Citations in Washington
Comprehensive analysis of citations, statistics, and compliance trends for long-term care facilities in Washington.
Statistics for Washington (Last 12 Months)
Financial Impact (Last 12 Months)
Some of the Latest Corrective Actions taken by Facilities in Washington
- Educated all staff on abuse-prevention policies and procedures to reinforce resident-rights protections (L - F0600 - WA)
Failure to Prevent and Address Resident-to-Resident Abuse
Penalty
Summary
The facility failed to identify, report, protect, assess, and prevent a pattern of resident-to-resident verbal and physical abuse, particularly involving a resident with severe cognitive impairment and a history of aggressive behaviors. Staff documented multiple incidents where this resident engaged in hitting, punching, kicking, grabbing, scratching, yelling, and making threats toward other residents. Despite these repeated altercations, the facility did not consistently recognize these events as abuse, nor did they analyze the circumstances or implement effective interventions to prevent recurrence. The facility's own policies required staff to observe, assess, care plan, and monitor residents exhibiting behaviors that could lead to conflict, but these measures were not adequately followed. The resident in question had a documented history of severe cognitive impairment, dementia, and worsening verbal and physical behaviors that interfered with care and placed others at risk. Over several months, this resident was involved in at least 11 documented altercations with 10 different peers, including incidents of physical aggression such as hitting with objects, grabbing, scratching, and verbal abuse. Nursing progress notes and incident logs revealed additional unreported or inadequately investigated incidents, with some resulting in physical injuries to other residents, such as skin tears and scratches. Staff interviews confirmed that the resident's behaviors were unpredictable and escalated quickly, often resulting in fear and distress among other residents. Despite the frequency and severity of these incidents, the facility did not consistently treat verbal altercations as potential abuse unless threats were involved, and physical altercations were not always thoroughly investigated or reported. The care plan interventions implemented, such as 15-minute safety checks and behavioral monitoring, were insufficient to prevent further incidents. Staff acknowledged that the resident's behaviors placed others at risk and that the facility had not adequately protected residents from abuse, as required by policy and regulation.
Removal Plan
- Reviewed Resident 19's medications
- Placed Resident 19 on one to one supervision until lower level of care was determined to be appropriate
- Educated all staff to the abuse prevention policies and procedures
- Interviewed all residents to determine feeling safe and secure in the facility
Failure to Maintain Financial Obligations Resulting in Disruption of Essential Resident Services
Penalty
Summary
Facility administration failed to maintain effective financial management, resulting in overdue payments to multiple vendors, including laboratory services, utilities, staffing agencies, and medical supply companies. The administration was aware of the outstanding balances and received multiple demand notices and service discontinuation warnings from vendors. Despite this awareness, the facility did not ensure timely payment, leading to a disruption in essential services. On a specific date, the laboratory services provider placed the facility on a non-payment hold, which resulted in the discontinuation of laboratory services. As a direct consequence, four residents did not receive critical laboratory tests as ordered. These included Depakote levels for two residents, which are necessary to monitor therapeutic drug levels and prevent toxicity, a Comprehensive Metabolic Panel and Complete Blood Count for another resident, and a Hemoglobin A1C test for a fourth resident. Staff interviews confirmed that the missed laboratory services were due to the vendor not coming to the facility because of unpaid bills, and there was no alternative laboratory available for these tests. Additionally, staff reported that the facility had experienced a delayed payroll, resulting in a temporary loss of staff benefits and out-of-pocket expenses for medical needs. The business office manager and administrator both indicated that invoices were forwarded to the corporate office for payment, but payments were not made in a timely manner. The failure to pay vendors on time directly impacted the facility's ability to provide necessary care and services to all residents, as evidenced by the missed laboratory tests and the risk of further service interruptions.
Removal Plan
- Ensured resident lab testing had been completed.
- Ensured an active laboratory services vendor was in place.
- Provided evidence of vendor contract payments to ensure continuity of essential services.
- Audited resident laboratory orders.
- Obtained ordered laboratory testing for affected residents.
