Failure to Properly Position Resident Upright During Assisted Feeding
Summary
Surveyors identified a deficiency in resident positioning during mealtime for a resident with Alzheimer's disease and severely impaired cognition, as evidenced by a Brief Interview for Mental Status score of 2. The resident’s MDS indicated a need for partial to moderate assistance with eating, and the care plan documented nutrition and hydration risk related to end-stage diagnosis, cognitive limitations, and weakness, with directions for a general diet, thin liquids, and assistance with eating. During a breakfast observation on the Magnolia Unit, the resident was seated in a Broda chair that was reclined back. A dietary aide placed food on the table in front of the resident, and a CNA then placed beverages and food on an overbed table before walking away, while the resident remained reclined with eyes closed and the plate of food untouched. Later in the same observation period, another CNA offered the resident chocolate milk while the Broda chair remained tilted backward, and the resident had to struggle to move her head up and forward to reach the cup. The same CNA then offered hot cereal, which the resident declined by saying “later.” A different CNA subsequently offered another drink of chocolate milk, again without adjusting the reclined position of the Broda chair. Policy review showed the facility’s “Feeding of Residents by Staff” policy required that residents unable to feed themselves be assisted per their care plan and be positioned comfortably in an upright position. In an interview, the DON stated there was no specific positioning policy, that staff received positioning education in training, and that her expectation was that residents be placed in an upright position whenever food or drink was offered.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
A resident who was cognitively intact activated a call light during breakfast to request assistance with toileting and reported waiting approximately 1.5 to 2 hours before staff responded. Facility call light records confirmed the call was activated and not answered for over two hours. Staff interviews indicated that management had communicated expectations that call lights be answered within about 15–20 minutes, but this expectation was not met in this instance, resulting in a prolonged delay in meeting the resident’s expressed need for assistance.
A resident admitted with a right hip fracture and cognitively intact status had physician transfer orders for an orthopedic follow‑up visit and staple removal within two weeks, but staff did not schedule or complete this follow‑up as ordered. The resident reported not seeing the orthopedic surgeon after admission and stated that the staples remained in for a long time before being removed, which was painful. Record review showed the staples were removed more than seven weeks after admission, and the DON acknowledged the transfer orders were not carried out due to an oversight, despite the administrator’s expectation that admission/transfer orders be completed as instructed.
A resident experienced multiple leg fractures after a fall, resulting in a significant change in condition and non–weight-bearing status. Although the MDS reflected that it was important for the resident to participate in group activities, favorite pastimes, and church services, the activity care plan was not revised after the injury to address her new limitations. The existing plan listed numerous preferred activities such as resident council, food committee, religious services, music, gardening, and in-room pursuits, but no new individualized interventions were added, and documentation showed only two 1:1 visits after her return from the hospital. The resident reported she could no longer get into her wheelchair, attend council or church, or join groups she enjoyed, and stated that activity staff did not visit often, while the Director of Recreation confirmed she had not attended groups since the injury and that in-room social visits were not consistently documented, resulting in a decline in activity participation and social isolation.
A resident with multiple medical conditions, including a femur fracture, gout, COPD, and HTN, activated the call light for incontinence care but remained in a soiled brief for over 40 minutes while lunch was served. A CNA entered the room without knocking, turned off the call light, initially ignored the resident, and stated she could not provide peri-care because the roommate was eating. The CNA later claimed she had been told not to provide such care when someone in the room was eating, while the CN and DSD denied giving such instructions and referenced expectations for immediate response and use of privacy curtains. Review of the facility’s dignity policy and the DON’s statements confirmed that required practices for prompt toileting assistance, respect, and privacy were not followed.
A wheelchair-dependent resident who was safe to smoke repeatedly missed smoke breaks because access to the outside smoking area depended on a working elevator and delays caused the resident to arrive after the designated smoking time had ended. The resident, who had diagnoses including seizures, hemiplegia/hemiparesis, heart disease, cerebral infarction, anxiety, and depression, stated this happened often and was very upsetting. The resident’s care plan and smoking risk assessment indicated the resident had the ability to smoke, and facility staff stated the smoke break ended when the scheduled time was over.
