Citations in Washington
Comprehensive analysis of citations, statistics, and compliance trends for long-term care facilities in Washington.
Statistics for Washington (Last 12 Months)
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Latest Citations in Washington
Surveyors found that the facility did not follow its abuse/neglect policy when multiple grievances involving potential abuse and neglect were logged only as staff concerns and not treated as reportable incidents. A resident reported lack of assistance and care from an LPN, another resident experienced a verbal confrontation with a CNA, and a third resident was observed by a representative to have a soiled face and clothing and a urine-saturated brief dripping down the hallway. These events were not entered into the incident reporting log, were not promptly or thoroughly investigated as abuse/neglect allegations, and the residents were not protected from possible ongoing abuse or neglect, as confirmed by the administrator and DON.
The facility failed to report multiple potential allegations of abuse and neglect to the State Agency. One cognitively intact resident with ALS alleged a staff member withheld their eyeglasses and reported feeling unsafe and poorly cared for, including concerns about staff’s ability to manage choking and positioning. Another resident with dementia and Parkinson’s was found by their representative with dried toothpaste on their clothing and face and so wet with urine that it left a trail down the hallway, prompting concerns about dignity and care. A third resident reported that a NA spoke to them in an unprofessional and unnecessary manner regarding a locked bathroom door, constituting a potential allegation of verbal abuse. These concerns were handled as internal grievances, were not entered into the reporting log as abuse/neglect allegations, and were not reported to the State Agency, with the DON stating they did not view the incidents as purposeful or willful abuse or neglect.
The facility failed to thoroughly investigate multiple allegations of abuse and neglect involving three cognitively intact residents with significant care needs. One resident with ALS reported that an LPN ignored a request for help with eyeglasses and left without assisting or communicating. Another resident with dementia and incontinence was reportedly found by a representative with dried toothpaste on their face and clothing and a urine-soaked brief that leaked down the hallway, yet no staff statements, additional resident interviews, skin checks, or care plan changes were documented. A third resident with heart and lung disease reported that a NA spoke to them in an unprofessional, scolding manner about a locked shared bathroom door and then left while the resident was speaking, but the investigation lacked root cause analysis, interviews with other residents, or monitoring for adverse effects. None of these allegations appeared on the incident reporting log, and documentation did not show complete analyses to rule out abuse or neglect.
A resident with Parkinson’s disease, hyperparathyroidism, and cognitive impairment had an elevated calcium level and provider orders for PTH, vitamin D, and ionized calcium testing. On two separate occasions, ordered PTH and ionized calcium labs were not performed because no specimens were received by the lab, despite facility policy requiring completion and follow-up of ordered tests and tracking of pending or missing results. Later, after additional lab orders including a CMP, the lab reported a critical calcium value, and the resident was transferred to the hospital, where a markedly elevated calcium level and related diagnoses were documented. The Administrator acknowledged that the ordered labs were not obtained and that nursing was responsible for ensuring collection, submission, and receipt of lab results.
A resident with dementia, vision problems, and existing pressure injuries was dependent on staff for all ADLs and required two-person assistance and mechanical lift transfers. Hospital discharge orders specified wound care frequencies, turning every two hours, getting the resident out of bed three times daily, nutritional supplements (Ensure TID, Juven BID), and transfer to a tilt-in-space wheelchair. The facility did not enter or clarify the out-of-bed orders, delayed starting Ensure and Juven, reversed the wound treatment frequencies on the TAR, and POC documentation showed no transfers out of bed and multiple shifts with no or "activity did not occur" entries for bed mobility. The resident frequently refused meals, weights, some medications, repositioning at times, and certain procedures, but staff documentation often lacked follow-up actions or provider notification, and the behavior care plan did not include specific behaviors or interventions to guide staff in managing these refusals.
A resident with complex medical conditions, cognitive impairment, and total dependence on staff for care was admitted with two suspected deep tissue injury pressure ulcers and identified as at risk for skin breakdown. Facility policy required weekly wound evaluations with measurements and characteristics, and notification of the provider and RD, but the admission wound evaluation lacked measurements and pain assessment, one of the existing PIs was not evaluated as scheduled, and a new unstageable PI on the upper back was not fully assessed until several days after it was found, with RD notification left blank. Observations later showed significant wounds to the buttocks and upper back with reported pain. Documentation also showed repeated refusals of meals, weights, some medications, and care, yet progress notes did not show that the provider was informed or that reasons for refusals were determined, while staff acknowledged required weekly wound documentation was not consistently completed and could not explain the delay in assessing the new PI.