Failure to Assess and Supervise Resident Smoking, Leading to Immediate Jeopardy
Penalty
Summary
The facility failed to consistently and accurately assess residents' smoking abilities and implement safety interventions to prevent smoking-related injuries for three residents. Despite having a policy that prohibited smoking on facility grounds and required staff to secure smoking materials found with residents, the facility did not ensure that these procedures were followed. Staff were often unaware of which residents smoked, and there was a lack of clear documentation and care planning regarding residents' smoking status, supervision needs, and the storage of smoking materials. One resident with Parkinson's disease and diabetes was observed smoking unsupervised in the facility's patio area, near a propane tank, and without access to proper safety equipment such as ashtrays or fire blankets. This resident had a history of fluctuating consciousness and required assistance with mobility, yet was able to keep cigarettes and a lighter in their possession and smoke multiple times a day. The care plan for this resident did not include specific interventions to address their inability to manage smoking supplies safely, nor did it document where smoking materials were kept. Additionally, although a nicotine patch was recommended as part of a smoking cessation plan, it was not provided as indicated. Another resident with COPD and a history of tobacco abuse continued to smoke on facility property and in their room, even after being educated about the non-smoking policy and offered nicotine patches, which they refused. This resident set off the fire alarm by smoking in their bathroom and repeatedly refused to relinquish smoking materials, resulting in the need for increased supervision. A third resident with severe cognitive impairment had a history of daily smoking, but the facility's assessment failed to identify their tobacco use, and staff did not discuss smoking or the facility's policy with them. These failures led to unsafe conditions and represented an immediate jeopardy to resident health and safety.
Removal Plan
- Placed Resident 73 on one-to-one surveillance.
- Secured Resident 73's smoking paraphernalia.
- Re-assessed Resident 73's ability to smoke.
- Revised Resident 73's care plan to show the level of assistance and supervision required to smoke safely.
- Closed access to unsupervised patio areas.
- Added a fire blanket and an outdoor ashtray to the designated smoking area.
- Interviewed other residents and staff to identify other residents who smoked.
- Completed smoking safety evaluations of all residents in the facility and for any residents identified as a smoker/tobacco user.
- Developed or revised care plans for residents identified as smokers/tobacco users to show individualized interventions and supervision levels related to smoking preference.
- Completed a facility-wide sweep to remove unauthorized smoking materials.
- Notified residents of the smoking policy.
- Educated staff on the smoking policy, and identifying, managing, and reporting unsafe smoking behaviors.
Failure to Prevent Repeated Falls and Injuries Due to Ineffective Supervision and Intervention
Penalty
Summary
The facility failed to provide effective monitoring, supervision, and implementation of interventions to prevent repeated falls and injuries for multiple residents. For one resident with severe cognitive impairment and a history of falls, there were at least 15 documented falls, some resulting in serious injuries such as a dislocated hip, femur fracture, and back fracture. The facility did not consistently review or revise care plan interventions after each fall, and there were omissions in required neurological checks and documentation. Staff education on fall prevention was not always documented, and some falls were not included in the facility’s incident log. Another resident with dementia, impaired vision, and a history of frequent falls experienced 36 falls over a period of time, resulting in various injuries including abrasions, contusions, lacerations, and head injuries, with several hospital transfers. The care plan interventions remained largely unchanged despite repeated falls, and the facility continued to rely on ineffective strategies such as reminders to use the call light, even though the resident was impulsive and forgetful. There was no evidence that the facility evaluated the reasons for failed interventions or increased supervision, and staff interviews confirmed that increased monitoring was not attempted despite ongoing falls. A third resident, dependent on staff for transfers due to left-sided weakness from a stroke, fell while left unattended on the toilet, resulting in a fracture to the eye socket and left lower leg. The care plan had instructed staff to stay with the resident during toileting, but this intervention was not followed. The facility’s investigation acknowledged that staff left the resident unattended despite existing care plan instructions. Across these cases, the facility failed to assess, evaluate, and implement effective interventions to prevent repeated falls and injuries, and did not ensure that staff consistently followed care plan instructions or documented required assessments.
