used a different N-95 respirator without being fit-tested, contrary to facility policy. The Infection Control Preventionist confirmed that staff should not wear two masks simultaneously and should be fit-tested for N-95 respirators, highlighting a lapse in adherence to PPE protocols.
Deficiency in Nurse Aide Training and Competency Verification
Penalty
Summary
The facility failed to develop, implement, and maintain an in-service training program for nurse aides, which resulted in four nurse aides not completing the required training, including dementia care management and training for the special needs of residents. The facility assessment indicated that nurse aides required training in various areas such as basic personal care skills, vital signs monitoring, and dementia management, among others. However, the facility did not ensure that nurse aides received at least 12 hours of continuing education annually, nor did they conduct annual performance evaluations to identify areas needing additional training. Interviews with facility staff revealed a lack of a structured system for verifying nurse aide competency and tracking training completion. The Human Resources Director and Administrator acknowledged that the training program was incomplete and that documentation for the required training was missing. The Director of Nursing confirmed the absence of a system for annual evaluations, and the Staff Development Specialist admitted to not tracking the completion of training checklists. Consequently, the facility did not meet the regulatory requirements for nurse aide training and competency verification, placing residents at risk for receiving less than competent care.
Failure to Obtain Informed Consent for Psychotropic Medications
Penalty
Summary
The facility failed to obtain informed consent before administering psychotropic medications to three residents, which is a violation of their policy and residents' rights. Resident 53, who was severely cognitively impaired and had a designated Resident Representative (RR) for healthcare decisions, was administered antianxiety medications without obtaining consent from the RR. Similarly, Resident 212 was prescribed multiple psychotropic medications, but the consent forms lacked signatures, and verbal consents were improperly documented. Resident 213, who was moderately cognitively impaired, also had psychotropic medications administered without proper consent documentation, as the consent forms were incomplete and lacked witness signatures for verbal consents. The facility's policy requires collaboration with residents or their representatives and proper documentation of informed consent, including signatures and witness verification for verbal consents. However, the records for these residents showed significant lapses in following these procedures. Staff E, a Registered Nurse and Resident Care Manager, acknowledged the failure to obtain consent for Resident 53 and explained the expected process for obtaining and documenting consent, which was not followed in these cases. This oversight placed the residents at risk for unwanted treatment, as they were not fully informed or involved in the decision-making process regarding their psychotropic medication regimens.
Failure to Provide Written Transfer Notifications
Penalty
Summary
The facility failed to provide required written notices to residents or their representatives at the time of transfer or discharge to an acute care hospital. This deficiency was identified for three residents who were reviewed for hospitalizations. The facility's policy, revised on 08/08/2024, mandates that a notice of transfer or discharge must be provided to the resident or their representative, including the specific reason for the transfer, the date, and the name of the hospital. However, for Residents 16, 35, and 46, there was no documentation that such notifications were provided. Interviews with facility staff revealed a lack of awareness and adherence to the policy. Staff F, a Resident Care Manager, admitted to not knowing about the process for written notification, and Staff B, the Director of Nursing, acknowledged the importance of providing written transfer notifications but confirmed that the facility did not follow its policy. This oversight placed residents at risk for discharges that might not align with their stated goals for care and preferences.
Incomplete PASRR Process for Resident with Mental Health Needs
Penalty
Summary
The facility failed to ensure the Preadmission Screening and Resident Review (PASRR) process was properly followed for a resident with complex conditions, including a psychiatric mood disorder and confusion. Upon admission, the Minimum Data Set (MDS) indicated these conditions, and subsequent reviews showed diagnoses of depression and anxiety. The resident's Cognitive Care Plan included interventions for impaired cognitive function and thought processes, with goals to prevent delirium. However, the PASRR Care Plan did not indicate a Level 2 referral, and the PASRR form was incomplete, lacking necessary indicators for mood or anxiety disorders and missing a decision on the need for a Level II evaluation. The clinical record revealed that the admission PASRR was signed by hospital staff but was incomplete, with no updates since the initial assessment. During an interview, the Social Services Director confirmed the PASRR I form was not fully completed and acknowledged the resident's increased antidepressant medication and nighttime wandering, suggesting a potential need for a PASRR II. The incomplete PASRR process placed the resident at risk of not receiving necessary specialized mental health services.
