Alderwood Post Acute & Rehabilitation
Inspection history, citations, penalties and survey trends for this long-term care facility in Lynnwood, Washington.
- Location
- 3701 188th Street Southwest, Lynnwood, Washington 98037
- CMS Provider Number
- 505319
- Inspections on file
- 43
- Latest survey
- March 30, 2026
- Citations (last 12 mo.)
- 60
Citation history
Health deficiencies cited at Alderwood Post Acute & Rehabilitation during CMS and state inspections, most recent first.
The facility failed to revise and individualize care plans to reflect current needs and preferences for multiple residents, including one cognitively intact resident with hemiplegia, hemiparesis, and mononeuropathy who had bilateral shoulder surgery and could not tolerate BP measurements on the upper arms but preferred forearm readings. Despite repeatedly informing staff, this preference was not documented in the care plan or Kardex, and direct care staff and the RN/UM were unaware of it. Another cognitively intact resident with hemiplegia, contractures, and weakness reported they were supposed to get out of bed for two hours daily, but some NACs did not know this, even though the MAR/TAR contained an order to document times up and back to bed. The surveyors concluded that care plans were not accurately revised for several residents, placing them at risk for unidentified and unmet care needs and diminished quality of life.
Surveyors found that two residents with hemiplegia, hemiparesis, weakness, and contractures did not receive restorative nursing services, including ROM exercises and splint/brace or orthotic assistance, after therapy discharge. Although PT and OT discharge summaries documented established restorative ROM and transfer programs, recommended PROM to affected extremities, and recommended splint/brace use and assistance with orthotic wear, these recommendations were not entered as restorative referrals in the EHR. As a result, the residents’ care plans and records showed no restorative programs, and both residents reported that therapy and restorative exercises had stopped, while the DON, rehab director, and MDS coordinator confirmed they were unaware of and had not implemented the recommended restorative services.
A resident with diabetes, a right foot wound, depression, and moderate cognitive impairment was discharged home without complete discharge instructions, a discharge summary, or physician orders for wound care. The discharge packet lacked documentation that blood pressure, antidepressant, and insulin medications were provided, and there was no evidence that wound care supplies or training were given to the resident or family. Facility staff, including social services, an LPN nurse manager, and the DON, acknowledged that the discharge documentation was incomplete and that required wound care orders, education, and medications were not included.
A resident dependent on hemodialysis missed all scheduled treatments due to the facility's failure to accommodate their need for a closer HD center and a bed during treatment, despite repeated requests. Facility staff were unaware of the missed treatments, did not notify the provider or resident representative, and failed to document or monitor the resident's condition. The lack of coordination and documentation resulted in the resident being hospitalized in intensive care for volume overload and heart failure.
A resident was discharged AMA without receiving discharge instructions, a discharge summary, or arrangements for home health services or equipment. Staff confirmed that required discharge documentation was missing from the EHR and that no preparations were made until the issue was identified by a surveyor.
The facility did not have a full-time RN designated as the DON after the previous DON was terminated. A corporate nurse provided intermittent coverage, but no full-time DON was in place, as confirmed by staff interviews and review of personnel records.
A resident with cognitive and physical impairments reported an allegation of sexual assault, but the facility failed to conduct a thorough assessment, did not immediately suspend the alleged staff member, and did not ensure interventions such as female care only were followed. A subsequent injury of unknown origin was not investigated or reported, and documentation and follow-up were lacking.
A resident with moderate cognitive impairment and a recent allegation of sexual assault was found to have a new skin tear in a vulnerable area. Despite documentation of the injury, staff including the DON and LPN did not report or investigate the incident, and the Administrator was unaware until later. The event was not reported to the state survey agency, and no investigation was conducted.
A resident with cognitive and physical impairments reported a sexual assault by a CNA, but the facility failed to conduct a thorough investigation, did not immediately suspend the accused staff, and did not document a comprehensive skin check or alert monitoring. The resident later developed a new skin tear in a sensitive area, which was not reported or investigated, and key notifications to the resident's power of attorney and physician were missing.
The facility did not maintain adequate nursing staff on two units, leading to delayed medication administration and slow responses to call lights. Nurses were required to cover multiple medication carts and had more residents than they could manage, resulting in late medication passes and insufficient supervision of nursing assistants. Residents and family members reported frequent delays in receiving care and medications, and staff confirmed ongoing staffing shortages that prevented timely completion of duties.
The facility failed to develop and document patient-centered discharge plans for two residents, including one who was cognitively intact and another with moderate cognitive impairment. Neither resident nor their families were adequately involved or informed about the discharge process, and there was no evidence of interdisciplinary team planning or communication. This resulted in residents being unprepared for discharge and lacking necessary support and information.
Surveyors identified that two nurses administered medications outside of scheduled times, resulting in a 27% medication error rate. Multiple residents received medications such as Levothyroxine, Acetaminophen, and Hydrocortisone cream significantly later than ordered, and the facility lacked a policy specifying the acceptable administration window.
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.
The facility did not have a qualified Infection Preventionist (IP) during a viral respiratory disease outbreak. Staff B was acting as the IP without the necessary training or certification. Interviews confirmed that Staff B was hired for the IP/Staff Development Coordinator role but had not been enrolled in a certification program. The facility's key personnel list showed no official IP designation, risking infection transmission among residents and staff.
A resident was transferred to a hospital due to neurological changes, but the facility failed to notify the emergency contact as required by policy. The family discovered the hospitalization only after visiting the facility the following day. The administrator confirmed the oversight, with no documentation of notification found.