Removal Plan
- Placed both Resident 19 and 50 on one to one (1:1) supervision.
- Educated all staff to the policies and procedures for accident prevention and fall interventions, including notification to management of ineffective fall interventions.
- Reviewed accidents to ensure care planned interventions were resident specific.
- Reviewed Resident 19 and 50's care plans and ensured interventions were pertinent to the root-cause of the falls.
Unsafe Hot Water Access and Inadequate Supervision Result in Resident Injury
Penalty
Summary
The facility failed to ensure safe water temperatures and adequate supervision to prevent accidents, resulting in serious harm to two residents. One resident, who had hemiplegia and cognitive impairment, was provided with hot water directly from a nurse's lounge auxiliary spout, which was measured at temperatures significantly above the safe limit of 120°F. The resident attempted to drink the water, spilled it on themselves, and sustained second-degree burns to the neck, chest, and abdomen. Staff interviews revealed that the hot water was routinely provided to this resident without checking or mixing the temperature, and staff were unaware of the actual temperature or the policy requirements. Another resident, with Alzheimer's disease and cognitive impairment, was observed entering the nurse's lounge unsupervised and accessing the same hot water auxiliary spout. This resident filled a metal container with hot water and resisted staff attempts to intervene, leaving the lounge with the hot water. Staff acknowledged that this resident had a history of entering nourishment areas to obtain hot water or use the microwave, often without supervision, and that residents were not permitted in the nurse's lounge. However, staff did not consistently prevent access or monitor the water temperature. Record reviews and staff interviews confirmed that the facility's policy required hot liquids to be served at safe temperatures, with water provided by dietary staff and not exceeding 120°F. Despite this, staff frequently used the nurse's lounge hot water spout, did not log or check temperatures, and were unaware of the risks. The lack of supervision and failure to adhere to safety protocols directly led to one resident's injury and placed another at risk of harm.
Removal Plan
- Remove the hot water auxiliary spout in the nurse's lounge
- Lock door to the nurse's lounge and require key access to nourishment rooms
- Provide training to staff
- Complete hot liquids evaluations for all residents
- Revise hot liquids safety policy
Failure to Assess, Notify Physician, and Ensure CPR-Certified Staff Leads to Resident Harm
Penalty
Summary
A deficiency occurred when staff failed to provide a thorough assessment and timely recognition of a significant change in condition for a resident with a history of congestive heart failure and cellulitis. The resident experienced a rapid weight gain of 18.7 pounds in 24 hours, swelling in the left arm, slurred speech, difficulty breathing, and changes in mentation throughout the day. Despite these symptoms, there was no documentation that the physician was notified of the significant weight gain or the resident's deteriorating condition, as required by the care plan and physician orders. Multiple nursing assistants observed and reported the resident's changes, including incoherence, slurred speech, and abnormal appearance, to the assigned RN. However, the RN did not assess the resident in a timely manner, did not notify the physician, and did not document appropriate interventions. The last recorded vital signs were taken in the morning, and the resident's condition continued to decline throughout the day. When the resident became unresponsive and pulseless, there was a delay in initiating emergency interventions, and the RN did not perform CPR, leaving it to the nursing assistants. Further review revealed that the RN and other staff members lacked current CPR certification, contrary to facility policy requiring all RNs and LPNs to maintain active certification. The facility's failure to ensure adequate assessment, timely physician notification, and the presence of properly certified staff contributed to the resident's unexpected death. The resident was a full code and was not expected to pass away, with plans to return home after rehabilitation.
Removal Plan
- Terminated the staff that failed to assess, treat and notify the physician of Resident 1 regarding their significant change in condition.
- Audited the records of all residents for unidentified changes in condition.
- Educated staff on what to do when a resident has a change in condition.
- Audited employee Cardiac Pulmonary Resuscitation (CPR) certifications to ensure there were an adequate number of staff working each shift with active CPR certifications.
