Woodard Creek Health & Rehabilitation
Inspection history, citations, penalties and survey trends for this long-term care facility in Olympia, Washington.
- Location
- 3333 Ensign Road Northeast, Olympia, Washington 98506
- CMS Provider Number
- 505387
- Inspections on file
- 36
- Latest survey
- March 2, 2026
- Citations (last 12 mo.)
- 54
Citation history
Health deficiencies cited at Woodard Creek Health & Rehabilitation during CMS and state inspections, most recent first.
A resident with severe dementia, high fall risk, and on anticoagulant therapy experienced an unwitnessed fall in the dining room after apparently reaching for a dropped stuffed animal. Despite obvious signs of left hip and leg pain, including grimacing and yelping during movement, the resident was transferred from the floor to a wheelchair and then to bed with a Hoyer lift rather than being immobilized. Pain assessment and documentation were inconsistent, Eliquis was not held after the fall, and an x-ray confirming a left hip fracture was not obtained until later that evening. A family member reported the resident remained in significant pain, staff did not propose earlier hospital transfer, and the ambulance crew indicated staff lacked clear details about the fall, while the DON later acknowledged poor post-fall documentation and uncertainty about immobilization.
Surveyors identified a 23.5% medication error rate during an observed medication pass by an LPN, despite facility policy requiring timely administration, explanation of medications to residents, and immediate documentation. Multiple residents with conditions such as diabetes, metastatic prostate cancer, lumbar fracture, liver disease, and depression did not receive ordered medications, received partial doses, or received medications late, while the MAR and audit reports showed the medications as given at the scheduled times. The LPN frequently could not explain why medications were signed off before administration, why some ordered medications (including metformin, aspirin, torsemide, glycolax, amoxicillin, and topical lotion) were omitted or delayed, or why a reduced dose of abiraterone acetate was not documented, and one resident reported that medications were often not passed timely or at all.
The facility failed to maintain complete and accurate medical records for three residents, including one with alcoholic cirrhosis who had physician orders for daily weights that were frequently not documented on the TAR, despite the resident reporting inconsistent monitoring of weights and VS and staff citing inconsistent assignments. Another resident with dementia and metabolic encephalopathy experienced a fall with a subsequent hip fracture; while the fall and x-ray results were noted, there was no documentation of the resident’s status prior to hospital transfer, and EMS records indicated staff could not provide clear fall details or confirm whether the resident hit their head while on anticoagulants. A third resident with a history of stroke and COPD had an unwitnessed fall documented on a fall report and SBAR as increased pain, but the fall itself was not recorded in progress notes or clearly communicated on hospital forms, and the DON acknowledged the absence of fall documentation in the record.
A resident with severe cognitive impairment, failure to thrive, severe protein-calorie malnutrition, and advanced kidney disease had a designated health care power of attorney, but the facility failed to involve this representative in care planning. The representative reported being unaware of the resident’s significant weight loss and observed the resident eating without needed assistance, prompting concerns about dietary care, pain, and poor communication. Progress notes indicated that staff told the representative a care conference would be held to discuss possible hospice and end-of-life care, but the DON later confirmed there was no follow-up and no care conference occurred, and the resident was not receiving hospice or end-of-life services.
A resident with alcoholic cirrhosis, esophageal varices, and alcohol dependence had a care plan that only generally directed staff to monitor for signs of cirrhosis and alcohol withdrawal, without specific guidance on daily weights, abdominal girth, or medication management. The resident reported that staff inconsistently obtained weights and vitals, administered medications, drew labs correctly, and applied prescribed skin creams, and felt the care plan lacked sufficient detail to guide care. A CNA stated that inconsistent staff assignments meant they did not always know when vitals or weights were needed, and the DON acknowledged the care plan should have been more personalized to the resident’s health conditions.
Two residents with indwelling urinary catheters were not properly assessed for continued catheter use or monitored according to provider orders. One resident with BPH and urinary obstruction had a catheter documented on admission and in the care plan, but there was no assessment of the need for ongoing use, no discussion of infection risk at care conference, and no documented provider decision to continue the catheter; the resident attempted to pull out the catheter, an outside provider later recommended removal due to high infection risk, and a voiding trial was only initiated at the receiving facility on the day of discharge. Another resident with urinary retention and prior UTI had a catheter care plan with no stated reason, incomplete documentation of ordered PVR scans and straight catheterization after catheter removal, and reinsertion of the catheter after failed voiding trials; later catheter removal occurred without a documented order or PVR monitoring, and the resident subsequently had difficulty voiding with high PVR before discharge, without documented urology referral or clear post-catheterization care planning.
A resident with alcoholic cirrhosis, esophageal varices, and ADHD experienced repeated omissions of ordered medications, including folic acid, eczema relief lotion, Adderall, and carvedilol, as documented on the MAR for January. The resident reported that daily medications, including liver-related supplements and Adderall, were not consistently given. During an observed med pass, an LPN failed to administer folic acid, thiamine, or eczema lotion and admitted he did not obtain missing folic acid, did not give the lotion, and had not administered Adderall on multiple prior days despite its availability. The DON confirmed that all ordered medications were expected to be administered as scheduled and that missing medications should be promptly obtained.
Surveyors found that staff did not follow required infection control practices, including entering EBP rooms and performing high-contact care with only gloves and without gowns, failing to disinfect shared equipment such as a mechanical lift, and leaving soiled linen and trash in room doorways. Multiple EBP and quarantine precaution rooms lacked necessary PPE (gowns, masks, disinfectant wipes) in door caddies, despite expectations that all staff restock them. The facility also lacked an effective respiratory protection program: there was no active process for N95 fit testing, and none of 21 newly hired staff had documentation of fit testing, with at least one NA unaware of what fit testing was and using whatever N95 was provided.
The facility failed to follow care plans and orders for meal assistance and weight monitoring for several residents. A resident with dementia, stroke, and swallowing difficulties, on aspiration precautions and ordered for 1:1 supervision with meals, was repeatedly observed eating independently in bed without staff present, while NAs cited staffing issues and gave conflicting statements about the resident’s need for assistance. Another resident, at risk for weight loss and with abdominal surgical wounds, experienced a notable weight decline over about two months without any assessment or interventions documented in the medical record, despite staff stating weight loss should be reviewed in weekly meetings. A third resident with dementia and CHF, ordered to receive tray setup, 1:1 and intermittent supervision, and bolt-upright positioning for meals, had a tray left unsetup, ate with the head of bed partially elevated and no staff present, and also had documented weight loss that was not addressed or recorded in the chart.
The facility did not submit complete results of abuse/neglect investigations to the State Agency Hotline within the required 5 working days for three residents. One resident with severe cognitive impairment and tube feeding allegedly went without food for an extended period, but the follow‑up report lacked resident interviews and no staff interviews were provided when requested. Another resident with a history of stroke reported staff were rude and unprofessional, yet the 5‑day report omitted staff interviews and none were later supplied. A third resident, who had requested only female caregivers, received care from a male staff member, and the follow‑up report lacked resident interviews, which also were not provided upon request. The DON and Administrator acknowledged that staff and resident interviews should be part of investigations reported to the State Agency.
A resident with severe cognitive impairment, sepsis, pneumonia, and a chronic NG tube was identified as being at elevated risk for pneumonia, with a care plan calling for nebulizer use and monitoring for respiratory symptoms. After the family reported respiratory concerns and the resident showed coughing and distress, a chest x-ray revealed right upper lung atelectasis versus consolidation, and albuterol nebulizers were ordered three times daily with a repeat chest x-ray. The resident received nebulizer treatments, but the ordered follow-up x-ray was not completed, and there was no progress note documentation for several days to reflect the resident’s respiratory status during this change in condition. When documentation resumed, the resident had increased congestion, required suctioning, had a fever, and was sent to the hospital, where records described progressive respiratory symptoms over two weeks and treatment limited to nebulizers, and facility leadership later acknowledged the lack of ongoing assessment and documentation.
The facility did not report an allegation of sexual abuse by a resident to law enforcement within the required two-hour window, and failed to log or notify APS or the State Agency when three residents left AMA, despite staff acknowledging these actions were necessary. These lapses involved residents with cognitive and physical impairments and were not documented or reported as required by policy.
The facility did not implement required interventions for two residents at risk of elopement, including failing to update care plans and use recommended safety devices. Additionally, two residents who left against medical advice did not receive proper discharge education, documentation, or completion of required Release of Responsibility forms, as outlined in facility policy.
A resident with cognitive impairment and a history of PTSD from prior abuse made an allegation of sexual abuse by a staff member. Despite physician orders to monitor and document the resident's psychosocial wellbeing after the allegation, staff did not perform or record the required monitoring.
The facility did not adequately assist two residents with discharge planning, resulting in incomplete arrangements for primary care and caregiver support, poor communication among staff, and missing documentation in the medical record. One resident with multiple medical conditions experienced delays and threatened to leave against medical advice, while another left the facility without a documented discharge plan. Staff interviews confirmed confusion and lack of coordination in the discharge process.
The facility did not complete a required discharge summary for a resident transferred to another LTC facility and failed to provide written bed hold notices to a resident who left on therapeutic leaves. Staff confirmed that discharge instructions were not always completed and that bed hold notices were not provided, as required.
Two residents' care plans were not updated to reflect their current needs: one resident's care plan lacked specific dietary and swallowing interventions despite physician and dietary assessments, and another resident's care plan was not revised after an allegation of sexual abuse by staff, even though the incident was documented elsewhere.
The facility did not have documentation showing that several agency and facility-employed nursing staff had received training on the use of mechanical lifts for resident transfers. Nursing assistants reported inconsistent practices and concerns about improper use of lifts, particularly by agency staff, and supervisors were unable to provide evidence of required training.
Four out of five sampled residents did not have documentation of assessment or offers for influenza and pneumococcal vaccines. In one case, a resident received a pneumococcal vaccine dose, but there was no evidence a second dose was offered. The DON confirmed the absence of vaccine history or offers in current records, and no further documentation was provided.