A resident with hypertension, CKD, heart failure, vision deficit, and high fall risk experienced multiple falls and a significant injury after staff repeatedly administered antihypertensive medications outside ordered BP parameters and failed to update the fall care plan to address medication-related risks. The care plan focused on environmental and behavioral fall interventions but did not include specific strategies for cardiac BP medications despite the CAA identifying medications as a fall risk factor. Over time, the resident had several falls, including one associated with orthostatic hypotension and dehydration, and later sustained a forehead hematoma and L2 compression fracture after a fall they attributed to blood pressure issues. The MAR showed repeated administration of BP meds when diastolic BP was below the hold parameter, which staff later acknowledged as med errors. The facility’s post-fall investigation documented no injuries despite obvious facial trauma, left key assessment sections blank, lacked documentation of neuro checks, and did not analyze medications as a contributing factor, while interviews described the resident’s decline, ongoing dizziness, pain, and delayed call light response.
A resident with HTN, CKD, CHF, and a history of falls had multiple antihypertensive and diuretic medications ordered with specific BP hold parameters, but nursing staff administered these medications even when systolic or diastolic BP values were below the physician-ordered thresholds. On one such occasion, after receiving the medications despite a low diastolic BP, the resident became dizzy while standing at the sink, fell, and sustained a forehead hematoma and an acute L2 compression fracture. The resident and a representative reported ongoing problems with BP medications, including falls and dehydration, and the DON later acknowledged these administrations were medication errors that had not been identified as contributing factors during the initial fall investigation.
Multiple residents with lower extremity ulcers, surgical wounds, and large abdominal wounds did not consistently receive ordered wound care or NPWT (wound vac) therapy. One resident with bilateral leg ulcers and later documented wound infection had numerous missed, refused, or undocumented dressing changes and an antibiotic dose, with no care-plan interventions addressing repeated refusals despite the resident expressing concern about irregular dressings and odor. Another resident ordered for NPWT after surgical debridement of a right leg infection arrived without a wound vac, had repeated NN, blank, held, and refused entries on the MAR, and was treated with wet-to-dry dressings while the facility awaited wound vac equipment and supplies. A third resident with an abdominal NPWT order had multiple blank and refused MAR entries while the facility ran short on supplies. Two additional residents with recent surgical procedures (a below-knee amputation and a repaired hip fracture) lacked timely, clear wound care orders and care-plan interventions; one had an 11‑day delay before any wound order and then an unclear order that was later discontinued with another 11‑day gap, and the other had no surgical wound care or monitoring orders documented during their stay.
The deficiency involves failures in pressure ulcer prevention and treatment for three residents. One resident was admitted with heel pressure injuries documented by the hospital, yet admission assessments and the MDS did not reflect these wounds, and despite a care plan noting unstageable bilateral heel injuries with directions for monitoring and offloading, there was no documented skin checks or wound care until the wounds were later assessed as unstageable blisters. A second resident admitted with multiple Stage 3 and DTI pressure injuries had wounds that enlarged over time while MARs showed repeated missed and refused dressing changes, with no care plan interventions for handling refusals and no documented risk–benefit discussions about the impact of refusing wound care. A third resident with a Stage 3 left hip ulcer had no wound care orders entered for several days after admission, and an initially ordered wound culture was not completed as scheduled, requiring a new order and delaying culture collection and results.
Failure to Identify and Investigate Allegations of Abuse and Neglect
Penalty
Summary
Surveyors identified that the facility failed to implement its abuse, neglect, and exploitation policy for three residents when allegations were documented but not treated as reportable abuse/neglect events. The written policy dated 01/2026 required the facility to prohibit and prevent abuse, neglect, and exploitation of residents with ongoing oversight and supervision of staff to ensure policies were implemented. Review of the grievance log from 07/01/2025 through 01/25/2026 showed multiple entries that involved potential abuse or neglect concerns, but these were only logged as staff concerns or grievances and not identified, reported, or investigated as allegations of abuse or neglect. For one resident, a staff concern was logged regarding lack of assistance and care from an LPN when asked. For another resident, a staff concern was logged regarding a verbal confrontation with a nursing assistant. For a third resident, the resident’s representative reported the resident was left with a soiled face and clothing and a brief so saturated with urine that it dripped down the hallway. Record review showed that none of these three incidents were entered into the facility’s reporting log, which is used to document incidents that may involve abuse, neglect, or mistreatment of residents, and there was no evidence of thorough investigation to rule out abuse or neglect. Completion dates on the grievance log, when present, were several days after the concerns were reported, and one concern had no completion date at all. During interviews, the administrator and DON acknowledged confusion among staff about which concerns should be placed on the grievance log versus the reporting log and confirmed that the concerns involving these three residents were not identified as allegations of abuse or neglect and were not investigated as such, meaning the residents were not provided protection from the possibility of ongoing abuse or neglect.
