Woodland Convalescent Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Woodland, Washington.
- Location
- 310 Fourth Street, Woodland, Washington 98674
- CMS Provider Number
- 505232
- Inspections on file
- 22
- Latest survey
- March 30, 2026
- Citations (last 12 mo.)
- 34
Citation history
Health deficiencies cited at Woodland Convalescent Center during CMS and state inspections, most recent first.
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 did not report multiple incidents of suspected abuse, neglect, misappropriation, and falls with significant injury involving several residents with cognitive impairment and complex medical conditions. Grievances and incident logs showed that allegations and injuries, including head trauma and deep lacerations, were not reported to authorities or fully investigated as required.
Surveyors found that the facility did not maintain a medication error rate below 5%, with nearly half of observed medications administered outside the required time window. Multiple residents received medications for conditions such as end-of-life care, hypertension, Parkinson's disease, and infection later than scheduled, as confirmed by MAR review and staff interviews. Facility expectations for timely administration were not met, resulting in a regulatory deficiency.
Surveyors found that medications and medical supplies were not properly stored, labeled, or secured. Expired OTC medications and supplies were present in storage areas and on emergency carts. Opened medications on a medication cart lacked required labeling, and both medication and treatment carts were left unlocked and unattended. Staff interviews confirmed that carts should be locked when not in use, but this was not consistently followed.
A resident's trust fund balance was not disbursed to the resident or their representative within the required timeframe after discharge, with funds remaining undispersed for several months. The business office manager confirmed the delay, which did not comply with regulatory expectations.
A resident with PTSD and hypertension reported $80.00 missing after a canceled store trip and filed a grievance. The facility did not investigate, follow up, or resolve the grievance, and staff confirmed the lack of action, citing a staffing gap in Social Services.
The facility did not accurately complete PASRR assessments for two residents with serious mental illnesses, resulting in missing or incomplete documentation of required mental health evaluations. The Social Services Director confirmed that the PASRR Level I screenings were done incorrectly at both admission and upon repeat, leading to failures in identifying and addressing the residents' mental health needs.
A resident who was moderately cognitively impaired experienced over five days without a bowel movement, during which the facility failed to initiate the required bowel management protocol. Staff interviews and record reviews confirmed that no interventions were administered or documented as per policy, resulting in a deficiency in providing appropriate care.
The facility did not submit the required Payroll Based Journal (PBJ) staffing data to CMS for a fiscal quarter, as confirmed by record review and administrator interview, resulting in no staffing data being available for that period.
The facility failed to label and date opened food items in both the kitchen freezer and the Unit 100 nourishment refrigerator/freezer. Undated and unlabeled items included meatballs, potato wedges, Chicken Cordon Blue, French fries, vegetables, Jello, and ice cream. Staff acknowledged the oversight.
The facility failed to initiate Enhanced Barrier Precautions for eight residents, properly implement standard precautions during dressing changes for two residents, and ensure proper aseptic techniques for urinary catheter maintenance for one resident. Additionally, a staff member did not perform hand hygiene before and after assisting a resident with meals.
A facility failed to promote dignity while assisting a resident with meals. The CNA did not communicate properly, placed a clothing protector without permission, and stood over the resident during meal assistance. This did not align with the care plan or facility expectations for promoting resident dignity.
The facility failed to maintain comfortable sound levels, leading to complaints from two residents about excessive noise from TVs and staff conversations, particularly at night and early in the morning. Despite staff awareness, the issue persisted, affecting the residents' quality of life.
The facility failed to investigate an allegation of inappropriate resident-to-resident touching involving a severely cognitively impaired resident. The incident was not documented in the incident report log or the resident's progress notes, and proper procedures such as alert charting were not followed.
The facility failed to initiate bowel interventions for two residents as per the established bowel management policy, resulting in prolonged periods without bowel movements and lack of documented actions. Interviews with staff confirmed the protocol was not followed, placing residents at risk for discomfort and health complications.
The facility failed to offer and/or administer the influenza and pneumococcal vaccines to two residents, both severely cognitively impaired, despite signed consents. The medical records lacked documentation of vaccine administration, and staff confirmed the vaccines were not given.