Latest Citations in Washington
A resident with moderate cognitive impairment had their antipsychotic medication dosage increased on two occasions without the responsible party being notified, despite facility policy requiring notification within 24 hours. Both the RN and DON processed the medication changes but did not inform or document communication with the responsible party, who was known to be concerned about medications causing drowsiness.
The facility did not maintain a completed state reporting log for two months, with incidents being logged only at the end of each month instead of within five days of discovery. This delay was attributed to a new DNS and lack of oversight during the DNS's absence, as confirmed by the administrator.
A resident with multiple sclerosis and depression was not allowed to use a personal refrigerator in their room due to unclear communication of facility policy regarding size limits. The resident was initially told they could not have the refrigerator, was not updated about its whereabouts after staff could not locate it, and only later received clarification that a smaller refrigerator was permitted. Other residents were observed to have personal refrigerators in their rooms.
A resident with hemiparesis, epilepsy, and cognitive impairment, assessed as unsafe to smoke independently, was repeatedly able to smoke without staff supervision, resulting in two smoking-related injuries. Despite staff awareness of the risks and a policy requiring supervision, interventions were limited to encouragement and education, which did not prevent the resident from obtaining and using cigarettes unsupervised.
A resident with severe intellectual disabilities, impaired vision, and a history of falls was left unsupervised in a hallway when their assigned staff left to take out the garbage without notifying others. The resident, who required constant line-of-sight supervision, was later found with a hematoma and bruising around the right eye, indicating an unwitnessed fall or contact with a firm surface. Staff interviews confirmed the care plan was not followed, resulting in the resident being left alone and injured.
A resident reported feeling threatened by a staff member described as the head of nurses. Despite facility policy requiring immediate suspension of any accused staff pending investigation, the DON—who matched the initial description—was not suspended and instead conducted the follow-up interview, ultimately ruling themselves out as the alleged perpetrator. Staff interviews confirmed knowledge of the suspension policy, but it was not followed in this case.
A resident with impaired memory and a known history of wandering and elopement risk was able to leave the facility unsupervised, despite being redirected by staff earlier. The resident exited through the front door and was later found walking alone on a busy street, indicating a failure to provide adequate supervision as required by facility policy.
A resident with severe cognitive impairment and a history of aggressive behaviors repeatedly engaged in verbal and physical abuse toward multiple peers, including hitting, grabbing, scratching, and yelling. Staff failed to consistently identify, report, or investigate these incidents as abuse, and interventions such as frequent safety checks and behavioral monitoring did not prevent further altercations. Other residents experienced fear and physical injuries as a result, and the facility did not adequately protect residents from abuse as required by policy.
Multiple residents with cognitive and physical impairments experienced repeated falls, some resulting in serious injuries such as fractures and hospitalizations, due to the facility's failure to consistently monitor, supervise, and implement effective fall prevention interventions. Care plans were not adequately revised after incidents, required neurological checks were sometimes omitted, and staff did not always follow or document care plan instructions, leading to continued risk and harm.
A facility failed to provide enough nursing staff to meet the needs of residents with high acuity, leading to inadequate supervision, repeated falls, and resident-to-resident altercations. Several residents suffered serious injuries, including fractures and hospitalizations, due to insufficient staff, delayed responses, and care plans not being updated after incidents. Staff and resident council feedback confirmed ongoing concerns about long call light wait times and unmet care needs.
Failure to Notify Responsible Party of Antipsychotic Medication Change
Penalty
Summary
The facility failed to notify the responsible party when a resident's antipsychotic medication order was changed. Specifically, a resident with moderately impaired cognitive ability was admitted on risperidone, and the dosage was increased on two separate occasions. There was no documentation in the clinical record that the responsible party had been notified of these medication changes, as required by facility policy, which states that notification must occur within 24 hours of a change in treatment. Interviews with the Resident Care Manager/Registered Nurse and the Director of Nursing Services confirmed that both processed the medication order changes but did not notify the responsible party or document any such notification. The responsible party was known to be particularly concerned about medications that could cause drowsiness, yet was not informed of the changes to the resident's antipsychotic regimen.