Inaccurate PASRR Assessment for Resident with Mental Disorders
Penalty
Summary
The facility failed to ensure an accurate Pre-Admission Screening and Resident Review (PASRR) assessment for a resident, identified as Resident 14, who was reviewed for mental disorders or intellectual disabilities. Resident 14, who was admitted to the facility with diagnoses including non-Alzheimer's dementia, seizure disorder, psychotic disorder, delusional disorders, and an unspecified mental disorder, was receiving antipsychotic medications. Despite these conditions, the Level I PASRR conducted on 08/06/2021 did not indicate the need for a Level II evaluation, which should have been triggered by the presence of serious mental illness indicators such as psychotic and delusional disorders. This oversight was confirmed during an interview with the Social Service Director, who acknowledged that a Level II PASRR referral was necessary but not made.
Deficiencies in Comprehensive Care Planning
Penalty
Summary
The facility failed to develop and implement comprehensive care plans for two residents, leading to deficiencies in meeting their care needs. Resident 53, who was admitted with severe cognitive impairment and chronic pain, did not have a care plan addressing pain management despite having a physician's order for scheduled pain medication. This oversight was acknowledged by Staff F, a Registered Nurse and Resident Care Manager, who confirmed the absence of a pain care plan and emphasized the importance of individualized care plans for providing necessary care. Similarly, Resident 2, who had right-side weakness due to a stroke, was observed with a contracted right hand and long fingernails over several days. Staff interviews revealed that there were no care plan instructions for managing the contracted hand, making it difficult for nursing assistants to provide appropriate nail care. Staff F confirmed the lack of a care plan for Resident 2's contracted hand, acknowledging that such a plan should have been in place to guide staff in providing necessary care.
Care Plan Deficiencies and Unmet Resident Needs
Penalty
Summary
The facility failed to ensure that care plans were accurately reviewed and revised to reflect the current status and needs of residents, leading to unmet care needs and diminished quality of life for three residents. Resident 24, who had a pressure ulcer on their sacrum, required repositioning every two hours and needed to be laid back in bed after meals to relieve pressure. However, observations showed that the resident was left sitting in their wheelchair for extended periods, and the care plan was not updated to reflect the necessary interventions. Staff interviews confirmed the oversight in revising the care plan to address the resident's current needs. Resident 213, admitted with medically complex conditions, was at risk for wandering due to memory impairment and dementia. Despite documented behavior issues, the care plan did not reflect the resident's wandering risk. Staff interviews revealed that the care plan needed timely updates to reflect the necessary care services. Additionally, Resident 212, who was at risk for falls, had a transfer pole installed without a corresponding assessment or consent documented in the care plan. Staff acknowledged the absence of a transfer pole assessment, highlighting a potential risk of harm if not used properly.
Failure to Document and Provide Catheter Care
Penalty
Summary
The facility failed to provide appropriate care for a resident with a urinary catheter, as evidenced by the lack of documentation and awareness among staff. Resident 212, who was admitted with muscle weakness, Parkinson's disease, and a urinary catheter, did not have the catheter documented in their Care Plan (CP). The CP incorrectly indicated that the resident had urge and functional bladder incontinence, with no mention of the indwelling catheter or instructions for its care. Additionally, the resident's Kardex did not include any instructions for catheter care. Interviews with facility staff revealed a lack of awareness and oversight regarding the resident's catheter care. Staff E, a Registered Nurse and Resident Care Manager, was unaware of the catheter's presence and acknowledged that it should have been included in the CP. Staff B, the Director of Nursing, emphasized the importance of addressing the indwelling catheter in the CP to ensure all caregivers had access to the necessary care instructions. This oversight placed the resident at risk for infections, skin breakdown, and diminished quality of care.