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 Report Abuse, Neglect, Misappropriation, and Significant Injuries
Penalty
Summary
The facility failed to timely report incidents of suspected abuse, neglect, misappropriation, and falls with significant injury for five residents, as required. For one resident with moderate cognitive impairment and hemiplegia, a grievance was filed by a friend alleging staff yelled at and were rude to the resident, but there was no evidence that this allegation of abuse or neglect was reported to the appropriate authorities. Another resident, who was cognitively intact and had hypertension and PTSD, reported missing money, but the grievance was not completed or investigated, and there was no report of misappropriation made. A third resident with moderate cognitive impairment and supranuclear ophthalmoplegia experienced multiple falls, including two with head injuries, but these incidents were not reported to Residential Care Services (RCS) as required. Documentation showed injuries such as bumps, abrasions, and facial bruising, with neuro checks initiated, but no external reporting occurred. Similarly, another resident with moderate cognitive impairment and acute kidney failure sustained a fall resulting in a hematoma near the eyebrow, but this was not reported to RCS. Documentation included witness and nursing notes describing the incident and injury. A fifth resident with moderate cognitive impairment and lung cancer suffered a fall resulting in a deep laceration to the left lower extremity, requiring hospital transport. Despite the severity of the injury, there was no evidence that this incident was reported to RCS. Across all cases, review of facility logs and reported incidents confirmed that required reports for significant injuries, misappropriation, and abuse/neglect allegations were not made, and in some cases, investigations were incomplete or not conducted.
Medication Error Rate Exceeds Regulatory Threshold Due to Late Administration
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, as required, resulting in a medication error rate of 48.15% during a medication pass audit. Surveyors observed that 13 out of 27 medications for four residents were not administered within the required time frame. Specifically, medications scheduled for administration at 9:00 AM, 8:00 AM, and 6:00 AM were instead given significantly later, with some being administered more than an hour past the scheduled time. The medications involved included treatments for end-of-life comfort, dry eyes, dysphagia, hypertension, Parkinson's disease, chronic pain, and antibiotic therapy for infection. Staff interviews and record reviews confirmed that the facility's expectation was for medications to be administered within one hour before or after the scheduled time as listed on the Medication Administration Record (MAR). However, observations showed that this standard was not met for multiple residents, as medications were prepared and administered outside of the required time window. This failure to adhere to scheduled medication administration times constituted a deficiency under the cited regulation.
Failure to Properly Store, Label, and Secure Medications and Supplies
Penalty
Summary
Surveyors observed multiple failures in the facility's medication management practices, including improper storage, labeling, and disposal of medications and medical supplies. In the medication storage room, numerous unopened bottles of over-the-counter medications and supplements were found to be expired, such as B Complex, B-12, Folic Acid, Vitamin C, Fish Oil, and liquid Iron. The emergency cart contained six expired Suction, Catheter, and Glove Kits. On the Flagship medication cart, several opened bottles of medication lacked documentation of the date opened and the date for disposal. Additionally, both the Flagship medication cart and a treatment cart were left unlocked and unattended for approximately half an hour, allowing potential unauthorized access to medications and supplies. Further observations revealed that medication carts were not consistently secured when not in use. On one occasion, a bottle of probiotics requiring refrigeration was left on an ice pack on the medication cart, which was then locked and left unattended by an LPN. The medication remained unsecured on the cart until the nurse returned. Staff interviews confirmed that the expectation was to keep medication and treatment carts locked when not in direct use, but this was not consistently practiced. These actions and inactions resulted in medications and medical supplies being improperly stored, labeled, and secured, contrary to facility policy and accepted professional standards.
Delayed Disbursement of Resident Trust Funds After Discharge
Penalty
Summary
The facility failed to ensure that resident funds were conveyed to the resident or their representative within 30 days of discharge, as required. Specifically, one discharged resident had a trust account balance of $100.05 that remained undispersed 147 days after discharge. Review of records confirmed the resident was discharged with no return anticipated, and the business office manager acknowledged that the funds were not distributed as expected. This deficiency was identified through interview and record review, and it was noted that the delay in dispersing the funds did not meet regulatory requirements.
Failure to Investigate and Resolve Resident Grievance Regarding Missing Money
Penalty
Summary
The facility failed to initiate, investigate, and resolve a grievance submitted by a cognitively intact resident who was admitted with diagnoses including post-traumatic stress disorder and hypertension. The resident reported missing $80.00 from their funds after a canceled store trip, and a grievance was filed regarding the missing money. The grievance form documented the resident's account of the incident but contained no evidence of investigation, follow-up, or resolution. Interviews with the resident confirmed that the money remained missing and that there was no follow-up from the facility. Staff interviews revealed that grievances related to misappropriation were managed by Social Services, but the grievance in question had no documented follow-up or resolution. The facility administrator acknowledged that the grievance was not completed, attributing the lapse to a period when there was no social worker on staff, resulting in the grievance being overlooked.
