LACEY, WA - Roo-lan Healthcare Center faced multiple federal violations during a February 2025 inspection, with the most significant failures occurring in patient transfer notifications and care documentation systems.
Transfer and Discharge Notice Failures
Federal inspectors documented widespread failures in the facility's notification procedures when residents required hospital transfers. The nursing home violated regulations by failing to provide written transfer notices to residents and their families in five of six sampled cases, while also failing to notify the state ombudsman in all six cases reviewed.
The violations affected residents transferred to hospitals between October 2024 and January 2025. In each case documented by inspectors, the facility's electronic health records showed no transfer notifications were provided to residents before their hospital transfers, despite federal requirements mandating such notices.
One case highlighted the serious consequences of these notification failures. A resident with post-traumatic stress disorder, depression, and anxiety was transferred to the hospital on January 16, 2025. When inspectors interviewed the resident's power of attorney eleven days later, they discovered the family member was unaware the resident had even left the facility.
"When was he discharged?" the power of attorney asked inspectors, revealing they had received no notification of the transfer. The facility also failed to send the resident's belongings with them, requiring the family to collect personal items on a cart nearly two weeks later.
Medical Assessment Documentation Problems
The inspection revealed significant issues with the facility's Minimum Data Set assessments, which are standardized evaluation tools used to determine residents' care needs and Medicare reimbursement rates. Nine of 23 sampled residents had inaccurate or incomplete MDS assessments.
These documentation failures included incorrect coding of medication reduction dates for residents receiving antipsychotic medications, missing information about specialized medical equipment like dialysis catheters, and inaccurate reporting of rehabilitation services provided to residents.
For residents requiring dialysis treatment, inspectors found critical information missing from assessment records. One resident's MDS assessment failed to note their hemodialysis catheter, despite hospital discharge notes clearly documenting the presence of this central venous access device. Such omissions can lead to inadequate care planning and missed safety protocols for residents with complex medical equipment.
Care Plan Deficiencies
The facility's individualized care plans lacked resident-specific interventions and essential medical information. Seven of 23 sampled residents had care plans that failed to address their documented medical needs or safety requirements.
Inspectors observed residents with beds positioned against walls without corresponding care plan interventions or physician orders. This positioning can create safety risks and mobility limitations, yet no documentation addressed these arrangements or provided staff guidance for safe resident transfers.
For residents with dementia receiving multiple medications, care plans lacked non-pharmacological intervention strategies. These approaches, such as environmental modifications and behavioral techniques, are considered best practices for dementia care and can reduce reliance on psychiatric medications.
Medical analysis indicates these care plan deficiencies can lead to fragmented care delivery, as nursing staff lack clear guidance on individualized approaches for each resident's specific conditions and needs.
Mental Health Screening Violations
The facility failed to complete accurate pre-admission screening assessments for residents with mental health diagnoses. Federal law requires nursing homes to conduct Preadmission Screening and Resident Review evaluations to ensure appropriate placement and specialized services for residents with mental illness.
Two residents had incomplete or inaccurate mental health screenings despite documented psychiatric diagnoses requiring medication management. One resident's screening from 2023 only addressed a PTSD diagnosis, failing to account for subsequently diagnosed depression and anxiety requiring additional psychiatric medications.
These screening failures can result in residents not receiving required specialized mental health services, potentially compromising treatment outcomes and medication management protocols.
Industry Standards and Required Protocols
Federal regulations require nursing homes to provide written transfer notices to residents and their representatives before hospital transfers, including information about appeal rights and bed hold policies. Facilities must also notify the state ombudsman of all transfers to ensure resident protection services can respond when needed.
The Medicare assessment system requires accurate documentation of residents' medical conditions, treatments, and functional abilities to ensure appropriate care planning and resource allocation. When assessments contain errors, residents may not receive necessary services or may have their care needs incorrectly calculated for reimbursement purposes.
Care plans must be individualized to each resident's specific needs and updated regularly to reflect changing conditions. Generic care plans without resident-specific interventions fail to provide adequate guidance for nursing staff and may not address the full scope of a resident's medical and psychosocial needs.
Facility Response and Corrective Actions
During interviews with inspectors, facility administrators acknowledged the notification failures and indicated expectations that proper procedures would be followed going forward. The Director of Nursing confirmed that transfer notifications and ombudsman notifications should have been completed for the affected residents.
The facility's MDS Director acknowledged multiple coding errors in assessment documentation and indicated plans to submit corrections for inaccurate assessments. Administrative staff confirmed that care plans should include resident-specific information about medical equipment, physician contacts, and individualized intervention strategies.
Regulatory Context and Oversight
These violations occurred during a routine federal inspection conducted under Medicare and Medicaid certification standards. The Centers for Medicare & Medicaid Services requires nursing homes to demonstrate compliance with resident rights, quality care standards, and documentation requirements to maintain federal funding eligibility.
The inspection findings reflect broader challenges in nursing home compliance with transfer notification requirements and assessment accuracy standards. Federal oversight has intensified focus on these areas following concerns about resident and family communication during healthcare transitions.
Nursing homes face potential financial penalties and increased oversight when inspection findings document violations affecting resident safety, rights, or quality of care. The facility must submit detailed correction plans addressing each violation and demonstrate sustained compliance during follow-up monitoring.
The complete inspection report provides additional details about facility operations and compliance with federal nursing home regulations.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Roo-lan Healthcare Center from 2025-02-06 including all violations, facility responses, and corrective action plans.
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