Inadequate Pain Management During Wound Care
Penalty
Summary
The facility failed to provide appropriate pain management for a resident, identified as Resident 33, during wound care, which led to avoidable pain and refusal of treatments. Resident 33, who was admitted with conditions including multiple sclerosis and pressure ulcers, had a care plan that required evaluation of pain and administration of pain medication prior to wound therapy. However, the Medication Administration Records indicated that pain medications were not administered on several occasions, and the resident refused wound care on multiple days due to pain. Interviews with Resident 33 revealed that they experienced significant pain during wound treatments and suggested that earlier treatment times might be more tolerable. Despite this, no discussions about changing treatment times were documented. Staff interviews confirmed the importance of pre-medicating residents for comfort and documenting refusals and treatment effectiveness. The Director of Nursing expected treatments and medications to be administered as ordered, with proper documentation of wound conditions and treatment outcomes.
Failure to Ensure CNA Licensure for NAR Staff
Penalty
Summary
The facility failed to ensure that staff with a Nursing Assistant Registered (NAR) certificate completed a Certified Nursing Assistant (CNA) class and passed the state license exam within four months of hire. This deficiency was identified for two staff members, Staff J and Staff L, who were both hired as NARs on April 9, 2024. As of October 28, 2024, both staff members were still working as NARs without having obtained their CNA licenses. The Washington State Provider Credential Search website confirmed that neither Staff J nor Staff L had transitioned from NAR to CNA status, despite having worked at the facility for more than four months. The facility's daily schedules for October 2024 showed that both staff members were actively working with residents in their NAR capacity. During an interview, the facility's administrator acknowledged that both staff members had been employed for longer than four months without obtaining the necessary CNA licensure.
Failure to Implement Non-Pharmacological Interventions Before Psychotropic Medications
Penalty
Summary
The facility failed to ensure that three residents were free from unnecessary psychotropic medications, as required by their policy. Resident 3, diagnosed with schizophrenia and depression, received antidepressant and antipsychotic medications daily without documentation of non-pharmacological interventions being attempted prior to medication administration. Staff F, the Resident Care Manager, confirmed the lack of documentation and acknowledged that non-pharmacological interventions should have been attempted and recorded. Similarly, Resident 35, who received antidepressant medication, had no documented non-pharmacological interventions prior to medication administration, despite being assessed with no behavior or rejection of care. Staff C, the Social Services Director, and Staff B, the Director of Nursing, both admitted that non-pharmacological interventions were not attempted as required. Resident 53, admitted with depression and anxiety, received antidepressant medications and narcotic pain medication without any non-pharmacological pain interventions ordered. Staff E, a Registered Nurse, confirmed the absence of non-pharmacological interventions, emphasizing their importance in preventing unnecessary medication use.
Medication Administration Errors Lead to High Error Rate
Penalty
Summary
The facility failed to maintain a medication error rate of less than 5%, resulting in a significant error rate of 68% during a medication pass observation. This deficiency was observed in the administration of medications to four residents, where 28 out of 35 medications were not administered according to the prescribed schedule. Staff G, a registered nurse, administered morning medications several hours later than the times specified in the Medication Administration Record (MAR) for Residents 54, 6, 44, and 163. The medications included antibiotics, blood pressure medications, antidepressants, and pain medications, which were given without consulting the residents' providers for approval of the delayed administration. Interviews with staff revealed a lack of awareness and adherence to the facility's medication administration policy, which requires medications to be given within a 60-minute window of the scheduled time unless otherwise directed by a physician. Staff G admitted to not knowing the policy regarding late medication administration and did not report the delay to management or the residents' providers. The Director of Nursing emphasized the importance of notifying management and the provider if medications are administered outside the designated time frame and monitoring residents for adverse effects. This oversight placed residents at risk of not receiving the intended therapeutic effects of their medications.
Failure to Implement Dietary Orders for Residents
Penalty
Summary
The facility failed to implement dietary orders for three residents, leading to the provision of inappropriate food textures that could pose risks such as choking. Resident 34, diagnosed with oral phase dysphagia, was observed being fed a sandwich and dinner roll, despite a dietary order excluding bread due to swallowing difficulties. The meal ticket for Resident 34 did not list bread products, and the Certified Nursing Assistant acknowledged the oversight in reviewing the meal ticket before serving the meal. Similarly, Resident 37, who had a dietary order for no bread due to chewing difficulties, received a lunch tray with two sandwiches, contrary to the instructions on the meal ticket. Resident 45, on a mechanically altered diet, was served a sandwich with chopped meat instead of the required ground meat, as per the dietary order. The Registered Nurse confirmed that the kitchen staff did not adhere to the meal ticket instructions. In all cases, the dietary expediter supervisor was responsible for ensuring the correct meal components were served according to the residents' diet orders, but errors occurred, resulting in the residents receiving inappropriate food items.