Failure to Accurately Complete PASRR Assessments for Residents with Mental Illness
Penalty
Summary
The facility failed to ensure that the Pre-admission Screening and Resident Review (PASRR) assessments accurately reflected mental health diagnoses for two residents. For one resident admitted with a diagnosis of depressive disorder and documented as severely cognitively impaired, the admission PASRR Level I did not indicate the presence of major depressive disorder. A repeat PASRR Level I later documented depressive disorder but did not clarify whether a PASRR Level II evaluation was indicated. For another resident admitted with diagnoses including post-traumatic stress disorder, anxiety disorder, and major depressive disorder, the admission PASRR Level I noted serious mental indicators but did not require a Level II evaluation due to an exempted hospital discharge. A subsequent PASRR Level I again documented serious mental illness but lacked documentation regarding the need for a Level II evaluation. During interviews, the Social Services Director acknowledged that both residents had serious mental illnesses prior to admission and that the PASRR Level I screenings were completed incorrectly at admission and upon repeat. The lack of accurate and complete PASRR documentation resulted in the failure to properly identify and address the residents' mental health needs as required.
Failure to Initiate Bowel Protocol for Resident with Extended Constipation
Penalty
Summary
The facility failed to implement its bowel management protocol for a resident who was moderately cognitively impaired. According to the facility's policy, specific interventions such as administering Polyethylene Glycol, Docusate Sodium, Milk of Magnesia, Sodium Phosphate enema, or Bisacodyl Suppository were to be initiated if a resident had not had a bowel movement for three days. Documentation showed that the resident went over five days without a bowel movement, yet the bowel protocol was not initiated during this period, and there was no documentation of interventions or refusals. Interviews with staff confirmed that an alert should have triggered after three days without a bowel movement and that interventions should have been administered and documented per policy. The Medication Administration Report for the relevant period did not show any bowel interventions provided, and the Director of Nursing was unable to provide further documentation of successful interventions. This lapse resulted in a failure to provide appropriate treatment and care according to physician orders and facility policy.
Failure to Submit Required Payroll Based Journal Staffing Data
Penalty
Summary
The facility failed to submit complete and accurate direct care staffing information to CMS for Fiscal Year Quarter 3, 2024, as required. Review of the Q3 2024 HPRD Reporting Results showed that the facility had zero data available for this period. During an interview, the Administrator confirmed that the Payroll Based Journal (PBJ) data had not been submitted to CMS for the specified quarter. This deficiency was identified through record review and staff interview, with no PBJ data available for the required reporting period.
Failure to Label and Date Opened Food Items
Penalty
Summary
The facility failed to ensure food items were labeled and dated when opened in both the kitchen freezer and the Unit 100 nourishment refrigerator/freezer. During an observation of the kitchen freezer, several undated and unlabeled opened items were found, including plastic bags of meatballs, potato wedges, Chicken Cordon Blue, French fries, and vegetables. Staff L, a cook, acknowledged that the items should have been dated but were not. Similarly, an inspection of the Unit 100 nourishment refrigerator/freezer revealed undated and unlabeled opened items such as Jello in a red plastic cup, a 14 oz container of vanilla bean ice cream, and Talenti ice cream. Staff M, the Dietary Manager, and Staff B, the Director of Nursing Services and Registered Nurse, confirmed that all items should be dated when opened and acknowledged the failure to do so.
Infection Control Deficiencies
Penalty
Summary
The facility failed to initiate Enhanced Barrier Precautions (EBP) for eight residents who had pressure ulcers or indwelling catheters. Despite having a policy in place, the facility did not implement EBP for these residents, which was confirmed by the Infection Preventionist and other staff members. The staff acknowledged that they were still working on a plan to implement EBP effectively, but it had not been put into practice during the survey period. The facility also failed to properly implement standard precautions during dressing changes for two residents with wounds. In one instance, a nurse did not change gloves or perform hand hygiene after cleaning a resident's bowel movement and proceeded with the dressing change. In another instance, a nurse did not perform hand hygiene between removing dirty dressings and applying new ones. Both instances were acknowledged by the staff as not meeting the facility's expectations for aseptic techniques. Additionally, the facility did not ensure proper aseptic techniques for urinary catheter maintenance for one resident. The resident's Foley catheter drainage bag was observed lying on the floor multiple times, which is against the facility's policy. Staff members admitted that the drainage bag should not be on the floor and acknowledged the need to find a solution to prevent this from happening. Furthermore, a staff member failed to perform hand hygiene before and after assisting a resident with meals, which was also against the facility's policy and CDC guidelines.