Three residents did not have documentation in their medical records showing assessment of vaccination history or that the COVID-19 vaccine was offered or administered. The DON confirmed the absence of this documentation, and no further records were provided.
The facility did not ensure proper monitoring, documentation, or justification for the use of psychotropic medications for several residents, including the absence of required diagnoses, lack of non-pharmacological interventions, missing stop dates for as-needed medications, and failure to act on pharmacist recommendations. Staff confirmed these deficiencies, and medication records showed inadequate documentation of behaviors and side effects.
The facility did not transmit required MDS assessment data to CMS within the mandated timeframe for multiple residents. This deficiency was identified through review of records and validation reports, and was attributed in part to a recent change in ownership and EHR systems, which led to delays in accessing and submitting the necessary assessment data.
Twelve residents did not have care plans that accurately reflected their medical needs, diagnoses, or physician orders. Omissions included missing plans for nutrition, catheter type and justification, daily or weekly weights, NPO status, mental health diagnoses, non-pharmacological interventions, advanced directives, and individualized safety measures. These deficiencies were confirmed by staff interviews and record reviews.
Facility staff did not consistently follow physician orders or document care as required, including missing or incomplete documentation for tube feeding equipment changes, nail and foot care, daily or scheduled weights for residents with heart failure, and monitoring for medication side effects. Staff also failed to properly document PICC line care and left resident information visible on unattended computer screens, contrary to facility expectations and professional standards.
The facility did not provide enough nursing staff to meet residents' needs, resulting in long wait times for call light responses, missed or delayed ADLs such as toileting, showers, and oral care, and incomplete medication administration. Residents and staff reported that agency personnel often failed to perform required duties, and multiple grievances documented concerns about slow response times and inadequate care.
The facility was found to have a medication error rate of 15.38%, exceeding the acceptable threshold, after observations showed that two residents received multiple medications, including insulin and Baclofen, outside the required administration timeframes. The DON confirmed that these medications were not given within the expected window.
Surveyors identified multiple deficiencies in food storage and handling, including uncovered prepared foods, expired and unlabeled items in kitchen and dining room refrigerators, improper storage of raw meats above ready-to-eat foods, and failure to monitor refrigerator temperatures as required. Staff confirmed these lapses in procedure, which were observed throughout the facility.
The facility did not maintain an environment free from accident hazards by failing to implement or update care plans and assessments for three residents. One resident with hemiplegia suffered a hip fracture during a shower without a fall care plan in place. Another resident with multiple falls was not provided with new interventions or proper documentation for a bed against the wall, and a third resident permitted to smoke unsupervised lacked a completed smoking safety evaluation. The DON confirmed these deficiencies in care planning and assessment.
Staff did not interact respectfully with two residents, including one who was repeatedly dismissed when requesting assistance and another whose clothing was not changed daily or before bed as preferred. These actions failed to honor residents' dignity and personal preferences.
The facility did not provide or document information about advance directives for two residents, one of whom was severely cognitively impaired and another who was cognitively intact. Staff interviews and record reviews confirmed that neither resident had documentation of an advance directive or evidence that the opportunity to formulate one was offered, and the only related documentation found was a POLST, which staff clarified does not count as an advance directive.
A resident was not given the required SNF ABN to inform them of Medicare coverage and potential financial liability for non-covered services. This was confirmed by record review and staff interview.
A resident who required significant assistance with toileting reported being left uncovered and wet for an extended period after staff failed to return to complete care. The incident was not documented or reported to the State Agency within the required timeframe, and facility leadership was unaware of the allegation until informed by surveyors.
A resident with diabetes and COPD experienced multiple falls, including one resulting in bruises. The facility did not collect staff statements, identify root causes, or update care plans after these incidents. Investigations were delayed and lacked necessary steps to rule out abuse or neglect, as confirmed by the DON.
Four residents dependent on staff for ADLs did not consistently receive scheduled assistance with bathing, nail care, or oral hygiene. One resident's nails were left untrimmed despite documentation, and multiple residents experienced extended periods without being offered or provided showers or oral care, as confirmed by staff and records.
Several residents did not receive PRN bowel medications or scheduled weight monitoring as ordered, due to missed orders and documentation failures following an EHR transition. These lapses resulted in residents going multiple days without bowel movements and not having their fluid status monitored as required.
A resident with cognitive impairment and high ADL needs developed an open area on the coccyx, but staff did not complete or document an initial wound assessment, notify the provider or representative, or update the care plan to reflect the active pressure injury. Required wound characteristics and ongoing monitoring were not documented, and no new treatment orders were obtained.
Two residents with hemiplegia and hand contractures did not receive required daily ROM and splint care as documented in their care plans. Care was provided inconsistently, with gaps in documentation and no current orders or care plans for daily restorative services. Staff interviews revealed confusion over responsibility for providing this care, and the DON confirmed that the expected daily care was not delivered.
A resident with diabetes and kidney disease experienced significant unaddressed weight loss, with staff failing to reweigh, notify the provider, or implement a nutrition care plan as required. The resident frequently did not receive the ordered nutritional supplement, and no alternative interventions were attempted or documented.
Surveyors found that three residents requiring respiratory support did not receive care in accordance with physician orders and facility policy. One resident's CPAP orders were incomplete and the humidifier reservoir was left empty, another resident's nebulizer equipment was not labeled or changed as ordered and CPAP settings were missing from the record, and a third resident did not consistently receive oxygen at the prescribed rate, with staff failing to ensure oxygen was administered as ordered.
Two residents received as needed and scheduled pain medications without documented attempts of non-pharmacological interventions (NPIs) prior to administration. One resident, able to express needs, was given oxycodone multiple times daily with no NPIs ordered or documented. Another, with severe cognitive impairment, received scheduled oxycodone despite consistently documented zero pain scores, with no NPIs or adverse side effect monitoring in place. Staff confirmed these practices did not align with facility expectations.
Surveyors found expired medications and equipment, improperly labeled medication containers, and an unlocked, unattended medication cart. Staff acknowledged the presence of expired or mislabeled items and the failure to secure the cart when not in use, while the DON confirmed these practices did not meet expectations.
Multiple residents reported receiving cold, unappetizing meals, with observations confirming that food was often served at improper temperatures and not in accordance with dietary preferences. Staff did not follow recipes or use measured ingredients for pureed diets, and correct portion sizes were not provided as indicated on tray cards. Food preferences documented in care plans were not honored, resulting in repeated serving of disliked items.
A resident with hearing issues and morbid obesity was not provided with necessary accommodations at an LTC facility. Despite a physician's order for an ENT referral, the resident could not attend an appointment due to inadequate transport options. Additionally, the facility lacked bariatric equipment to support the resident's weight, leading to potential transfer discussions. Staff acknowledged the equipment limitations and the resident's frustration, but no plans were made to address these needs.
A facility failed to create a comprehensive care plan for a resident with recurrent UTIs and specific urinary care needs. Despite multiple UTIs and the resident's need for a special urinal, staff were not trained to assist properly, leading to prolonged exposure to urine. The DON acknowledged the lack of a care plan for these issues.
The facility did not update its assessment to address the needs of bariatric residents, leading to inadequate support for a resident weighing 482 pounds. The resident was informed that the facility lacked equipment for individuals over 500 pounds, and essential equipment like a mechanical lift and transfer pole were not suitable for their weight. The administrator confirmed the lack of necessary equipment and the failure to update the assessment.
A facility failed to thoroughly investigate allegations of abuse involving a resident with cognitive impairment and a staff member. The investigation lacked interviews with the resident, other residents, and staff peers, and did not document a return call to the resident who expressed concerns. The Director of Nursing admitted the investigation was not thorough.
A resident with moderate cognitive impairment reported financial exploitation by their significant other, but the facility failed to report the allegations to the state agency. Staff, including an LPN and social services, were aware of the situation but did not document or report it, leading to a deficiency in the facility's compliance with reporting requirements.
A resident with post-accident injuries was discharged without a personalized plan, leading to unmet care needs. Despite therapy notes suggesting the need for COPES and home support, the facility failed to coordinate these services, resulting in inconsistent discharge recommendations and a lack of follow-through on necessary assessments.
A resident with PTSD and depression experienced distress due to family dynamics and inadequate trauma-informed care. Despite expressing concerns about their significant other's behavior, staff failed to document or address these issues. The facility did not conduct a trauma assessment or update the care plan to reflect the resident's needs, leading to increased anxiety and suicidal thoughts.
The facility failed to follow professional standards in medication management for several residents, including improper administration and documentation of medications, incomplete IV orders, and lack of communication with pharmacy and physicians. These deficiencies involved holding or administering medications outside of physician-ordered parameters and inadequate documentation of controlled substances.
Failure to Adequately Assess and Manage High-Risk Resident After Unwitnessed Fall
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a known high fall-risk resident was adequately assessed and provided with appropriate supervision and resident-specific fall prevention interventions following a fall. The resident had severe cognitive impairment, dementia, metabolic encephalopathy, was dependent for ADLs, and was on Eliquis, an anticoagulant. The care plan identified the resident as at risk for falls related to advanced dementia, with interventions including non-skid socks, bed in lowest position, and staff reminders to use the call light. A fall risk assessment documented the resident as high risk due to a history of falls, incontinence, and anticoagulant use. On the date of the incident, nursing progress notes documented that the resident had an unwitnessed fall to the floor in the dining room, apparently after dropping a stuffed animal and reaching to retrieve it. It was unclear whether the resident hit their head, and staff were aware the resident was on Eliquis. After the fall, the resident reported or demonstrated pain in the left hip and thigh, with redness noted to the left hip in one note, and later documentation that no bruising or redness was seen. The resident, who had severe dementia and difficulty verbalizing pain, showed obvious pain through facial grimacing and yelping when attempts were made to place a Hoyer sling and when being rolled onto the left side. Despite these signs, the resident was transferred from the floor to a wheelchair and then to bed using a Hoyer lift, rather than being immobilized in place. Progress notes and the MAR showed that Eliquis 5 mg was administered later that day and was not held after the fall. Pain documentation was inconsistent, with pain levels recorded as 0/10 throughout much of the day, no pain score documented when Tylenol 650 mg was given, and later administration of oxycodone 5 mg for pain rated 7/10. A stat x-ray was ordered, but the radiology report confirming a left hip fracture was not completed until that evening. The resident’s family member reported that the resident was in pain for an extended period, that staff did not suggest sending the resident to the hospital sooner, and that the ambulance crew stated staff did not know details about the fall. The DON later acknowledged there was a lack of documentation on the resident’s status after the fall and stated the resident should have gone to the hospital if there was concern about a head injury or increased pain, and could not confirm whether the resident’s injury had been immobilized.