Failure to Report Allegations of Abuse and Neglect to State Agency
Penalty
Summary
The deficiency involves the facility’s failure to report potential allegations of abuse and neglect to the State Agency (SA) for three residents whose cases were reviewed. For one resident with ALS who was cognitively intact and dependent on staff for all ADLs, a grievance log and incident reports showed that the resident alleged a staff member did not place their eyeglasses on as requested, instead holding them out of reach for a couple of minutes before setting them on a table and leaving the room. The resident expressed concerns about how the staff member treated them and requested that this staff member no longer provide their care. The Social Services Director later learned, via an email from a community health reporter, that the resident had complained that staff did not know how to care for a person with ALS, did not feel cared for or safe, and felt staff did not know how to manage episodes of choking or position their head upright. Although this concern was investigated internally, the facility’s reporting log showed that this potential allegation of abuse and/or neglect was not entered into the reporting log and was not reported to the SA. A second deficiency component involved another resident with dementia and Parkinson’s disease, who was cognitively intact and required substantial to maximum assistance with toileting and dressing and was frequently incontinent of urine. A grievance form documented that the resident’s representative reported finding the resident in their wheelchair with dried toothpaste on their shirt, pants, and face, and that when they assisted the resident to the dayroom, the resident was so wet with urine that a trail of urine was left down the hallway. The representative stated they wanted the resident treated with dignity. This concern, which constituted a potential allegation of neglect, was handled as a grievance within the facility. Review of the reporting log showed that this potential allegation of neglect was not reported to the SA. The third component of the deficiency involved a resident with heart failure and depression, who was cognitively intact, independent with toilet transfers, and required substantial to maximum assistance with toileting hygiene. A grievance form documented that the resident reported being upset with the way a nursing assistant spoke to them, blaming them for locking a shared bathroom door and saying, “Would you stop locking the dang door?” The resident stated that the way they were spoken to was unprofessional and unnecessary. This concern, a potential allegation of verbal abuse, was investigated as a grievance rather than as an allegation of abuse. Review of the reporting log showed that no potential allegation of abuse for this resident was reported to the SA. In an interview, the DON stated they did not report the concerns for two of the residents as allegations of abuse or neglect because they did not believe the staff actions were purposeful or willful.
Failure to Thoroughly Investigate Multiple Abuse and Neglect Allegations
Penalty
Summary
The facility failed to conduct complete and thorough investigations into multiple reported allegations of abuse and neglect. For one resident with ALS, intact cognition, and total dependence on staff for all ADLs, a grievance was filed after the resident reported that an LPN did not respond to their request to have their glasses put on, instead holding the glasses out silently for several minutes, then placing them down and leaving the room without assisting or explaining. The resident reported feeling unsupported and mistreated and requested that this staff member no longer enter their room or provide care. Although the concern was reported to the DNS, the investigation as documented focused on educating the staff member, without evidence of a root cause analysis, contributing factors review, or measures to rule out abuse or neglect. For another resident with dementia, heart failure, urge incontinence, intact cognition, and frequent urinary incontinence, the resident’s representative reported finding the resident with dried toothpaste on their face, shirt, and pants and with a brief so saturated with urine that it leaked down the hallway when the representative assisted the resident to the day room. The grievance documentation showed the resident was interviewed and reported no concerns, and the DNS concluded that lack of dignity and timely care could not be substantiated and that abuse and neglect were ruled out. However, the grievance file contained no interviews with other residents, no identification of the staff involved in the incident, no staff statements, no care plan changes, no alert charting, and no skin checks to assess the resident after sitting in urine. The investigation lacked any documented root cause or analysis explaining why the resident was soaked with urine or why personal hygiene needs were not met. For a third resident with heart failure, lung disease, intact cognition, and frequent urinary incontinence, a grievance was filed after the resident reported that a nursing assistant entered their room and told them to stop locking the “dang” door, blaming them for locking a shared bathroom door. The resident reported being upset by the unprofessional tone, feeling as if they were being scolded and accused of lying when they tried to explain they had not used the restroom that day, and described the staff member throwing their hands up and leaving the room while the resident was talking. The grievance conclusion documented removal of the staff member from the room and unit and referenced education about sharing information on other residents, but there was no documented root cause or analysis to rule out abuse or neglect, no interviews with other residents about the staff member’s interactions, no care plan changes, and no alert charting to monitor for adverse reactions. Additionally, the facility’s reporting incident log contained no entries for these allegations, and the administrator and DNS acknowledged staff confusion about what should be entered on the grievance log versus the reporting log.