A deficiency occurred when the facility failed to ensure hot water was available in resident rooms for showers, preventing a warm and comfortable bathing experience for multiple residents. One cognitively impaired resident, fully dependent for personal care, had no documented showers or baths for an extended period despite a scheduled bathing routine, and her family had filed a grievance about the lack of hot water. Two cognitively intact male residents, one with paraplegia and one with cirrhosis and diabetes, reported that their room showers had only cold or lukewarm water for weeks; they often refused showers when hot water could not be found, sometimes accepting sponge or bed baths instead, and one refused to bathe in other residents’ rooms. Staff and the Maintenance Director confirmed ongoing hot water problems on one wing, acknowledged that management was aware, and described workarounds such as using other rooms with hot water, obtaining hot water from common areas, or pouring basins of hot water over residents in their own showers, which did not consistently meet the facility’s policy to provide comfortably tempered shower water.
Failure to Respond Timely to Resident Call Light for Toileting Assistance
Penalty
Summary
Facility staff failed to respond to a cognitively intact resident’s call light within a reasonable time, resulting in a documented delay of over two hours. The resident, who had been admitted earlier in the month, reported that during breakfast he activated his call light to request assistance with toileting and waited approximately 1.5 to 2 hours before staff responded. Facility records from the call light system on the same date showed the call light was activated at 6:22 AM and not answered until 2 hours and 23 minutes later. During interviews, a CNA stated that management had communicated an expectation that call lights be answered in about 15 minutes, and the Administrator stated that staff had been told they should ideally answer call lights within 20 minutes of activation. The facility’s failure to respond to the resident’s call light in a timely manner was cited under WAC 388-97-1060(1) for not honoring resident preferences, choices, values, and beliefs, and placed residents at risk of unmet care needs and diminished quality of life.
Failure to Follow Physician Orders for Timely Post-Operative Staple Removal
Penalty
Summary
The facility failed to provide treatment and care in accordance with professional standards of practice by not carrying out a physician’s transfer order for a cognitively intact resident admitted with multiple diagnoses including a right hip fracture. The 5‑day MDS dated 02/20/2026 showed the resident was cognitively intact, and transfer orders dated 02/13/2026 directed staff to schedule a follow‑up appointment with the orthopedic provider for staple removal in two weeks. Interview and record review revealed that the resident reported not having been seen by the orthopedic surgeon since admission and stated that the staples had remained in for a long time before being removed, which was painful. The electronic health record showed the staples were not removed until 04/08/2026, 51 days after admission, and the DON/RN acknowledged that the transfer orders were not carried out due to an oversight, despite the expectation that admission/transfer orders be completed as instructed. This failure was cited under WAC 388-97-1060 (1)-(3) for not honoring each resident’s preferences, choices, values, and beliefs and for not providing care in accordance with professional standards of practice for one of three sampled residents reviewed for quality of life.