High Medication Error Rate and Inaccurate MAR Documentation During LPN Medication Pass
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, with surveyors identifying an error rate of 23.5% (8 errors out of 34 observed medication administration opportunities). Facility policy dated 01/2023 required that medications be explained to residents, administered within 60 minutes of the scheduled time, and documented immediately after administration. During an observed medication pass on 01/21/2026 by Staff G, an LPN, multiple discrepancies were noted between medications actually administered and those documented on the Medication Administration Record (MAR) and Medication Admin Audit Reports. For Resident 15, who had spina bifida and diabetes mellitus and required supervision with ADLs, the scheduled metformin for diabetes was not administered during the observed pass, although the MAR and audit report showed metformin, Jardiance, and duloxetine as signed off as given earlier that morning. Staff G later acknowledged realizing the metformin had been missed and could not explain why it had been signed off as given. For Resident 16, who had influenza and diabetes and was dependent for ADLs, the medication abiraterone acetate, ordered as four tablets for metastatic prostate cancer, was administered as only two tablets because no additional packets were available. The shortage was not explained to the resident, and the MAR and audit report documented the dose as fully given without notation of the partial dose. For Resident 14, with lumbar fracture and diabetes and independent in ADLs, the observed pass included several medications but omitted aspirin and torsemide, both due at 6 AM. The audit report showed multiple medications, including aspirin, signed off as given earlier, and torsemide signed off later, while Staff G stated he did not give the torsemide and did not know what happened with the aspirin, acknowledging the medications were late. Resident 1, with alcoholic cirrhosis, esophageal varices, and ADHD, reported that medications were not passed timely or at all, and during observation did not receive ordered eczema lotion or amoxicillin; documentation showed amoxicillin signed off as given earlier and the lotion documented later, with Staff G unable to locate the cream and unsure about the antibiotic. For Resident 17, with lumbar fracture and diabetes and requiring substantial assistance with ADLs, several cardiac and psychiatric medications were administered, but aspirin and glycolax were not observed to be given, despite the audit report and MAR indicating they had been administered at the scheduled time. Staff G could not explain these discrepancies and stated that medications due at 6 AM were always going to be late because of his start time.
Incomplete and Inconsistent Medical Record Documentation for Weights, Vitals, and Falls
Penalty
Summary
The deficiency involves the facility’s failure to maintain complete, accurate, readily accessible, and systematically organized medical records for multiple residents. For one resident with alcoholic cirrhosis, esophageal varices, and alcohol dependence, the quarterly MDS documented no cognitive impairment and partial to moderate dependence for ADLs, and an order summary showed daily weights were to be taken. However, the TAR for December showed daily weights missing on 5 of 31 days, and the TAR for January showed daily weights missing six times. The resident reported that staff did not understand the importance of monitoring weights and vital signs, that they personally tracked vitals, and that weights and vitals were missing when they went to outside appointments, stating that staff performed these tasks inconsistently or not at all. A nursing assistant stated staff had inconsistent assignments and did not always know which residents needed vitals or weights, and the DON stated staff should be aware of when to take weights and vitals. For a second resident with dementia and metabolic encephalopathy, the admission MDS documented severe cognitive impairment and total dependence for ADLs, and the care plan identified fall risk with interventions such as non-skid socks, low bed position, and reminders to use the call light. The resident experienced a fall, was found on the floor with left lower extremity pain, and an x-ray later confirmed a left hip fracture. Progress notes documented the fall, pain, and x-ray results, but the record did not include documentation of the resident’s status before transport to the hospital. EMS notes indicated facility staff could not articulate details of the fall, only stating it occurred around midday, and that they were unable to obtain a mobile x-ray until the evening and did not have a copy of the x-ray. EMS documentation also noted uncertainty about whether the resident hit their head while on an anticoagulant, and described significant swelling and pain in the left leg and the resident’s verbal distress. A staff member later acknowledged they could not determine the resident’s status while waiting for hospital transfer from the record and that documentation was missing, and the DON confirmed a lack of documentation on the resident’s status after the fall and could not speak to whether the injury was immobilized due to missing documentation. For a third resident with a history of stroke and COPD, the MDS documented no cognitive impairment and partial to moderate dependence for ADLs, and the care plan identified fall risk with interventions similar to the other resident at risk for falls. A fall report documented that this resident was found lying on the right lateral side of the bed, with no injuries noted, stable vital signs, complaints of head and left shoulder pain, and subsequent transport to the hospital. However, progress notes did not reflect the fall event. An SBAR communication form to the hospital documented the onset of increased chronic pain to the scalp and right shoulder but did not document that a fall had occurred. The DON stated that staff did not document the fall in the medical record or on the hospital communication forms. These omissions across multiple residents demonstrate incomplete and disorganized documentation of ordered monitoring, fall events, and resident status in the medical record.
Failure to Involve Resident Representative in Care Planning and Hospice Discussion
Penalty
Summary
The facility failed to ensure that a resident and/or their representative were offered the opportunity to participate in the development and implementation of a person-centered plan of care. Resident 5, admitted with failure to thrive, severe protein-calorie malnutrition, and advanced kidney disease, had a quarterly MDS dated 10/30/2025 documenting severe cognitive impairment and dependence on staff for eating. A Durable Power of Attorney for Health Care designated a family member (CC5) as the decision maker if the resident could no longer make decisions. CC5 reported being shocked by the resident’s significant weight loss, which had not been communicated to him, and observed the resident eating without assistance, leading to concerns that the resident was not receiving needed care. CC5 raised concerns with the provider about the resident’s dietary status, pain, and communication with staff, and was told a care conference would be scheduled to further discuss these issues. Progress notes dated 11/19/2025 documented that a call was made to CC5 and that a care conference would be held the following week to determine if hospice was appropriate. However, during an interview on 03/02/2026, the DON (Staff B) stated there was no follow-up with CC5 after the 11/19/2025 note and confirmed that no care conference took place. Staff B also stated that the resident was not receiving end-of-life or hospice services and that end-of-life or hospice care needed to be discussed to address the potential for further weight loss and pain. This lack of follow-through on the planned care conference and failure to involve the designated representative in care planning constituted the deficiency under WAC 388-97-0300(3)(a).
Non-individualized Care Plan for Resident With Liver Disease and Alcohol Dependence
Penalty
Summary
Surveyors identified a failure to develop a comprehensive, person-centered care plan for one resident with alcoholic cirrhosis, esophageal varices, and alcohol dependence. The resident’s quarterly MDS showed no cognitive impairment and partial to moderate dependence for ADLs. The existing care plan, initiated on 10/24/2025, addressed cirrhosis only generally by directing staff to monitor for yellowing of the eyes/skin, abdominal ascites, and changes in mental status, and to obtain labs and diagnostics as ordered. A subsequent care plan entry dated 12/13/2025 instructed staff to monitor for alcohol withdrawal and check vitals as needed. The care plan did not include more specific interventions such as monitoring daily weights, monitoring abdominal girth, or addressing medications used to manage the resident’s liver disease and alcohol dependence. During interview, the resident reported that staff did not always understand the tasks needed to manage liver disease and alcohol dependence and stated, "I don't think they understand liver disease." The resident described inconsistent performance of key tasks, including obtaining weights and vitals, passing medications on time or at all, drawing laboratory samples correctly, and applying prescribed skin creams, all of which the resident identified as part of managing her condition. The resident felt the care plan lacked the detail staff needed to care for her health conditions. A nursing assistant reported that staff had inconsistent assignments and therefore did not always know if the resident needed vitals or weights and that staff did not always know residents well. The DON acknowledged that the resident’s care plan should be more personalized to address the resident’s health conditions.
Failure to Assess and Manage Indwelling Urinary Catheters and Voiding Trials
Penalty
Summary
The deficiency involves the facility’s failure to monitor and justify the continued use and removal of indwelling urinary catheters for two residents, and to follow ordered protocols for voiding trials and post-void residual (PVR) monitoring. For one resident with a history of left hip fracture, diabetes mellitus, benign prostatic hyperplasia, and urinary obstruction, the admission MDS and care plan documented the presence of an indwelling catheter and general catheter care tasks, but there was no assessment addressing possible removal of the catheter. Hospital transition orders recommended temporary catheter management per nursing protocol for urinary retention, yet the facility did not document evaluation of the ongoing need for the catheter. During a multidisciplinary care conference with the family, staff reviewed the resident’s care needs but did not address the indwelling catheter or infection risk related to its continued use. Subsequent nursing notes for this resident documented that blood was noted in the catheter because the resident was trying to pull it out, and an outside orthopedic provider later expressed concern that the catheter had remained in place since hospitalization, recommending removal when medically acceptable due to high infection risk and noting the resident had not received the care specifically needed. The facility’s alleged neglect investigation, initiated after the family reported concerns that staff refused to remove the catheter, concluded there was no abuse or neglect but did not address the continued use of the catheter. Staff interviews revealed that LPNs waited for direction from the nurse manager for catheter removal, that the supervising LPN was unsure whether the provider had been contacted about removal for this resident, and that if a provider chose to keep a catheter in place this decision would not be documented. The supervising LPN agreed there was no justification for continued catheter use and acknowledged that a voiding trial was only started on the day of discharge at another facility, and the DON confirmed there was no documentation of assessment for appropriateness of continued catheter use. For a second resident admitted with a lower leg fracture and urinary retention, the care plan documented an indwelling catheter but left the reason for the catheter blank, and the admission assessment noted no factors related to urinary incontinence and no justification for continued catheter use. Provider notes indicated the resident had a UTI and urinary retention in the hospital, had failed a voiding trial, and was started on medication for urinary retention. Later provider notes ordered removal of the catheter and initiation of bedside commode use, with specific orders to scan the bladder every shift for 72 hours, perform straight catheterization if bladder volume exceeded a set threshold, and replace the indwelling catheter after a third failed attempt. The record showed the catheter was removed and that the resident subsequently failed a voiding trial and required reinsertion of an indwelling catheter, but there was no documentation of PVRs during the initial ordered monitoring period. When the catheter was later removed again, there was no corresponding provider order in the record and no PVR monitoring to ensure the resident could tolerate removal. Staff interviews confirmed that PVRs were not done when ordered, that no urology consultation was obtained despite ongoing urinary retention, and that PVR monitoring before discharge was inconsistent. Discharge documentation noted the resident would need catheter replacement upon discharge and later documented difficulty voiding and high PVR with straight catheterization, without mention of post-catheterization care, further PVRs, or urology follow-up.