Food Safety and Sanitation Deficiencies
Penalty
Summary
The facility failed to adhere to food service safety standards, as observed during a survey. Staff AA, a cook, was seen wearing plastic gloves over knitted safety gloves while washing raw chicken at the prep sink. Without removing the contaminated gloves or washing their hands, Staff AA proceeded to touch various kitchen items, including a large spoon used to stir soup, soup warming pans, and a plastic bag of frozen corn. This improper hand hygiene and glove use were confirmed by Staff AA and Staff S, the Executive Chef, who acknowledged that gloves should be removed and hands washed after handling raw chicken. Additionally, the facility did not comply with its policy for food storage, which requires foods to be covered, labeled, and dated. Observations revealed expired foods in the walk-in refrigerator and undated items in both the dry storage and freezers. Staff Q, the Lead Cook, confirmed that expired food should be discarded and that opened food items should be labeled with open and use-by dates. Furthermore, the kitchen's sanitation was compromised by thick grey debris on overhead vents, which were located above the clean dish area and the food prep and serve area. Staff T, the Hospitality Manager, acknowledged that the vents should be clean and that kitchen staff should notify maintenance for cleaning needs.
Improper Disposal and Maintenance of Dumpsters
Penalty
Summary
The facility failed to ensure proper disposal and maintenance of garbage and recycling dumpsters, as observed over several days. Specifically, 2 of 3 garbage dumpsters and 1 of 2 recycling dumpsters were left uncovered, and the surrounding areas were not kept clean, with trash and food scraps scattered on the concrete. This situation was observed on multiple occasions, with sea gulls seen flying over the dumpsters and opening garbage bags for food scraps. During an observation and interview, the Director of Environmental Services acknowledged that the dumpsters should be covered and the area should be free of debris to prevent attracting pests.
Failure to Investigate Resident's Abuse Allegations
Penalty
Summary
The facility failed to thoroughly investigate and address allegations of abuse or neglect concerning a resident, identified as Resident 31. Resident 31, who has complex medical conditions including kidney insufficiency, high blood pressure, and heart failure, reported that another resident entered their room on two separate occasions during the early morning hours. Despite communicating these incidents to the staff and leaving a message for the Administrator, Resident 31 did not receive any follow-up or feedback regarding their concerns. The resident expressed feeling scared due to a history of domestic violence and felt neglected by the staff. Interviews with facility staff, including the Director of Nursing and the Social Services Director, revealed that no grievance reports were filed for Resident 31's complaints. The Administrator acknowledged being unaware of the initial incident and confirmed that a grievance report was only being initiated after the second occurrence. This lack of immediate response and failure to document and investigate the resident's concerns violated the facility's policy on abuse, neglect, and exploitation, which mandates thorough investigation and feedback to residents.
Failure to Ensure Safe Environment for Residents
Penalty
Summary
The facility failed to ensure a safe environment free from accident hazards for two residents, leading to potential risks of accidents and injuries. Resident 213, who was admitted with conditions including high blood pressure, urinary tract infections, and muscle weakness, exhibited wandering behavior that was not adequately addressed in their care plan. Despite frequent behavior issues documented by staff, the care plan did not reflect the resident's wandering tendencies. Interviews with staff revealed a lack of awareness and communication regarding Resident 213's behavior, with staff needing to check the resident's location every 15 minutes due to their confusion and tendency to wander into other residents' rooms. Resident 212, admitted with muscle weakness and unsteadiness, had a transfer pole installed in their room without proper assessment or consent. The care plan did not document the presence of the transfer pole, and staff interviews confirmed the absence of a necessary assessment and consent form. This oversight posed a risk of harm if the transfer pole was not used correctly, as there was no evaluation to ensure a safe distance between the pole and the bed to prevent the resident from getting wedged between them.
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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