Failure to Revise Activity Care Plan After Significant Change in Condition
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident received ongoing opportunities to participate in meaningful activities consistent with her interests and preferences following a significant change in condition. The resident experienced a fall on 02/18/26, was sent to a local emergency room for pain in both legs, and diagnostic radiology revealed an anterior apex angulated fracture of the distal left femur with impaction and an impaction and comminuted anterior apex angulated fracture of the distal right femur metaphysis, with osteopenia noted. She was hospitalized for these fractures and returned to the facility on 02/24/26. A subsequent MDS with an ARD of 02/27/26 documented a significant change in status and indicated that it was important for the resident to do things with groups of people, participate in her favorite activities, and attend church services. Record review showed that the resident’s activity care plan, originally initiated in 2020 and revised multiple times through 03/03/2025, contained numerous interventions reflecting her preferences, including in-room visits, participation in food committee and resident council, church and religious services, group singing and cooking, gardening, pet visits, listening to religious/bluegrass/country music, watching TV and keeping up with the news, and engaging in favorite activities such as church, sewing, cooking, reading, and gardening. The care plan also noted her use of a wheelchair and need for accommodations for visual impairments. However, there were no new or revised activity interventions added to address her new non–weight-bearing status and functional limitations after the fractures, and no changes to the activity care plan were documented following the significant change in condition. During interview, the resident, who had decision-making capacity and a BIMS score of 15, reported that prior to the fall she had been able to stand, pivot, and walk with therapy, and that she had been active in resident council, church, and social activities. She stated that since her return from the hospital she could not get into her wheelchair, could not attend resident council meetings or church, and could not participate in the group activities she enjoyed. She reported that activity staff did not visit her very often and became tearful while describing her situation. The Director of Recreation confirmed that the resident had not attended group activities since returning from the hospital, was non–weight-bearing for 10 weeks, and that anything done with her was now in-room. The Director of Recreation also stated that the resident did not receive one-to-one visits “per se” and that social visits were not documented. Surveyors identified that only two one-to-one visits had been documented since the resident’s return from the hospital and that there was a significant decline in her activity participation without corresponding revisions to her care plan, which led to the finding of failure to provide consistent, individualized activity interventions and ongoing opportunities for meaningful activities.
Failure to Provide Timely Incontinence Care and Maintain Resident Dignity
Penalty
Summary
The deficiency involves the facility’s failure to provide timely incontinence care and to honor a resident’s dignity and comfort. Resident 1, who had diagnoses including a left femur fracture, gout, COPD, hypertension, and a history of falling, reported that she activated her call light at 11:00 AM because she needed a diaper change. She stated that a CNA brought her lunch at 11:30 AM but refused to assist with the diaper change. At 11:41 AM, the resident was observed in bed stating she had been waiting since 11:00 AM for incontinence care. At 11:43 AM, while the surveyor was present, the resident again activated her call light. CNA 1 entered the room in less than a minute without knocking or announcing her presence, turned off the call light, ignored the resident, checked only on the roommate, and was about to leave the room until the visibly distressed resident requested assistance, stating she would not eat while soiled. CNA 1 told the resident she could not change the diaper because the roommate was eating. In a subsequent interview, CNA 1 stated she had been on lunch break from 10:40 AM to 11:20 AM, believed another staff member had answered the earlier call light, and claimed she had been instructed by the DSD not to provide peri-care if someone in the room was eating, and that the charge nurse had told her she could not do it. The charge nurse denied instructing CNA 1 not to change the resident and stated she had told CNA 1 to pull the privacy curtain and assist with the diaper change. The DSD denied ever instructing staff to delay care due to a roommate eating and stated staff were expected to attend to residents’ needs immediately and use privacy curtains during personal care. Review of the facility’s “Dignity” policy showed requirements that residents be treated with dignity and respect, that staff knock and request permission before entering rooms, promote and protect privacy, and promptly respond to toileting requests. The DON acknowledged that the policy was not followed when staff did not provide necessary personal care and left the resident in a soiled diaper for more than 40 minutes, in violation of facility standards and CMS regulations.