Repeated Medication Omissions and Inconsistent Administration
Penalty
Summary
The deficiency involves the facility’s failure to ensure medications were administered as ordered, resulting in repeated omissions of multiple prescribed drugs for one resident. The resident had diagnoses including alcoholic cirrhosis, esophageal varices, and ADHD, and was assessed as having no cognitive impairment with partial to moderate dependence for activities of daily living. The resident reported that staff did not pass all daily medications, including liver-related supplements, and that Adderall was not administered consistently, which the resident stated affected decision-making and increased stress. A January Medication Review Report listed folic acid, Sarna eczema relief lotion, Adderall, and carvedilol among the resident’s prescribed medications. The January MAR documented numerous missed doses: folic acid was missed 15 of 21 times, the eczema relief lotion 9 of 41 times, Adderall 8 of 21 times, and carvedilol 11 of 41 times. During an observed medication pass, an LPN did not administer folic acid, thiamine, or the eczema relief lotion to the resident. The LPN later stated he could not find the folic acid and did not retrieve more, acknowledged that thiamine was given but not at the scheduled time, and confirmed the lotion was not given. He also stated the resident had 16 tablets of Adderall available and verified that Adderall had not been administered the previous day or on many prior days, without being able to explain why it was not given. These observations and record reviews showed that ordered medications were not consistently administered as prescribed.
Failure to Implement PPE, EBP, and Respiratory Protection Requirements
Penalty
Summary
Surveyors identified a deficiency in the facility’s infection prevention and control program related to improper use of personal protective equipment (PPE) and implementation of enhanced barrier precautions (EBP). In one EBP room, a nursing assistant entered to assist a resident with a mechanical lift transfer, donned only gloves, and then exited the room carrying used gloves in the hallway while seeking assistance, before returning to dispose of them and don new gloves. The PPE caddy on that room’s door lacked gowns and disinfectant wipes, and the registered nurse who entered to assist with the transfer also wore only gloves, stating she typically wore gowns only for wound care. Facility policy and state guidance required gowns and gloves for high-contact resident care activities in EBP rooms and disinfection or dedicated use of equipment, but the mechanical lift used for the transfer was not wiped down after use. Additional observations on two halls showed multiple EBP and quarantine precaution rooms without required PPE stocked in the door caddies and improper handling of soiled linens and trash. Several rooms designated for EBP had no gowns available in the PPE caddies, and rooms on quarantine precautions had no gowns or masks available. Surveyors also observed bagged and unbagged dirty linen and a bag containing a soiled brief placed on the floor in resident doorways. The DON, infection preventionist, and other staff acknowledged that PPE caddies were expected to be stocked and that dirty linen and trash should not be left in doorways, and stated that all staff were responsible for restocking PPE. The facility also failed to implement a complete respiratory protection program as required by state guidance and its own policy. The Washington State Department of Health guidance and the facility’s Respiratory Protection Program policy required medical evaluation, respirator training, and initial and annual fit testing for N95 respirators before use. The infection preventionist and DON reported there was no current process in place for fit testing staff, that it had likely stopped when the facility changed ownership, and that newly hired staff had not been fit tested. A newly hired nursing assistant reported working about a month, was unfamiliar with fit testing, and stated they used whatever N95s were provided before entering rooms requiring an N95. Review of records for 21 staff hired in the past 90 days showed no documentation that any had been fit tested, and the administrator confirmed they did not have a good plan in place to protect residents from staff who may not have been fit tested for an appropriate N95.
Failure to Provide Required Meal Assistance and Address Significant Weight Loss
Penalty
Summary
The deficiency involves the facility’s failure to provide required assistance and supervision with meals and to promptly identify and address weight loss for multiple residents. One resident with dementia, a history of stroke, swallowing difficulties, and documented aspiration precautions was care planned and ordered to receive 1:1 assistance and supervision with meals, including cues to eat and encouragement to go to the dining room. Despite this, meal observation on two separate dates showed the resident eating independently in bed without staff present or assisting, and staff interviews revealed inconsistent understanding of the resident’s need for 1:1 supervision. Nursing assistants reported that staffing levels made it difficult to supervise residents who required it and, at times, the resident was left to eat independently, contrary to the care plan, dietary ticket, and physician orders. Another resident, admitted with a colostomy and hypothyroidism and care planned as at risk for weight loss due to advanced age, experienced a significant decline in weight over approximately two months, from about 167 pounds to about 155 pounds. The nutritional assessment had set a goal of no weight loss through the review period and noted surgical abdominal wounds, but the medical record contained no documentation addressing this weight loss. Staff interviews confirmed that weight loss was supposed to be addressed at a weekly weight loss meeting and that findings were entered into a computer system rather than the medical record, resulting in no documented assessment or interventions in response to this resident’s weight loss. A third resident with dementia and congestive heart failure, care planned and ordered to receive assistance with tray setup, 1:1 and intermittent supervision, and to be positioned bolt upright for meals, was observed with a meal tray left on the bedside table without setup and with the head of bed at about 45 degrees. The resident initially made no attempt to eat and later had to pull their body toward the tray to reach the food due to the bed position, with no staff present during the observation period. The dietary ticket and order details documented the need for 1:1 assistance and upright positioning, but a nursing assistant stated the resident did not require assistance with meals. Weight records showed this resident had notable weight loss over several months, and staff acknowledged that the weight loss should have been addressed at weekly meetings and documented in the medical record, but no such documentation or response was present.
Failure to Submit Complete Abuse/Neglect Investigation Results to State Agency
Penalty
Summary
The facility failed to ensure that results of abuse and neglect investigations were fully developed and reported to the State Agency Hotline within 5 working days for three residents. For a resident with sepsis, pneumonia, severe cognitive impairment, and dependence in ADLs, an investigation dated 09/23/2025 addressed an allegation that staff did not change the resident's tube feeding and the resident was without food for an extended period. The 5‑day follow‑up investigation submitted to the State Agency lacked interviews of sample residents, and when surveyors requested staff interviews on 12/11/2025 and 12/18/2025, none were provided. For a resident with a stroke, left‑side weakness, no cognitive impairment, and dependence in ADLs, an investigation dated 10/02/2025 documented that the resident reported staff were rude and unprofessional. The 5‑day follow‑up investigation submitted to the State Agency was missing staff interviews, and requested interviews on 12/11/2025 and 12/18/2025 were not provided. For another resident with a urinary tract infection, morbid obesity, no cognitive impairment, and dependence in ADLs, an investigation dated 11/04/2025 documented that the resident received care from a male staff member after requesting only female caregivers. The 5‑day follow‑up investigation submitted to the State Agency lacked interviews of sample residents, and requested resident interviews on 12/11/2025 and 12/18/2025 were not provided. The DON and the Administrator both stated that staff and resident interviews should be included in facility investigations.
Failure to Monitor and Follow Up on Resident Respiratory Change in Condition
Penalty
Summary
The facility failed to assess, monitor, and intervene appropriately when a resident experienced a change in respiratory status. The resident, who had severe cognitive impairment, sepsis, pneumonia, and a chronic nasogastric tube, was care planned as being at elevated risk for pneumonia, with interventions including administering nebulizers as ordered and observing for signs and symptoms of pneumonia. On one date, progress notes documented that the resident’s family inquired about the need for nebulizer treatments, and the resident was observed to be uncomfortable, coughing, and making a distressing facial expression, prompting an order for a chest x-ray. The x-ray showed right upper lung atelectasis versus consolidation related to pneumonia. Subsequent progress notes documented that the resident was to receive albuterol nebulizer treatments three times a day for four days with a repeat chest x-ray, and that the family reported the resident was short of breath, although staff did not find concerns upon assessment. The family later requested a nebulizer treatment, and the medication record showed the resident received albuterol nebulizers three times a day over several days. Despite the order to repeat the chest x-ray after the nebulizer course, no follow-up x-ray was completed, and there was no progress note documentation for a several-day period to show the resident’s status following the identified change in condition. When documentation resumed, notes indicated the resident had increased congestion, required airway suctioning, had a fever of 101.4 degrees, and was transferred to the hospital, where records described progressive respiratory symptoms over two weeks, shortness of breath, altered breath sounds over the prior week, and fevers occurring the previous night and a few days earlier. The family reported that the resident had respiratory symptoms for two weeks and had no treatment besides nebulizers. The DON later acknowledged that there was no documentation from the gap period to show the resident’s status and that staff should have been documenting the resident’s condition given the change, and the Administrator confirmed there was no follow-up chest x-ray in the medical record.