Failure to Complete Ordered Laboratory Tests for Resident With Hyperparathyroidism
Penalty
Summary
The facility failed to ensure ordered laboratory tests were completed and followed up for a resident with hyperparathyroidism and elevated calcium levels. Facility policy required that laboratory services ordered by a provider be obtained, that results and pending or missing labs be included in shift report, and that pending or missing labs be followed up in daily clinical meetings. The resident, admitted with Parkinson’s disease and hyperparathyroidism and documented cognitive impairment, had a calcium level of 12.2 (normal 8.6–10.2). A provider ordered PTH, vitamin D, and ionized calcium testing, but laboratory results for that date showed PTH and ionized calcium were not performed because no specimen was received. A subsequent provider note documented that PTH and ionized calcium had not been performed and were reordered. A later physician order again directed that PTH and ionized calcium be obtained, but laboratory results again showed these tests were not performed due to no specimen being received. Another order was written for a CBC and CMP, and on that date the lab called the facility with a critical calcium value, after which the resident was transferred to the hospital. Hospital records documented a calcium level of 17 and admission for acute pulmonary embolism, aspiration pneumonia, and hypercalcemia. During interview, the Administrator acknowledged that the resident had provider orders for PTH and ionized calcium on two separate dates, that the lab indicated specimens were not obtained on those dates, and that nursing was responsible for ensuring labs were collected, sent, and results received as ordered.
Failure to Follow Physician Orders and Address Care Refusals per Professional Standards
Penalty
Summary
The deficiency involves the facility’s failure to ensure services met professional standards of practice for a resident with complex medical conditions, including a history of blood clots, dementia, vision problems, and dependence on staff for all ADLs. The admission MDS and ADL care plan documented that the resident had significant cognitive loss, exhibited care-rejecting behaviors, and required two-person assistance for bed mobility and transfers with a mechanical lift. A hospital discharge summary documented two pressure injuries (right heel and right buttocks) and included specific physician orders for wound care, turning every two hours in bed, getting the resident out of bed three times daily, nutritional supplements (Ensure TID and Juven BID), and transfer with a sit-to-stand lift to a tilt-in-space wheelchair. Record review showed that key physician orders were not timely implemented or were entered incorrectly. The physician orders for the resident to be out of bed three times daily were not entered into the physician order system from admission through early February, and there was no documentation that staff clarified these orders despite repeated notation by the provider in progress notes. POC documentation for transfers out of bed showed no entries indicating the resident was ever transferred out of bed, and bed mobility documentation contained multiple shifts with no documentation or entries that no assistance was given or the activity did not occur. The facility delayed implementation of the Juven order until six days after admission and the Ensure order until twenty days after admission, and the MAR showed several days when Juven was not administered because it was on order and unavailable. The TAR showed the wound treatment frequencies for the right heel and right buttocks were reversed from the hospital discharge orders, with the heel ordered daily instead of every three days and the buttocks ordered every three days instead of daily. The facility also failed to adequately assess, document, and address the resident’s refusals of care and to notify the provider. The behavior care plan contained no specific behaviors or interventions despite documentation that the resident refused seventeen meals, one bath, weekly weights on five occasions, and medications at times. Progress notes documented episodes where the resident refused to swallow medications, refused repositioning at times, refused a bladder scan, and refused or spit out an antibiotic and Ensure, but the notes did not consistently indicate what actions staff took in response or whether the provider or resident representative was notified. The DON later stated that the resident did not have the cognitive ability to understand the risks and benefits of refusing turning, and acknowledged that the provider should have been notified of refusals and that refusals and related behaviors should have been reflected in the behavior care plan to direct staff in managing them.