Failure to Promote Resident Dignity During Meal Assistance
Penalty
Summary
The facility failed to provide care in a manner that promoted dignity while assisting with meals for one resident. Resident 47, who had severely impaired cognition but could adequately hear and communicate, was observed being assisted with meals by a Certified Nursing Assistant (CNA) without proper communication or respect for the resident's dignity. The CNA placed a clothing protector on the resident without warning or permission and stood over the resident while assisting with eating, engaging in minimal conversation. This was observed on two separate occasions, with the CNA failing to sit at the resident's level or engage in meaningful conversation as expected by the facility's standards. Interviews with Registered Nurses (RNs) confirmed that the expectation was for staff to sit next to residents and communicate with them while assisting with meals. The care plan for Resident 47 included interventions to ensure staff conversed with the resident, allowed time for the resident to answer questions, and encouraged the resident to express their feelings. The observed actions of the CNA did not align with these care plan interventions, leading to a failure in promoting the resident's dignity and respect during meal assistance.
Failure to Maintain Comfortable Sound Levels
Penalty
Summary
The facility failed to maintain comfortable sound levels for two residents, leading to complaints about excessive noise. Resident 34, who was cognitively intact, reported that the TV in the hallway was too noisy at night, waking him up early in the morning. He had to use headphones to sleep and expressed a desire to see the facility's TV/noise policy. Resident 21, who was moderately cognitively impaired, also complained about noise, specifically her roommate's loud TV. Despite being moved to the main lounge to escape the noise, the issue persisted, and she reported no improvement in the noise levels in her room. Staff members corroborated the residents' complaints, noting that noise issues, particularly loud TVs and staff conversations, were common around 10:00 PM and early in the morning. The Social Services Director and an LPN acknowledged the frequent noise complaints, and the Admissions Director confirmed that managers would ask residents to lower their TV volumes. However, the Administrator seemed unaware of the extent of the noise concerns, stating that such issues would go through the grievance process and that the facility had a noise policy in place.
Failure to Investigate Resident-to-Resident Abuse
Penalty
Summary
The facility failed to thoroughly investigate an allegation of inappropriate resident-to-resident touching involving a severely cognitively impaired resident. The incident was reported in the facility's grievance log, but there was no documentation in the April 2024 Incident Report Log or the resident's progress notes about the incident. Additionally, there was no alert charting or interventions documented to ensure the safety of the residents involved. Staff interviews revealed that proper procedures were not followed. According to the facility's policy, an incident investigation should have taken place, and the residents involved should have been put on alert charting for at least 72 hours. However, this did not occur, indicating a failure to adhere to the facility's abuse prevention program and investigative protocols.
Failure to Initiate Bowel Interventions
Penalty
Summary
The facility failed to ensure bowel interventions were initiated for two residents reviewed for quality of care related to constipation. Resident 44, who was cognitively intact, did not have a bowel movement for nine days, from 04/05/2024 to 04/14/2024. Despite the facility's bowel management policy, which mandates specific interventions after three days without a bowel movement, no actions were documented or taken for Resident 44 during this period. Similarly, Resident 39, who was severely cognitively impaired and unable to express care needs, did not have a bowel movement for four days, from 04/20/2024 to 04/24/2024. Again, the bowel management protocol was not initiated as required by the facility's policy. The April 2024 Medication Administration Record (MAR) confirmed that the bowel protocol was not followed for either resident. Interviews with staff members, including a Registered Nurse, the MDS Coordinator, and the Director of Nursing Services, revealed that the bowel protocol should have been triggered after three days without a bowel movement. However, none of the staff could provide documentation that the protocol was initiated for either resident. This failure to follow the established bowel management policy placed the residents at risk for discomfort, health complications, and a diminished quality of life.
Failure to Administer Influenza and Pneumococcal Vaccines
Penalty
Summary
The facility failed to offer and/or administer the influenza and pneumococcal vaccines to two residents, placing them at risk for developing influenza and/or pneumonia. Resident 46, who was severely cognitively impaired, was admitted to the facility and had consents for both vaccines signed by the guardian. However, the medical record did not show documentation of the administration of either vaccine. Staff C, the Infection Preventionist and RN, confirmed that the vaccines were not given despite the signed consent and the expectation from the Director of Nursing Services that they should have been administered. Similarly, Resident 39, also severely cognitively impaired, was admitted to the facility and had consents for influenza, pneumococcal, and COVID vaccinations signed by the Power of Attorney. However, there was no documentation in the medical record showing the administration of the pneumococcal vaccine. Staff C was unable to provide additional documentation to confirm the vaccine was given. These failures were in violation of the facility's policies and procedures for offering and administering vaccines within specified timeframes.
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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