Failure to Timely Report Abuse Allegations and AMA Discharges
Penalty
Summary
The facility failed to ensure that allegations of abuse were reported to law enforcement within the required two-hour timeframe. Specifically, a resident with moderate cognitive impairment and significant dependence on staff for activities of daily living made an allegation of sexual abuse by a staff member. The incident was not reported to law enforcement within two hours as required by facility policy, and staff could not provide a reason for the delay, despite acknowledging the requirement. Additionally, the facility did not properly log or report residents who left against medical advice (AMA) to Adult Protective Services (APS) or the State Agency. Three residents with varying medical conditions, including congestive heart failure, cirrhosis, hip fracture, anxiety disorder, and chronic obstructive pulmonary disease, left the facility AMA. In these cases, there was no documentation of the incidents in the facility's log, nor evidence that APS was contacted, even when residents' whereabouts were unknown or their safety was potentially at risk. Staff interviews confirmed that these discharges should have been reported to APS, but this was not done.
Failure to Prevent Elopement and Ensure Safe AMA Discharges
Penalty
Summary
The facility failed to implement appropriate interventions to prevent elopement and did not act effectively when elopement occurred for two residents identified as at risk. One resident, with a history of leaving healthcare facilities against medical advice (AMA) and documented risk factors for elopement, expressed a desire to leave upon admission. Despite recommendations to implement care plan interventions and consider a wander bracelet, these measures were not put in place, and the care plan did not address the resident's elopement risk. The resident subsequently eloped from the facility. Another resident, admitted for a hip fracture and anxiety disorder, was not assessed for elopement risk and was found missing after signing out to retrieve a wheelchair. The resident did not return as expected, and staff were initially unaware of their whereabouts, with staff later acknowledging that elopement protocol should have been followed. The facility also failed to ensure safe discharges for residents leaving AMA. For one resident with congestive heart failure and cirrhosis, documentation showed the resident left AMA without receiving their stored medications or having them sent to a pharmacy. The medical record did not reflect efforts to encourage the resident to stay, nor was there a completed Release of Responsibility form as required by facility policy. Another resident, dependent on oxygen and diagnosed with chronic obstructive pulmonary disease, requested to leave AMA, but the medical record lacked the required Release of Responsibility form and did not document actions taken to ensure a safe discharge. Facility policy requires that residents leaving AMA be educated on the risks, that the attending physician be notified, and that all efforts to ensure a safe discharge be documented, including completion of a Release of Responsibility form. In the cases reviewed, these steps were not consistently followed, and documentation was incomplete or missing, failing to demonstrate that the facility made reasonable efforts to ensure the safety of residents leaving AMA.
Failure to Monitor Psychosocial Wellbeing After Abuse Allegation
Penalty
Summary
The facility failed to monitor and document the psychosocial wellbeing of a resident following an allegation of sexual abuse by a staff member. The resident, who had a history of post-traumatic stress syndrome due to previous physical and emotional abuse, was admitted with moderate cognitive impairment and was dependent on staff for many activities of daily living. Physician orders required staff to monitor the resident for psychosocial wellbeing, including observing and charting progress notes for behavior, refusal of care, social isolation, and pain management, and to notify the provider of any concerns, with monitoring to occur every shift for five days. However, a review of progress notes showed no documentation of such monitoring related to the abuse allegation, and staff confirmed that this monitoring was not performed.
Failure to Ensure Safe and Timely Discharge Planning
Penalty
Summary
The facility failed to adequately assist residents with discharge planning, resulting in unmet discharge needs for two residents. For one resident admitted with blood clots in the lungs and chronic obstructive pulmonary disease, the care plan indicated a short-term stay and required coordination with the physician and community referrals. However, the resident’s power of attorney (POA) repeatedly requested assistance in setting up a primary care provider (PCP) and home caregivers, but was told by staff that this was not the facility’s responsibility. Documentation showed ongoing communication issues, incomplete discharge planning assessments, and a lack of coordination among staff, leading to delays and the resident threatening to leave against medical advice due to feeling unprepared for discharge. For another resident with congestive heart failure and cirrhosis, the care plan documented a long-term stay, but there was no evidence of a discharge evaluation, care conference notes, or progress notes regarding discharge goals. The social service evaluation was incomplete, with key sections left blank, including the resident’s wishes for discharge and anticipated length of stay. Although social services staff reported working on community housing for the resident, this was not documented in the medical record or reflected in the care plan. The resident ultimately left the facility against medical advice, and staff acknowledged the absence of a documented discharge plan or reassessment. Interviews with staff, including the Director of Nursing and social services, confirmed confusion and lack of communication regarding discharge planning for both residents. Staff admitted that necessary services, such as arranging a PCP and caregiver support, were not set up, and that discharge planning was not properly documented or coordinated. These failures resulted in delayed or unsafe discharges and were not aligned with the residents’ needs or preferences.
Failure to Complete Discharge Summaries and Provide Bed Hold Notices
Penalty
Summary
The facility failed to complete a discharge summary for one resident who was reviewed for discharge planning. Specifically, the medical record for this resident, who had diagnoses including dementia and dysphasia and was admitted for a short-term stay, did not contain a completed discharge summary or discharge instructions. Although the resident's medications and belongings were reviewed and sent with the resident upon transfer to another LTC facility, the required discharge summary was not prepared or sent. Staff confirmed that they did not always complete the discharge summary or instructions as required. Additionally, the facility did not provide written bed hold notices to a resident who left on therapeutic leaves of absence. The medical record for this resident, who had diagnoses of congestive heart failure and cirrhosis and was independent with activities of daily living, showed multiple instances of leaves of absence without documentation that a bed hold was offered. Staff in social services stated they were not aware of the requirement to provide bed hold notices for therapeutic leaves and did not provide them to residents.
Failure to Update and Revise Care Plans for Resident Needs
Penalty
Summary
The facility failed to ensure that care plans were reviewed, revised, and accurately reflected the care needs of two residents. For one resident with dementia and dysphagia, the care plan did not include specific dietary needs as indicated by physician orders and a nutritional assessment, such as the requirement for moderately thick liquids, thin water between meals, small bites of food, and specific swallowing techniques. Despite these needs being documented in other records, the care plan was not updated to reflect them. For another resident with Parkinsonism syndrome and chronic pain, the care plan documented a history of post-traumatic stress syndrome due to past abuse but was not revised to include a new allegation of sexual abuse by a staff member. The incident was documented in an incident report, but the care plan was not updated to address this significant event. These omissions were confirmed by facility staff during interviews.
Lack of Documented Mechanical Lift Training for Nursing Staff
Penalty
Summary
The facility failed to ensure that both agency and facility-employed nursing staff demonstrated competency in the use of mechanical lifts for resident transfers. Specifically, five staff members, including both agency and facility staff, did not have documentation of mechanical lift training in their personnel files. Interviews with nursing assistants revealed inconsistent practices regarding the number of staff required for mechanical and standing lift transfers, with some staff expressing concerns about agency staff using improper techniques, such as attempting transfers with only one staff member. These concerns were reported to supervisors, but no documentation of required training was found for the identified staff. During interviews, staff members described varying practices and acknowledged intervening when improper transfer methods were observed. The Administrator and DON were unable to provide evidence of mechanical lift training for the staff in question, despite further attempts to locate such documentation. No additional documentation was provided to demonstrate that the staff had received the necessary training to safely operate mechanical lifts, as required by facility policy and state regulations.
Failure to Assess and Document Influenza and Pneumococcal Vaccinations
Penalty
Summary
The facility failed to ensure that four out of five sampled residents received appropriate assessment and documentation regarding influenza and pneumococcal vaccinations. For three residents, there was no documentation in their medical records indicating that their vaccination history was assessed or that they were offered the influenza or pneumococcal vaccines. One resident had documentation of receiving a dose of the pneumococcal vaccine, but there was no evidence that a second dose was offered as required. The Director of Nursing confirmed that there was no documentation of vaccine history or vaccine offers in the current medical records, and no additional documentation was provided from previous record systems.
Failure to Document and Offer COVID-19 Vaccination
Penalty
Summary
The facility failed to ensure that the COVID-19 vaccine was provided or offered to three out of five residents reviewed for immunizations. For these residents, there was no documentation in their medical records indicating that their vaccination history had been assessed or that the COVID-19 vaccine was offered or administered. The Director of Nursing confirmed that there was no documentation of vaccine history or vaccine offers in the current medical records, and was unable to provide further documentation from previous record systems. This lack of documentation and action resulted in the deficiency identified during the survey.
Failure to Monitor and Document Psychotropic Medication Use
Penalty
Summary
The facility failed to ensure proper management and monitoring of psychotropic medications for multiple residents, resulting in deficiencies related to unnecessary medication use, lack of documentation, and failure to implement non-pharmacological interventions. For one resident with bipolar and depressive disorders, antipsychotic and antianxiety medications were administered without clear documentation of target behaviors, clinical rationale for medication duration beyond 14 days, or evidence that non-pharmacological interventions were attempted prior to medication administration. The care plan did not address all relevant diagnoses or specify the symptoms being treated, and staff interviews confirmed these omissions. Another resident was prescribed multiple psychotropic medications, including antianxiety, antipsychotic, and antidepressant drugs, without corresponding diagnoses documented in the medical record or care plan. The Director of Nursing Services acknowledged the lack of appropriate diagnoses and justification for these medications. Additionally, for several residents, as-needed psychotropic medications were ordered without required stop dates or re-evaluation, and pharmacist recommendations regarding medication duration and documentation were not acted upon in a timely manner. For residents on hospice or palliative care, as-needed psychotropic medications were ordered for periods exceeding regulatory limits without documented clinical justification or end dates. Medication administration records showed instances where medications were given without documentation of target behaviors or attempted non-pharmacological interventions. Staff interviews confirmed that monitoring for side effects and behaviors was not consistently ordered or documented, and that medication orders often lacked appropriate diagnoses or rationale.