Failure to Timely Log and Report Incidents
Penalty
Summary
The facility failed to maintain a completed state reporting log for two of the three months reviewed, specifically April and May 2025. Incidents that occurred during these months were not logged within the required five days of discovery, as all incidents for April were entered on the last day of the month and all incidents for May were entered at the end of the month. The dates of the incidents ranged over several days in each month, indicating a delay in timely reporting. During an interview, the administrator stated that the April log was not updated on time due to a new Director of Nursing Services (DNS) and was unaware that the May log was also not updated timely, especially during the DNS's vacation. This failure to log incidents promptly was identified through record review and staff interview.
Failure to Honor Resident's Right to Use Personal Possessions
Penalty
Summary
The facility failed to ensure that a resident was able to use a personal possession, specifically a refrigerator, in accordance with facility policy and the resident's rights. The resident, who was cognitively intact and required assistance for personal care due to multiple sclerosis and depression, purchased a refrigerator online and had it delivered to the facility. The administrator informed the resident that they could not have the refrigerator in their room, without providing a clear explanation of the facility's policy. The resident subsequently arranged for family to pick up the refrigerator, but staff were unable to locate it, and the resident was not updated about the missing property. Further review revealed that the facility policy allowed residents to have a small refrigerator (2 cubic feet or less) in their room, and this was not clearly communicated to the resident. The refrigerator purchased by the resident exceeded the size limit, but this was only clarified after the resident expressed concerns about feeling retaliated against and not being allowed to have a refrigerator at all. Observations confirmed that other residents had personal refrigerators in their rooms, and the resident in question was only able to use a much smaller refrigerator without a freezer component.
Failure to Supervise Unsafe Smoking Leading to Resident Injuries
Penalty
Summary
The facility failed to provide adequate supervision and monitoring for a resident with a history of hemiparesis, epilepsy, and moderately impaired cognition, who was assessed as unsafe to smoke independently. Despite a care plan and smoking evaluation indicating the need for supervised smoking, the resident was repeatedly observed smoking without staff supervision, obtaining cigarettes from other residents and visitors, and searching for discarded cigarettes in designated smoking areas and the parking lot. Staff interviews confirmed that the resident was not safe to smoke independently and that current interventions, which focused on encouraging smoking cessation and education, were ineffective in preventing unsupervised smoking. The resident sustained two separate injuries related to unsupervised smoking: a burn to the inner thigh and a fluid-filled blister, both attributed to dropped cigarettes while smoking alone. Observations and staff interviews revealed that the resident was able to leave the facility unaccompanied and smoke without supervision, contrary to the facility's policy requiring supervision for residents deemed unsafe to smoke independently. The lack of effective supervision and failure to modify interventions placed the resident at increased risk for further smoking-related injuries.
Resident Left Unsupervised, Sustains Injury Due to Failure to Follow Supervision Requirements
Penalty
Summary
A deficiency occurred when a resident with severe intellectual disabilities, anxiety disorder, obsessive-compulsive disorder, and bilateral cataracts was not provided the required level of supervision as outlined in their care plan. The resident, who had a history of falls and was assessed as needing Level of Supervision (LOS) 3 due to lack of safety awareness, impaired vision, and poor coordination, was left unsupervised in a back hallway. The assigned staff member left the resident alone to take out the garbage without notifying other staff, despite the care plan requiring the resident to always be within staff's line of sight. As a result of being left unsupervised, the resident experienced an unwitnessed fall or contact with a firm surface, leading to a hematoma and bruising around the right eye. Staff later found the resident walking in the hallway with visible injuries. Interviews confirmed that the staff member did not follow the care plan and failed to communicate the resident's whereabouts to other staff, resulting in the resident being left alone and sustaining harm.