Missed Smoking Breaks for Wheelchair-Dependent Resident
Penalty
Summary
The facility failed to assist a wheelchair-dependent resident, who relied on the elevator to get outside to smoke, resulting in missed smoking opportunities. The resident was observed waiting in a wheelchair at the 2nd floor elevator at approximately 1:00 PM and later at the 1st floor elevator at approximately 1:20 PM. When asked whether they had gone outside to smoke, the resident stated they had missed it. The resident reported that smoke breaks were often missed because only one of the building’s two elevators was working and it could take up to 30 minutes to get on the elevator due to residents and staff waiting to use it. The resident also stated it was very upsetting to miss smoke breaks and that if the break was missed, the door was closed and smoking was not allowed. Record review showed the resident was admitted with diagnoses including seizures, hemiplegia and hemiparesis, heart disease, cerebral infarction, anxiety, and depression. The resident’s MDS indicated no cognitive impairment and that partial moderate assistance was needed for transfers from bed to wheelchair. A smoking risk assessment identified the resident as safe to smoke, and the care plan indicated the resident had the ability to smoke. Facility smoking times were posted as 9:15 AM, 1:00 PM, and 5:15 PM. The Activity Director stated that once the smoke break was over, activity staff moved on to other responsibilities and the smoke break ended. The Nursing Home Administrator stated the resident should be allowed to smoke. The facility policy stated that any resident deemed safe to smoke would be allowed to smoke in designated smoking areas at designated times and in accordance with the care plan.
Failure to Provide Hot Water for Resident Showers and Maintain Comfortable Bathing Conditions
Penalty
Summary
The deficiency involves the facility’s failure to provide residents with hot water in their own showers, resulting in an inability to ensure a warm and comfortable bathing experience for multiple residents over an extended period. For one cognitively impaired female resident with a history of stroke, vascular dementia, and total dependence on staff for personal care, record review showed she was scheduled for bathing three times weekly, but there were no showers, baths, or sponge baths documented in her medical record for nearly a month. Her care plan listed showers/baths as not applicable, and a grievance from her family reported no hot water to provide a shower or bath, with no documentation of how this concern was resolved. When water temperatures were tested in her room, the shower measured 94°F and the sink 77°F after running for three minutes. A cognitively intact male resident with paraplegia, type 2 diabetes, and a need for maximal assistance with showering/bathing reported that there had been no hot water in his room for 2–3 weeks. His care plan did not identify his showering/bathing needs. ADL documentation showed a mix of refusals, full body baths, and one shower during the review period. He stated that if staff could not find hot water, he refused showers, and although staff suggested he shower in another resident’s room, he declined because he wanted to shower and change in his own room. He reported accepting sponge baths multiple times when staff could find hot water, but expressed a preference for showers with clean hot water in his own room. Temperature checks in his room showed both the shower and sink at 80°F after running for three minutes. Another cognitively intact male resident with cirrhosis, type 2 diabetes, and a need for assistance with personal care was documented as requiring two staff for bathing/showering and having set-up assistance for showering. ADL records showed frequent showers earlier in the month and a full body bath later, but he reported he was only taking showers once a week because the water was too cold. He stated staff were aware of the cold water, and when he refused showers due to the temperature, staff simply accepted the refusal; he sometimes accepted bed baths because they were warmer, and at other times took cold showers when he could not tolerate going without. Temperature checks in his room showed shower water at 80°F and sink water at 77°F after three minutes. Staff interviews confirmed ongoing hot water problems affecting multiple rooms on one wing, including those of the three residents. The Maintenance Director reported fluctuating water temperatures since the end of December, acknowledged that most rooms on one wing were affected, and stated that all facility management, including the Administrator, were aware of the lack of hot water. CNAs described that some rooms had hot water and some did not, and that they were taking residents without hot water to other residents’ rooms of the same gender or to empty rooms with hot water, if available. They also reported using hot water from the dining room sink or coffee machine for bed or basin baths, and one CNA described filling containers with hot water from another room and pouring them over residents in their own showers to simulate a shower. Staff stated that some residents refused to bathe in other residents’ rooms or refused bed baths when hot water was not available. The DON, who was new to the facility, acknowledged that residents should be showered every other day, that hot water availability varied by room and day, that Resident #1’s family had complained about hot water and showers, and that moving shower locations could be confusing for residents with dementia. The facility’s bath/shower policy required adjusting water to a comfortable temperature before turning the stream toward the resident, which was not consistently achievable due to the lack of hot water in affected rooms.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release June 24, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