Failure to Timely Transmit MDS Assessment Data
Penalty
Summary
The facility failed to transmit required Minimum Data Set (MDS) assessment data to the Center for Medicare and Medicaid Services (CMS) within 14 days of completion for eight out of nine residents reviewed. According to the Long-Term Care Resident Assessment Instrument (RAI) 3.0 User's Manual, MDS assessments, including Admission, Significant Change, Quarterly, and Annual assessments, must be completed no later than 14 days after the Assessment Reference Date (ARD) and submitted to the CMS database within 14 days of completion. Review of the electronic health records (EHR) for the identified residents showed no MDS data was present for assessments with ARDs in March 2025, and there was no indication that these MDSs had been scheduled, completed, or transmitted as required. The deficiency was further substantiated by the facility's March 2025 MDS Final Validation Report (FVR) from CMS, which showed that for each of the eight residents, the most recent MDS assessments were submitted more than 14 days after their completion dates. The administrator explained that a recent change in facility ownership and EHR systems resulted in an inability to access the data for MDS assessments completed in March 2025, which contributed to the delay in submission. The lack of timely MDS transmission was identified through both record review and staff interview.
Failure to Develop and Implement Comprehensive, Individualized Care Plans
Penalty
Summary
The facility failed to develop and implement comprehensive care plans that accurately reflected the care needs of twelve residents. For several residents, care plans did not address critical medical conditions or physician orders, such as malnutrition, use of ace/compression wraps, specific catheter types and justifications, daily or weekly weights with notification parameters, and NPO status. In multiple cases, the care plans omitted essential details about the residents' diagnoses, treatments, and monitoring requirements, despite these being documented in the residents' medical records and confirmed by staff interviews. Residents with complex medical histories, including severe cognitive impairment, heart failure, kidney disease, malnutrition, and those on hospice or palliative care, were affected by these omissions. For example, one resident with severe cognitive impairment and malnutrition did not have a nutrition care plan, and another with a suprapubic catheter did not have the catheter type or justification documented in the care plan. Additionally, care plans failed to address specific interventions such as daily weights for residents on diuretics, non-weight bearing status affecting bathing routines, and individualized smoking safety plans. Further deficiencies included the lack of person-centered care planning for mental health diagnoses, such as anxiety and PTSD, and the absence of non-pharmacological interventions for psychotropic medication use. Care plans for residents on hospice did not specify advanced directives, goals of care, or the hospice provider. Other omissions included not updating continence care plans to reflect current status, not care planning for bed placement against the wall, and not specifying respiratory care details such as oxygen saturation targets and delivery methods. These failures were confirmed through staff interviews and record reviews, indicating a systemic issue in care plan development and implementation.
Failure to Follow Physician Orders, Document Care, and Protect Resident Information
Penalty
Summary
Facility staff failed to ensure that services provided met professional standards for multiple residents, as evidenced by incomplete or missing documentation, failure to follow physician orders, and improper record-keeping. For example, one resident who was cognitively impaired and received tube feeding had a physician order for daily syringe changes, which was not properly documented or initialed, despite staff signing off as completed. Another resident, also cognitively impaired and dependent on staff, had orders for weekly fingernail trimming and daily foot checks, but observations and record reviews showed these tasks were not performed as documented, with staff signing off on tasks that were not completed. Additional deficiencies included failure to record and monitor daily or scheduled weights for residents with heart failure and diuretic therapy, as ordered by physicians. In several cases, weights were not recorded for extended periods, and significant weight variances that required physician notification were not documented or communicated. Staff interviews confirmed that these tasks were not optional and should have been completed, but issues with order entry into the electronic health record (EHR) or task administration records (TAR/NTAR) may have prevented nurses from seeing the required tasks. Other deficiencies included blank documentation on medication administration records (MARs) for required monitoring of side effects and behaviors related to psychotropic medications, lack of documentation and proper timing for PICC line dressing changes and measurements, and failure to protect resident information by leaving computer screens with resident data visible and unattended. Staff interviews consistently confirmed that these actions did not meet facility expectations or professional standards.
Failure to Provide Sufficient Nursing Staff and Timely Resident Care
Penalty
Summary
The facility failed to provide sufficient nursing staff to meet the daily needs of residents, resulting in delayed care and incomplete activities of daily living (ADLs). Multiple residents reported excessive wait times for staff response to call lights, with some waiting up to two hours, particularly during night shifts and shift changes. Several residents described incidents where they were left in soiled briefs or had to wait extended periods for assistance with toileting, leading to episodes of incontinence. Residents also reported missed showers, infrequent oral and hair care, and delays in receiving pain medication. Resident council interviews and meeting notes further documented ongoing concerns about inadequate staffing, delayed medication administration, and insufficient attention to personal care needs such as catheter care and timely showers. Residents expressed that agency staff were often unresponsive, did not perform required duties, and were sometimes disrespectful. Grievance logs corroborated these issues, with multiple complaints about slow call bell responses and lack of timely check and change care. Staff interviews confirmed that CNAs did not have enough time to complete all required assignments, often having to forgo non-mandatory but important aspects of care such as oral hygiene, nail care, and hair care. Staff reported that agency personnel frequently failed to provide adequate care, including not changing briefs or assisting with meals. The Director of Nursing acknowledged expectations for timely call bell response and completion of ADLs but was unaware of the extent of the issues reported by staff and residents.
Medication Error Rate Exceeds Acceptable Threshold
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, resulting in a calculated error rate of 15.38% based on 4 errors out of 26 observed medication administration opportunities. On 06/17/2025, one resident was administered three insulin medications, including Insulin Degludec, Insulin Lispro, and a sliding scale dose of Insulin Lispro, all after the scheduled 8:00 AM time, with the resident reporting that breakfast had already been completed and the tray removed. On 06/18/2025, another resident received Baclofen for muscle spasms late, after the scheduled 12:00 PM administration time. The Director of Nursing Services confirmed that medications are expected to be administered within one hour before or after the scheduled time, and acknowledged that these medications were not given within the required timeframe.
Deficient Food Storage, Labeling, and Monitoring Practices Identified
Penalty
Summary
Surveyors observed multiple deficiencies in the facility's food storage and handling practices. In the kitchen's walk-in refrigerator, large uncovered bins of white rice and brown gravy were found cooling without lids. Staff confirmed these items had just been prepared and were left uncovered to cool. In another refrigerator, a container of peaches and pineapple was found past its use-by date, and staff acknowledged it should have been discarded. In the walk-in freezer, chicken and pepperoni were stored above a tray of sugar cookies covered only by wax paper, which staff confirmed was improper storage. Further deficiencies were noted in resident-accessible dining room refrigerators. In the Country Kitchen dining room, the refrigerator temperature log had not been checked or recorded for seven days, despite the expectation for twice-daily monitoring. In the Bistro dining room, several food items were found to be outdated or unlabeled, including eggs and pancakes, strawberries and cantaloupe, pineapple, and a bag of tortillas with beans and meat. Staff confirmed these items were expired and should have been discarded after three days. These findings demonstrate failures in food storage, labeling, and monitoring procedures.
Failure to Prevent Accident Hazards and Incomplete Resident Assessments
Penalty
Summary
The facility failed to maintain an environment free from accident hazards and did not implement or update care plans and assessments to prevent accidents for three of four residents reviewed. One resident with a history of stroke and hemiplegia experienced a fall during a shower, resulting in a right hip fracture, and there was no fall care plan in place for this resident. The Director of Nursing Services (DNS) confirmed that the resident was showered in a different stall than usual, with grab bars on the resident's weaker side, and acknowledged that a fall care plan should have been implemented but was not. Another resident with diabetes and COPD had multiple falls, including one in the bathroom without footwear, and was observed without proper footwear and with the bed against the wall, which was not care planned, assessed, or consented. The DNS confirmed that new interventions were not added to the fall care plan after repeated falls and that the bed against the wall lacked required documentation. A third resident, who was cognitively intact and permitted to smoke unsupervised, did not have a completed smoking safety evaluation in their record. The DNS confirmed that the required safety assessment for independent smoking was missing and could not be found by therapy staff.
Failure to Provide Dignified Care and Respect Resident Preferences
Penalty
Summary
Staff failed to provide care and services in a dignified manner for two residents. One resident, who was cognitively intact and exhibited verbal and physical behaviors, repeatedly requested assistance to return to their room from the dining area. The assigned CNA responded dismissively, telling the resident to wait increasing amounts of time and making comments such as, 'Ok, when you are on the floor I will come get you.' The resident continued to express discomfort and urgency, but the staff member did not respond in a respectful or timely manner, only assisting after requesting help from another staff member. Another resident, who was cognitively impaired and dependent on staff for activities of daily living, was not having their clothing changed daily as reported by their spouse. The spouse observed that the resident remained in the same clothes for multiple days and was not changed into night clothes before bed, despite a preference for sleeping in a hospital gown. The resident was observed resting in bed during the day still wearing day clothes, which was confirmed by the spouse and observed by surveyors.
Failure to Inform and Document Advance Directives for Residents
Penalty
Summary
The facility failed to inform and provide written information to residents regarding their right to formulate an advance directive. For two of three residents reviewed, there was no documentation in the electronic health record (EHR) of an advance directive or evidence that the facility had offered the opportunity to formulate one. One resident was admitted with severe cognitive impairment, and staff could not locate any documentation of a power of attorney (POA) or advance directive in the EHR or social work evaluation. Staff interviews confirmed that this information was not present or documented for this resident. Another resident, who was cognitively intact at admission, also had no documentation of an advance directive or that the opportunity to formulate one had been offered. Staff reviewed the EHR and found only a POLST (Portable Orders for Life Sustaining Treatment) documented under advance directive, but clarified that a POLST does not count as an advance directive. The Director of Nursing Services confirmed that the lack of documentation for both residents did not meet facility expectations.
Failure to Provide SNF Advanced Beneficiary Notice of Non-Coverage
Penalty
Summary
The facility failed to provide the required Skilled Nursing Facility Advanced Beneficiary Notice of Non-Coverage (SNF ABN) to one of three sampled residents reviewed for beneficiary notices. Record review showed that the Notice of Medicare Non-Coverage, dated 03/28/2025, documented that the resident was not given the SNF ABN. During an interview, the Administrator confirmed that the resident had not been provided with the SNF ABN as required.