Failure to Suspend Alleged Perpetrator During Abuse Investigation
Penalty
Summary
The facility failed to follow and implement its abuse and neglect policies and procedures during the investigation of an abuse allegation involving a cognitively intact resident. According to the facility's policies, any employee accused of abuse, mistreatment, neglect, or exploitation must be immediately suspended pending the outcome of the investigation. However, when a resident reported feeling threatened and fearful after an interaction with a staff member described as the head of nurses, the staff member fitting that description (the Director of Nursing) was not suspended or ruled out as a possible alleged perpetrator at the outset of the investigation. The investigation report showed that the resident initially described the alleged perpetrator as a tall nurse and the head of nurses, which matched the Director of Nursing. Despite this, the Director of Nursing conducted a follow-up interview with the resident, during which the resident provided a different description. The Director of Nursing then ruled themselves out as the alleged perpetrator based on this new description and their claim of not being present during the alleged incident. There was no documentation that the Director of Nursing was suspended or excluded from the investigation process, as required by policy. Interviews with other staff confirmed their understanding that any staff member accused of making a resident feel threatened or afraid should be suspended pending investigation. Staff also identified the Director of Nursing as the head of nurses, matching the resident's initial description. The Executive Administrator stated that staff are expected to follow the facility's abuse and neglect policies, but the investigation did not reflect adherence to these procedures in this case.
Failure to Supervise Resident at Risk for Elopement
Penalty
Summary
The facility failed to provide necessary supervision to prevent an elopement for one resident who was assessed as being at risk for wandering and elopement. The resident, who had impaired memory and required assistance to walk safely, was documented as wandering in the nursing unit and was redirected from the front desk/lobby area twice by staff. Despite these interventions, the resident was not observed on the unit, and it was discovered that they had exited the facility through the front door and were seen walking on a busy street outside. The resident was found approximately a block away from the facility. Interviews with staff and review of records confirmed that the resident had a history of wandering and elopement risk, as indicated in the initial admission elopement risk assessment. Staff acknowledged that the resident did not receive the level of supervision required to prevent them from leaving the building. The facility's elopement policy required assessment for exit-seeking and wandering behaviors, but the necessary supervision was not maintained, resulting in the resident's unsupervised exit.
Failure to Prevent and Address Resident-to-Resident Abuse
Penalty
Summary
The facility failed to identify, report, protect, assess, and prevent a pattern of resident-to-resident verbal and physical abuse, particularly involving a resident with severe cognitive impairment and a history of aggressive behaviors. Staff documented multiple incidents where this resident engaged in hitting, punching, kicking, grabbing, scratching, yelling, and making threats toward other residents. Despite these repeated altercations, the facility did not consistently recognize these events as abuse, nor did they analyze the circumstances or implement effective interventions to prevent recurrence. The facility's own policies required staff to observe, assess, care plan, and monitor residents exhibiting behaviors that could lead to conflict, but these measures were not adequately followed. The resident in question had a documented history of severe cognitive impairment, dementia, and worsening verbal and physical behaviors that interfered with care and placed others at risk. Over several months, this resident was involved in at least 11 documented altercations with 10 different peers, including incidents of physical aggression such as hitting with objects, grabbing, scratching, and verbal abuse. Nursing progress notes and incident logs revealed additional unreported or inadequately investigated incidents, with some resulting in physical injuries to other residents, such as skin tears and scratches. Staff interviews confirmed that the resident's behaviors were unpredictable and escalated quickly, often resulting in fear and distress among other residents. Despite the frequency and severity of these incidents, the facility did not consistently treat verbal altercations as potential abuse unless threats were involved, and physical altercations were not always thoroughly investigated or reported. The care plan interventions implemented, such as 15-minute safety checks and behavioral monitoring, were insufficient to prevent further incidents. Staff acknowledged that the resident's behaviors placed others at risk and that the facility had not adequately protected residents from abuse, as required by policy and regulation.