Failure to Assess and Manage Pressure Injuries and Resident Refusals
Penalty
Summary
The facility failed to provide necessary care and services for pressure injuries (PIs) to one resident by not consistently assessing existing wounds, not documenting required wound characteristics and measurements, and not preventing the development of new PIs. The resident was admitted with medically complex conditions including a history of blood clots, dementia, impaired vision, significant cognitive loss, and behaviors of rejecting care. The admission MDS documented that the resident was at risk for PIs and had two unhealed, unstageable PIs suspected as deep tissue injuries (DTIs) on the right buttock and right heel. A Braden Scale assessment rated the resident at moderate risk for PIs due to being bedfast with very limited mobility and sensory perception, though later facility investigation documents described the resident as at extreme risk for impaired skin integrity. The resident was dependent on staff for eating, hygiene, toileting, bed mobility, transfers, bathing, and dressing. The facility’s skin integrity policy required licensed nurses to document skin impairments with measurements of size, color, odor, exudate, and pain on weekly wound evaluations, and to notify the medical provider, resident representative, and registered dietician, especially when wounds failed to improve or deteriorated. However, the admission skin/wound evaluation, created after admission and backdated, identified the two suspected DTIs but did not include measurements, wound assessment details, or pain documentation. There was no skin/wound evaluation completed on the documented admission date for either PI, and only the right heel PI was assessed on a subsequent date. A new unstageable PI on the resident’s right upper back was documented as identified several days after admission, but the skin/wound evaluation for this lesion was not completed until five days after it was found, and the section for registered dietician notification was left blank with no date entered. Observations later showed the upper back wound as an oblong open area and the right buttock wound as a large wound extending from the right buttock to the tailbone, with the resident stating that the buttocks hurt. Facility investigation of the newly acquired PI on the upper back identified the resident as at extreme risk for impaired skin integrity, citing profound immobility, deconditioning from sepsis, malnutrition, and inadequate hydration as root causes. Staff interviews indicated the resident refused to get out of bed and refused most oral intake, and documentation showed multiple refusals of meals, weekly weights, some medications, and one bath. Despite these refusals, progress notes over several weeks contained no indication that staff informed the provider of the resident’s refusals or explored the reasons for them. Staff also acknowledged that there should have been weekly wound documentation with measurements and characteristics, and could not explain the delay in assessing the new PI on the back or the discrepancy between the Braden assessment rating and the description of the resident as at extreme risk.
Failure to Prevent Falls and Medication Errors Related to Antihypertensives
Penalty
Summary
The deficiency involves the facility’s failure to maintain an environment free from avoidable accident hazards and to provide adequate supervision and monitoring for a resident with a known fall risk and complex medication regimen. The resident was admitted with hypertension, chronic kidney disease, heart failure, and vision deficit, and was assessed as high risk for falls. The Care Area Assessment (CAA) identified medications as a fall risk factor and directed staff to proceed to a fall-related care plan. The care plan included a problem related to mood and behavior medications with side effects such as dizziness, drowsiness, unsteadiness, blurred vision, and orthostatic hypotension, and a separate fall risk problem related to deconditioning. Interventions focused on environmental and behavioral strategies such as call light within reach, proper footwear, keeping the room free of clutter, and having the resident sit at the edge of the bed before standing. The care plan did not include a focus area or specific interventions related to the resident’s cardiac blood pressure medications, despite the identified medication-related fall risk. Beginning in early December, the resident experienced multiple falls. On one date, the resident fell, hit their head, underwent a neurological assessment, CT scan, and lab work, and one blood pressure medication was discontinued, but there were no new fall interventions or care plan updates. A subsequent fall occurred several days later with no new orders or care plan changes. Additional falls in early January included an event where the provider documented orthostatic hypotension with a significant drop in blood pressure upon standing and positive signs of dehydration, for which the resident received IV fluids. The resident also slid from a wheelchair and had another fall the following day, again