Failure to Timely Report Alleged Neglect to State Agency
Penalty
Summary
The facility failed to ensure that an allegation of neglect made by a cognitively intact resident was reported to the State Agency within 24 hours, as required. The resident, who required substantial to maximal assistance with toileting hygiene, reported that staff left them uncovered, unchanged, and wet for approximately two hours after a nurse had started to change their brief but did not return. The incident was not documented in the facility's incident or grievance logs, and there was no evidence that it was reported to the appropriate authorities. The resident stated that they had informed an Occupational Therapy Assistant (Staff V) about the incident, who in turn reported it to the charge nurse but could not recall who that was. Staff V also provided the resident with a grievance form and the contact number for the Ombudsman, but the resident declined to fill out the form. Facility leadership, including the Administrator and DON, were unaware of the incident until informed by surveyors and acknowledged that the allegation should have been reported. This lapse resulted in the failure to report the suspected neglect to the State Agency within the required timeframe.
Failure to Investigate and Address Resident Falls
Penalty
Summary
The facility failed to conduct a thorough investigation into multiple falls experienced by a resident with diabetes and chronic obstructive pulmonary disease, who was able to communicate needs. The resident had three documented falls within a short period, including one in the bathroom resulting in bruises. Review of the incident investigations revealed that no statements from care staff were collected, no root cause for the falls was identified, and no new interventions or care plan updates were implemented. All investigations were completed 13 days after the first fall, exceeding the expected timeframe. The Director of Nursing Services confirmed that the investigations lacked appropriate witness statements, did not rule out abuse or neglect, and failed to identify or implement measures to reduce further fall risk.
Failure to Provide Consistent ADL Assistance Including Bathing, Nail, and Oral Care
Penalty
Summary
The facility failed to provide necessary assistance with activities of daily living (ADLs) for four residents who were dependent on staff for care. For one resident with cognitive impairment, staff did not consistently trim fingernails as scheduled, despite documentation indicating the task was completed. The resident's representative observed that the nails were long and untrimmed, and the resident also experienced gaps of up to ten days without being offered or provided scheduled bathing. The Director of Nursing Services (DNS) confirmed that the expected bathing schedule was not consistently followed for this resident. Another resident, who was cognitively intact but required moderate to maximal assistance with ADLs, reported inconsistent provision of scheduled showers. Review of records showed an 11-day period without bathing, and the DNS acknowledged that the resident was not consistently offered or provided bathing as scheduled. A third resident with right-side hemiplegia, who required assistance with oral care, was observed multiple times with visibly unclean teeth and reported that staff did not offer help with brushing teeth. Staff interviews confirmed that oral care was not consistently provided, despite care plans indicating the need for daily assistance. A fourth resident, also cognitively intact and requiring substantial assistance with bathing, reported not receiving a bed bath since admission. Documentation initially showed no record of bathing for a week after admission, and subsequent records confirmed a seven-day gap without bathing. Staff acknowledged that going a week without a shower was not acceptable, and no additional documentation was provided to show the care was given. These findings demonstrate a pattern of failure to provide essential ADL support, including nail care, bathing, and oral hygiene, as required by residents' care plans and facility policy.
Failure to Administer Bowel Care and Monitor Weights per Orders
Penalty
Summary
The facility failed to provide care and services in accordance with professional standards and residents' person-centered care plans for several residents, specifically in the areas of bowel management and fluid volume monitoring. For four residents reviewed for bowel management, there were multiple instances where residents went several days without a bowel movement, and as-needed (PRN) bowel medications were not administered as per physician orders or the facility's bowel protocol. In some cases, PRN bowel medication orders were missing or not visible to nursing staff, particularly following a transition to a new electronic health record (EHR) system. Staff interviews confirmed that these medications should have been administered but were not, and that the EHR transition likely contributed to the oversight. Additionally, for two residents with orders for regular weight monitoring due to conditions such as heart failure and the use of diuretics, the facility failed to obtain and document weights as ordered. In one case, weights were not recorded for over a month, and in another, only a fraction of the required daily weights were documented over a 49-day period. Staff confirmed that these failures were due to issues with order input in the EHR, which prevented nurses from seeing the weight monitoring orders. These deficiencies resulted in residents not receiving care and monitoring as directed by their physicians and care plans.
Failure to Assess and Document Pressure Injury
Penalty
Summary
The facility failed to ensure ongoing assessment, monitoring, and documentation of an identified pressure injury for one resident. Upon discovery of an open area on the resident's coccyx, there was no documentation of an initial wound assessment, including measurements, wound type, tissue type, drainage details, or peri-wound description. Additionally, there was no evidence that the resident's provider or representative was notified of the new wound, nor were any new treatment orders obtained. The resident's care plan, while indicating risk for pressure injuries, did not reflect the presence of an active pressure injury or update interventions accordingly. Review of the electronic health record and treatment administration record showed that the only ongoing intervention was the application of lanolin cream, with no changes made after the wound was identified. Weekly skin observation notes lacked essential wound details, and staff were unable to provide documentation of required assessments or notifications. The facility's policy required prompt reporting, assessment, and care plan updates for pressure injuries, but these actions were not completed for the resident in question.
Failure to Provide Daily Range of Motion and Splint Care
Penalty
Summary
The facility failed to provide necessary care and services to maintain range of motion (ROM) for two residents with significant mobility limitations. One resident, who had a history of stroke, hemiplegia, and a right hand contracture, was observed lying in bed with a washcloth in their right palm. The care plan required daily hand/splint care, including washing and placing a rolled washcloth in the hand for at least 15 minutes each day. However, documentation showed that this care was only provided every other day, and there were no current orders or care plan in place for daily restorative services for the resident's hand contractures. Another resident with right-side hemiplegia was observed with a soft splint on their right hand and reported that staff no longer washed their hand or removed the splint, resulting in a musty odor. There was no care plan or orders for the right-hand splint, and the last documented care was several days prior to the observation. Interviews with staff revealed confusion about who was responsible for providing the required care, with restorative aides and CNAs each believing the other was responsible. The DON confirmed that care plans and daily care for splints and palm protectors were expected but not provided as required.
Failure to Address Significant Weight Loss and Nutrition Needs
Penalty
Summary
The facility failed to identify and address significant weight loss in a resident with diabetes and kidney disease. The resident experienced a weight loss of over 14% in just over three months, with documented weights showing a loss of 16.8 pounds. Despite physician orders to weigh the resident weekly and notify the provider if certain weight loss thresholds were met, there was no documentation of reweighing or provider notification after the resident met these criteria. Additionally, the resident was ordered a nutritional supplement, but records showed inconsistent administration and documentation, with the resident often not receiving the full amount or refusing the supplement. There was no evidence of a nutrition or weight loss care plan in the resident's comprehensive care plan, despite significant and ongoing weight loss. Staff interviews confirmed the lack of a care plan, absence of provider notification, and failure to attempt alternative nutritional interventions when the resident refused the prescribed supplement. The interdisciplinary team did not discuss the resident's weight loss, and the required documentation and follow-up actions were not completed as per facility policy and physician orders.
Failure to Provide Safe and Appropriate Respiratory Care per Physician Orders
Penalty
Summary
The facility failed to provide respiratory care and services in accordance with physician's orders and accepted professional standards for three residents requiring respiratory support. For one resident with obstructive sleep apnea, the CPAP machine was observed with an empty humidifier reservoir on two occasions, and the physician's orders lacked essential details such as the prescribed pressure setting, instructions for checking and refilling the humidifier with distilled water, and cleaning protocols for the humidifier reservoir. The Director of Nursing confirmed these omissions and acknowledged the orders were incomplete. Another resident with obstructive sleep apnea had a CPAP and nebulizer at the bedside, but the nebulizer tubing and mask were not labeled or dated as required. The medication administration record showed blanks for the order to change and label the nebulizer equipment weekly, indicating the task was not completed or documented. Additionally, the CPAP settings for this resident were not documented in the electronic health record, and staff reported they would need to contact the pulmonologist to obtain the settings if needed. A third resident with chronic obstructive pulmonary disease and respiratory failure had an order for continuous oxygen at 2 liters via nasal cannula. Observations revealed the resident was at times without the nasal cannula, connected to an empty portable oxygen tank, or receiving oxygen at a rate different from the order. Staff confirmed these deviations from the physician's order and acknowledged that the resident did not do well without oxygen. The Director of Nursing stated that staff were expected to ensure the resident received oxygen as ordered and to update orders if changes were needed.
Failure to Provide and Document Non-Pharmacological Interventions Prior to Pain Medication Administration
Penalty
Summary
The facility failed to ensure that residents were free from unnecessary medications by not providing or documenting non-pharmacological interventions (NPIs) prior to administering as needed pain medications for two residents. One resident, who had a history of falls, a humerus fracture, and chronic pain, was able to communicate needs and was administered oxycodone two to three times daily over a three-week period without any documentation of NPIs being attempted before medication administration. Staff interviews confirmed that it was the facility's expectation to attempt and document NPIs prior to giving as needed pain medication, but this was not done, and there were no orders for NPIs for this resident. Another resident, who was severely cognitively impaired, had orders for both scheduled and as needed oxycodone-acetaminophen. Review of medication administration records showed no NPIs were ordered or documented, and there was no monitoring for adverse side effects related to the pain medication. Additionally, the resident received 23 administrations of scheduled oxycodone with a documented pain score of zero, and there was no evidence that the provider was contacted regarding the continued use of pain medication despite the absence of reported pain. Staff confirmed that these practices did not meet facility expectations.
Expired and Improperly Labeled Medications, Unsecured Medication Cart
Penalty
Summary
Surveyors observed multiple deficiencies related to medication management and storage. On several medication carts, expired medications and equipment were found, including bottles of anti-itch lotion, Ibuprofen, Zinc, and control drops for an accu chek machine. Some medications were improperly labeled, such as a medication cup containing white pills labeled only with a marker and lacking an expiration date, and bottles with illegible or incomplete resident names. Staff present during these observations acknowledged the expired or improperly labeled items and indicated they would remove or replace them. The Director of Nursing Services confirmed that expired medications should have been removed and destroyed, and that medications should be properly stored and labeled. Additionally, a medication cart was found unlocked and unattended, with no staff in sight. When questioned, a staff member stated she had not noticed the cart was unlocked and believed it normally locks. The Director of Nursing Services stated that medication carts should be locked when staff are not present. These findings demonstrate failures in ensuring that drugs and biologicals are labeled and stored according to professional standards, and that expired items are discarded in a timely manner.