Removal Plan
- Reviewed Resident 19's medications
- Placed Resident 19 on one to one supervision until lower level of care was determined to be appropriate
- Educated all staff to the abuse prevention policies and procedures
- Interviewed all residents to determine feeling safe and secure in the facility
Failure to Prevent Repeated Falls and Injuries Due to Ineffective Supervision and Intervention
Penalty
Summary
The facility failed to provide effective monitoring, supervision, and implementation of interventions to prevent repeated falls and injuries for multiple residents. For one resident with severe cognitive impairment and a history of falls, there were at least 15 documented falls, some resulting in serious injuries such as a dislocated hip, femur fracture, and back fracture. The facility did not consistently review or revise care plan interventions after each fall, and there were omissions in required neurological checks and documentation. Staff education on fall prevention was not always documented, and some falls were not included in the facility’s incident log. Another resident with dementia, impaired vision, and a history of frequent falls experienced 36 falls over a period of time, resulting in various injuries including abrasions, contusions, lacerations, and head injuries, with several hospital transfers. The care plan interventions remained largely unchanged despite repeated falls, and the facility continued to rely on ineffective strategies such as reminders to use the call light, even though the resident was impulsive and forgetful. There was no evidence that the facility evaluated the reasons for failed interventions or increased supervision, and staff interviews confirmed that increased monitoring was not attempted despite ongoing falls. A third resident, dependent on staff for transfers due to left-sided weakness from a stroke, fell while left unattended on the toilet, resulting in a fracture to the eye socket and left lower leg. The care plan had instructed staff to stay with the resident during toileting, but this intervention was not followed. The facility’s investigation acknowledged that staff left the resident unattended despite existing care plan instructions. Across these cases, the facility failed to assess, evaluate, and implement effective interventions to prevent repeated falls and injuries, and did not ensure that staff consistently followed care plan instructions or documented required assessments.
Removal Plan
- Placed both Resident 19 and 50 on one to one (1:1) supervision.
- Educated all staff to the policies and procedures for accident prevention and fall interventions, including notification to management of ineffective fall interventions.
- Reviewed accidents to ensure care planned interventions were resident specific.
- Reviewed Resident 19 and 50's care plans and ensured interventions were pertinent to the root-cause of the falls.
Failure to Provide Adequate Staffing and Supervision Resulting in Resident Harm
Penalty
Summary
The facility failed to provide sufficient nursing staff to meet the needs of residents, resulting in inadequate supervision and unsafe care for multiple residents with high acuity and complex care requirements. Staffing levels were determined by census and minimum regulatory requirements, rather than by the actual acuity and care needs of the resident population. Staff interviews and resident council feedback confirmed that the facility was routinely short-staffed, leading to excessively long call light wait times, delayed responses to resident needs, and staff being required to perform duties outside their roles to compensate for shortages. The staffing guide used by the facility was based on headcount rather than resident acuity, and staff frequently reported being overworked and unable to provide adequate supervision, especially during night shifts and when 1:1 monitoring was required. Three residents experienced significant harm as a result of these staffing deficiencies. One resident with severe cognitive impairment and behavioral issues was involved in repeated resident-to-resident altercations and sustained multiple falls, resulting in serious injuries including a dislocated hip, femur fracture, and back fracture. Despite being placed on frequent safety checks and having care plan interventions, the resident continued to experience falls and altercations, with care plans not being reviewed or revised after each incident. Another resident, dependent on staff for toileting and transfers, fell multiple times, sustaining fractures to the eye socket and leg, and was left unattended on the toilet despite care plan instructions. A third resident with dementia and a history of frequent falls experienced 36 falls over a year, resulting in various injuries and hospital transfers, with care plan interventions not consistently updated after each fall. Documentation and interviews revealed that the facility did not consistently review or revise care plans following incidents, and staff were unable to provide the level of supervision required for residents at high risk for falls or with behavioral challenges. Grievance logs and resident council feedback highlighted ongoing concerns about insufficient staffing, long wait times for assistance, and unmet care needs. Staff acknowledged that some falls and altercations could have been prevented with adequate staffing, and that the facility's reliance on agency staff and minimum staffing guides was insufficient to address the actual needs of the resident population.
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