without new orders, interventions, or care plan revisions. A pharmacist review later noted frequent falls and frequent medication order changes due to dizziness, weakness, and falls, yet the care plan was not updated to address actual falls or medication side effect monitoring. On a mid-January date, the resident fell in their room, struck their face, and complained of back pain, later being diagnosed in the emergency department with a right forehead hematoma and an acute L2 vertebral compression fracture. The ED report documented that the resident stated they fell because of their blood pressure. Review of the Medication Administration Record (MAR) showed the resident had three blood pressure medications with parameters to hold doses if the diastolic blood pressure was below 60, but the medications were administered when the blood pressure was 112/58 on the day of the fall, and on multiple other occasions when the diastolic reading was below the ordered parameter. These administrations were later acknowledged by facility staff as medication errors that should not have occurred. The facility’s incident investigation for the mid-January fall documented no apparent injuries at the time of the incident and no injuries post-incident, left pain and level-of-consciousness sections blank, and left the predisposing factors section blank. Although the investigation stated that neurological checks were done, there was no documentation of these checks in the report or medical record, and medication risk factors previously identified in the CAA were not reviewed as part of the post-fall investigation. Interviews further described the resident’s decline and ongoing symptoms. The resident representative reported problems and overdosing with blood pressure medications since admission, frequent falls, dehydration requiring fluids, and that the resident had become weaker and in pain, impacting their ability to participate in therapy. Nursing staff explained that the electronic medication system required entry of vital signs but did not prevent administration outside ordered parameters, and that it was the nurse’s responsibility to hold medications when indicated; they confirmed that the administrations outside parameters were errors and that the provider should have been notified. Staff also reported the resident had been sleeping more, staying in bed, and not eating breakfast. The resident described ongoing dizziness, new problems with blood pressure and blood pressure medications, a fall associated with feeling dizzy at the sink, and persistent back pain after being told they had broken their back. The resident also reported using the call light as instructed but stated it usually took at least half an hour for staff to respond. The DON acknowledged that administering blood pressure medications outside ordered parameters constituted medication errors and that these errors and medication as a contributing factor were not identified during the fall investigation.
Failure to Follow Antihypertensive Parameters Leading to Fall and Injury
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident was free from significant medication errors when nurses did not follow physician-ordered blood pressure parameters for multiple antihypertensive medications. The resident had hypertension, chronic kidney disease, congestive heart failure, and a history of falls, and was ordered furosemide, hydralazine, and lisinopril at 11:00 AM with specific instructions to hold each medication if systolic blood pressure or diastolic blood pressure fell below defined thresholds. Review of the Medication Administration Record showed that on several dates, including when the resident’s diastolic blood pressure was below 60 or systolic blood pressure was below 110 as specified in the orders, staff still administered one or more of these medications instead of holding them and notifying the provider. Staff interviews confirmed that the electronic system did not prevent administration outside parameters and that it was the nurse’s responsibility to review the full order and hold medications when vital signs were outside the ordered range. On one of the days when medications were administered despite a diastolic blood pressure below the ordered parameter, the resident experienced dizziness while standing at the sink, attempted to turn and sit on the bed, and fell, striking the face and later being found to have a right forehead hematoma and an acute L2 compression fracture. The resident reported ongoing back pain and described having a lot of problems with blood pressure and blood pressure medications. The resident’s representative reported concerns about overdosing with blood pressure medications since admission, stating the resident had falls, dehydration requiring fluids, and increased weakness due to mismanagement. The Director of Nursing acknowledged that administering blood pressure medications outside the ordered parameters constituted medication errors and that these errors were not identified during the investigation of the resident’s fall, and medication was not identified as a contributing factor at that time.