Failure to Prepare and Serve Palatable, Appropriately Tempered Meals and Honor Resident Preferences
Penalty
Summary
The facility failed to ensure that food and beverages were prepared and served in a manner that maintained palatability, appropriate temperature, and honored resident preferences. Multiple residents reported that their meals were frequently served cold, dried out, or tasteless. Observations confirmed that food items such as oatmeal, soup, and bread were served cold or unappetizing, and a test tray revealed that cold items were not at the required temperature, with cranberry juice measured at 52 degrees and pudding at 71 degrees. Residents also expressed dissatisfaction with the repetitive menu and lack of variety, particularly noting the frequent serving of disliked items such as white bread and canned ham, despite documented preferences to the contrary. During meal preparation, staff did not consistently follow recipes or use measured ingredients for pureed diets, instead relying on visual assessment and unmeasured additions of water and thickener. The Food Service Supervisor acknowledged that recipes with specific measurements and the use of broth instead of water were intended to ensure consistency, nutritional value, and palatability, but these procedures were not followed. Additionally, staff failed to provide correct portion sizes as indicated on residents' tray cards, with only one scoop available for serving, resulting in residents not receiving their preferred or prescribed portion sizes. Resident interviews and record reviews further revealed that food preferences and dislikes documented in care plans were not honored. For example, a resident with a documented dislike of white bread continued to receive it with meals, and staff confirmed this was not acceptable. The lack of adherence to residents' dietary preferences and the improper preparation and serving of meals placed residents at risk of dissatisfaction with meals, decreased intake, and reduced quality of life.
Failure to Accommodate Hearing and Bariatric Needs
Penalty
Summary
The facility failed to accommodate the hearing needs of a resident, who had been experiencing ear and hearing issues. Despite having a physician's order for an ENT referral due to hearing loss and potential ear wax build-up, the resident was unable to attend an appointment. The facility had only one transport option, which the resident could not tolerate due to their size, and no alternative transportation was provided. Staff acknowledged the resident's hearing difficulties, but no further attempts were made to facilitate the necessary medical appointment. Additionally, the facility did not provide appropriate bariatric equipment for the resident, who weighed 475 pounds and had a BMI indicating morbid obesity. The resident was informed that if their weight exceeded 500 pounds, they would need to be transferred to another facility due to the limitations of the mechanical lift and other equipment. The resident expressed frustration and anger over the situation, particularly after being told that the transfer pole they used had been removed due to weight restrictions. Staff members confirmed that the facility's equipment could not support residents over 500 pounds and that there were no plans to purchase bariatric equipment. Despite the resident's lack of interest in losing weight, the facility's goal was for the resident to lose weight, which was not aligned with the resident's wishes. The facility had discussed the issue with senior leadership but had not developed a plan to address the resident's needs if they refused to transfer to another facility.
Failure to Develop Comprehensive Care Plan for UTI Prevention
Penalty
Summary
The facility failed to develop a comprehensive care plan for a resident with ongoing urinary tract infections (UTIs) and specific urinary care needs. The resident, who was admitted with diagnoses including diabetes mellitus, heart failure, and kidney failure, required maximal assistance with toileting due to deconditioning and poor activity tolerance. Despite multiple urine analyses indicating persistent UTIs caused by klebsiella pneumoniae, the facility did not establish a care plan addressing the resident's urinary care needs or UTI prevention. The resident reported difficulties using a standard urinal due to their anatomy and required a special, larger urinal, which staff were not adequately trained to use. The resident often experienced delays in staff assistance, resulting in prolonged exposure to urine, which they believed contributed to their recurrent UTIs. Interviews with staff revealed a lack of knowledge on preventing UTIs and proper use of the urinal, with the resident having to instruct staff on its use. The Director of Nursing Services acknowledged the absence of a care plan for these issues, which should have been addressed.
Failure to Update Facility Assessment for Bariatric Care
Penalty
Summary
The facility failed to update its facility-wide assessment to accurately determine and identify the resources needed for residents requiring bariatric care. The assessment, dated March 2024, included an evaluation of bariatric needs but lacked specific details on how the facility would support residents considered bariatric. This oversight was not addressed even when concerns arose regarding the care of bariatric residents. A resident, weighing 482 pounds, was informed by staff that the facility lacked equipment to support individuals weighing over 500 pounds. The resident was told they might need to transfer to another facility if their weight increased. The mechanical lift available could only accommodate up to 500 pounds, and the transfer pole, which the resident used, was removed due to weight limitations. The facility's administrator acknowledged that the facility did not have the necessary equipment to support bariatric residents and had not updated the facility assessment to address this need.
Incomplete Investigation of Alleged Abuse
Penalty
Summary
The facility failed to conduct a thorough investigation into allegations of abuse involving a resident with moderate cognitive impairment and a history of stroke-like symptoms, bipolar disorder, and PTSD. The resident was reported to have claimed a relationship with a staff member, a Physical Therapy Assistant, who was involved in activities such as going on walks, bringing groceries, and driving the resident to the store. Despite these claims, the investigation did not include an interview with the resident or a sample of other residents who received care from the staff member, nor did it include interviews with the staff member's peers. The investigation was incomplete, lacking documentation of a return call to the resident who had expressed concerns and made accusations about sharing an apartment with the staff member. The Director of Nursing acknowledged the absence of further interviews and stated that the investigation was not thorough. The failure to conduct a comprehensive investigation placed residents at risk for unidentified abuse and a diminished quality of life.
Failure to Report Financial Exploitation Allegations
Penalty
Summary
The facility failed to immediately report potential financial exploitation of a resident to the state agency, as required by their policy. The resident, who had moderate cognitive impairment and required assistance with activities of daily living, reported to staff that their significant other was withholding money and only providing small amounts after verbal abuse. Despite the resident's complaints to social services and spiritual services, the concerns were not addressed or reported to the appropriate authorities. Staff members, including a Licensed Practical Nurse and Social Services staff, were aware of the resident's allegations but did not document or report them. The Director of Nursing and the Administrator were also aware of the situation but did not take action to report the allegations. This lack of reporting and documentation placed residents at risk for potential unidentified mistreatment and a poor quality of life.
Failure to Develop Personalized Discharge Plan
Penalty
Summary
The facility failed to develop a personalized discharge plan for a resident, identified as Resident 2, who was admitted with post-accident traumatic injuries and fractures. Despite having no cognitive impairment and requiring only set-up assistance for activities of daily living, the resident's discharge plan was not tailored to their specific needs, goals, and preferences. The care plan indicated an improvement in mobility prior to discharge, but there was a lack of communication and coordination regarding the resident's discharge process. The resident and their family requested a COPES assessment to facilitate additional home services, but experienced delays and inconsistent information regarding the assessment's status. Therapy notes indicated that Resident 2 would benefit from COPES and home support, yet there was no consistent documentation or follow-through on these recommendations. The resident eventually opted to discharge without the COPES assessment, leading to unmet care needs at home. Staff interviews revealed that there was no individualized discharge care plan developed, and there were inconsistent recommendations regarding the resident's ability to manage independently at home. This lack of a comprehensive discharge plan placed the resident at risk for delayed discharge and diminished quality of life.
Failure to Provide Trauma-Informed Care
Penalty
Summary
The facility failed to provide trauma-informed and culturally competent care to a resident diagnosed with PTSD, major depressive disorder, and general anxiety disorder. The resident, who had moderate cognitive impairment and required assistance with activities of daily living, expressed feelings of worthlessness and distress due to changes in their health and family dynamics. Despite having a care plan that included interventions like family visits and mental health services, the resident's emotional needs were not adequately addressed, leading to increased anxiety and suicidal thoughts. The resident reported feeling traumatized and humiliated by their significant other's behavior, which included withholding money and making demeaning comments. Staff members, including a Licensed Practical Nurse and a Social Worker, were aware of these issues but failed to document or address them appropriately. The facility did not conduct a trauma assessment for the resident, and there was no care plan reflecting the resident's concerns about their family dynamics. Additionally, the facility was unaware of an open Adult Protective Services case related to the resident's situation. Interviews with staff revealed a lack of awareness and documentation regarding the resident's trauma and family issues. The Director of Nursing and the Administrator acknowledged the oversight in not conducting a trauma evaluation and not reporting the resident's allegations. The facility's failure to provide trauma-informed care and to document and address the resident's concerns contributed to the deficiency identified in the report.
Medication Management Deficiencies in LTC Facility
Penalty
Summary
The facility failed to adhere to professional standards of practice in medication management for several residents, leading to potential medication errors and unmet care needs. For Resident 90, nurses held medications such as propranolol, furosemide, and spironolactone despite the resident's blood pressure and pulse being within the parameters set by the physician's orders. There was no documentation or assessment indicating the resident was symptomatic, which would justify holding the medications. The Director of Nursing confirmed that the medications should have been administered as ordered. Resident 88 experienced a similar issue where medications like metoprolol, Lotensin, and torsemide were administered even when the resident's pulse was below the physician-ordered threshold. Additionally, the resident had an incomplete order for intravenous saline infusion, lacking instructions for monitoring the IV site or performing maintenance flushes. The Administrator acknowledged the oversight in medication administration and the incomplete IV orders, which should have been identified and addressed by the nursing staff. For Resident 62, there were discrepancies in administering hydrocodone for pain management, with doses not aligning with the physician's orders based on the reported pain levels. Resident 34's anxiety medication, Busperone, was held due to unavailability, and there was no documentation of notifying the pharmacy or physician. Furthermore, a pain reassessment was delayed after administering Tylenol. Lastly, Resident 427's administration of Clonazepam was not properly documented in the controlled medication book, as expected by the Director of Nursing Services.
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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