Failure to Provide, Document, and Order Appropriate Wound Care and NPWT Supplies
Penalty
Summary
The deficiency involves multiple failures to provide ordered wound care, to timely obtain and document wound care supplies, and to enter and clarify wound care orders for residents with non-pressure skin conditions and surgical wounds. One resident was admitted with multiple lower extremity ulcers and scheduled wound care, including Unna boots and compression wraps, later modified to various dressing regimens and oral antibiotics for infected bilateral lower extremity wounds. Medication administration records (MARs) for several months showed numerous entries marked as refused, held, or left blank for ordered dressing changes and one antibiotic dose, with at least one dressing change held without a corresponding provider order or indication that the provider was aware. The resident’s care plan included actual wounds and later an infection of bilateral lower extremity wounds, but contained no focus or interventions addressing the resident’s repeated refusals of wound care or any documented risk–benefit discussion, even though the resident reported concern that dressings were not done regularly and that their legs were starting to smell bad. Another resident was discharged from the hospital with an open surgical wound on the right lower leg requiring NPWT (wound vac) with specific frequency and settings. The facility care plan noted cellulitis and infection of the right lower extremity but did not address the wound vac order or refusals of wound care. MARs over several months showed repeated NN (other/progress note), blank, held, and refused entries for NPWT dressing changes. Progress notes documented that the resident did not arrive from the hospital with a wound vac and instead had wet-to-dry dressings, that the wound vac canister was found full with the dressing dripping with fluid, and that staff were using wet-to-dry dressings while awaiting wound vac supplies. A third resident with a large abdominal wound and an order for NPWT three times weekly had multiple blank, NA, and refused entries on the MAR, and the Resident Care Manager stated that supplies were running out because staff were not notifying them when supplies were low and that it took about seven days to obtain new supplies. Additional deficiencies involved failures to enter and clarify wound care orders for surgical wounds. One resident underwent a left below-knee amputation and was admitted with a surgical wound and sutures; the admit assessment documented that the resident removed the dressing due to itching, with some bleeding and redressing by staff, but no wound care focus or interventions were added to the care plan. No wound care orders were entered for this surgical site until 11 days after admission, and the initial order lacked a specified wound site and solution strength, with MAR entries coded NN and progress notes indicating the order was unclear and needed clarification. The order was discontinued, leaving an 11-day gap before a new, more detailed order was entered. Another resident admitted after right hip fracture repair had a surgical wound and required surgical wound care per the admission MDS, but no surgical wound care or monitoring orders appeared on the MARs during their stay, and the Resident Care Manager reported that the resident came from the hospital with unclear instructions and they were not sure if wound care was performed.
Failure to Prevent and Manage Pressure Ulcers and Address Refusals of Wound Care
Penalty
Summary
The deficiency involves the facility’s failure to provide appropriate pressure ulcer prevention and treatment for three residents. For one resident, preadmission hospital notes documented a right heel pressure injury, but the facility’s admission skin assessment recorded no issues with the feet, and the admission MDS indicated no pressure ulcers, only risk for development. Despite a care plan dated the same day as admission identifying actual unstageable bilateral heel pressure injuries and directing staff to assess, measure, and monitor the wounds and to offload the heels in bed, there was no documented monitoring or wound care for the heels until mid-December. Skin checks were not documented, and wound assessments for the bilateral heels were not entered into the record until late December, at which time the heels were described as unstageable with blistered, discolored wound bases. Nursing leadership acknowledged being informed of the heel pressure injuries only shortly before the resident left the facility and could not explain the lack of skin checks, monitoring, or wound care orders prior to that time. For a second resident with multiple pressure injuries on admission, the facility failed to consistently provide ordered wound care and did not address ongoing refusals of care. The admission MDS showed two Stage 3 pressure ulcers and two unstageable DTI wounds with pressure injury care being performed. A skin assessment documented four pressure injuries to both scapulae, the left gluteus, and the left lateral calf, and a later wound assessment showed all four wounds had significantly increased in size. Review of MARs over three consecutive months showed numerous blank boxes where daily or scheduled dressing changes were ordered, along with multiple documented refusals. The care plan identified the actual pressure ulcers and DTIs but contained no interventions for how to address the resident’s frequent refusals of wound care. The medical record did not contain any documented risk-versus-benefit discussions regarding the likelihood of wound worsening related to refusal of care. Nursing staff confirmed that the resident frequently refused wound care, that they did not monitor the MAR to ensure wound care was consistently provided, and that blank MAR boxes indicated wound care was not performed. For a third resident admitted with a left hip Stage 3 pressure injury, the facility did not enter wound care orders in a timely manner and did not complete a wound culture as initially ordered. The admission skin assessment documented a left hip pressure injury with specific measurements and depth, and the MDS indicated the resident had one Stage 3 pressure ulcer and was receiving pressure ulcer wound care. However, the MAR showed that an order for wound care to the left hip wound, which was present on admission, was not entered until eight days after admission. Later, an order for a left hip wound culture to be completed over a specified multi-day period was entered, but only one MAR box was signed to indicate the resident was out of the facility, and the remaining boxes were left blank, indicating the culture was not obtained as ordered. A second wound culture order was then entered several days later, and the culture was finally collected and resulted, showing mixed bacteria and leading to antibiotic treatment. Nursing leadership stated that clear wound care instructions were not present on the hospital discharge orders and acknowledged that wound care orders were delayed and that the original wound culture order was not completed, causing a delay in results.
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