The facility failed to ensure the Director of Nursing (DON) had an active professional license, placing residents at risk. Staff B, the new DON, was responsible for supervising the nursing department despite having a suspended and expired RN license. Staff members confirmed Staff B's role, and the administrator was aware of the license issue.
A facility failed to complete a background check for a newly hired DON, identified as Staff B, who was observed interacting with surveyors and moving unaccompanied in resident areas. The administrator confirmed the incomplete background check and lack of supervision, placing residents at risk of interactions with unqualified staff.
The governing body failed to ensure the DNS had a completed background check and an active professional license before employment. The DNS was hired despite an incomplete background check and a suspended RN license. The Administrator was aware of these issues, but the decision to hire was made by the governing body.
The facility failed to administer services effectively, impacting residents' well-being. The administration did not ensure thorough investigations of allegations or address repeated concerns about long call light wait times documented in Resident Council meeting minutes. Despite receiving these minutes monthly, the administrator did not implement corrective actions. The facility also had repeat deficiencies in areas such as resident rights and abuse prevention.
The governing body failed to provide adequate oversight of the facility's Administrator, resulting in repeated deficiencies in critical areas such as Abuse/Neglect, Resident Rights, and Infection Control. The governing body did not participate in QAPI meetings or communicate effectively with the Administrator, leading to a lack of clinical systems and insufficient staffing to meet residents' needs.
The facility failed to address concerns raised by the Resident Council, including slow call light response times and incorrect food orders. Despite documentation of these issues, there was no evidence of investigation or resolution, leading to unmet care needs and diminished quality of life for residents.
The facility failed to recognize, record, and resolve grievances for five residents, leading to unresolved issues such as malfunctioning equipment, missing medications, and personal belongings. Despite reporting these issues, no grievances were logged, and staff were unaware of the grievance process. This systemic failure placed residents at risk for anxiety and diminished quality of life.
The facility failed to address resident grievances regarding slow call light response times and food service issues over four months. Despite repeated concerns from the Resident Council, the administration did not investigate or resolve these issues, leading to neglect of necessary care and services. Staff interviews confirmed awareness of the grievances, but no actions were taken to address them.
The facility failed to implement abuse and neglect policies, affecting three residents. A resident was left on a commode for 45 minutes, another felt intimidated by a staff member, and a third was left in the bathroom for over an hour. The facility also ignored Resident Council concerns about call light response times and staffing issues. Staff interviews revealed a lack of understanding of reporting requirements.
The facility failed to conduct thorough investigations into multiple allegations of abuse, neglect, and other incidents involving residents. Complaints from residents about being left on a commode, dehydration, falls, and delayed pain medication were not properly addressed, with missing documentation and staff statements. Additionally, the facility did not adequately investigate concerns raised by the Resident Council regarding call light response times.
The facility failed to ensure comprehensive Resident Assessment Instrument (RAI) summaries for four residents, omitting crucial input on their needs and preferences. This deficiency involved incomplete Care Area Assessments (CAA) for residents with conditions such as surgical amputation, deep tissue injury, and chronic illnesses, risking inadequate individualized care.
The facility failed to develop comprehensive person-centered care plans for three residents, leading to potential risks in meeting their needs and desires. One resident's care plan lacked goals and nonpharmacological interventions for pain management, another's incorrectly identified their condition and lacked discharge goals, and a third's did not include comprehensive dementia care objectives. Staff interviews revealed a lack of awareness and performance plans for care planning issues, with this being a repeat deficiency.
The facility failed to follow professional standards in medication administration for four residents. A resident with a G tube had medications ordered orally, and an LPN pre-signed MARs for insulin administration before actually administering it, leading to potential medication errors.
The facility failed to provide adequate pressure ulcer care for three residents, leading to unresolved issues with malfunctioning equipment and inconsistent treatment. A resident's air mattress frequently malfunctioned, leaving them on a metal frame, while another developed pressure ulcers without proper documentation or consistent use of protective devices. A third resident's specialized mattress was not functioning, and staff were unaware of its status, indicating ongoing issues with equipment maintenance and care plan implementation.
The facility failed to provide restorative care for residents with limited ROM and mobility issues. A resident with spinal stenosis did not receive prescribed exercises, and another with a foot ulcer had therapy discontinued without alternative exercises. A resident with a hip fracture was not trained on a home exercise program, and a resident with multiple sclerosis was not on a restorative program despite being at risk for ROM loss. The facility lacked a structured restorative program, relying on the activity department for exercises.
The facility failed to adequately monitor and evaluate weights for several residents, leading to significant weight loss and poor nutrition. One resident with severe malnutrition lost 16 pounds over 60 days without timely intervention. Another resident requiring enteral feeding experienced significant weight loss due to missed tube feedings and inadequate monitoring. Additional residents also faced weight loss without proper re-weighing or notification to dietitians. The facility's failure to provide prescribed nutritional supplements and sack lunches for dialysis patients further contributed to these deficiencies.
The facility experienced significant staffing shortages, leading to long wait times for call light responses, missed bathing schedules, and inadequate care for residents. A resident with hemiplegia had to call 911 due to a six-hour wait for incontinence care. Other residents reported similar issues, with one left on a commode for 45 minutes. The facility lacked registered nursing staff on several night shifts, and the administration had not assessed the impact of these shortages.
A facility reported a 68.97% medication error rate due to incorrect doses, routes, and late administration. Staff admitted to signing MARs before administering medications to avoid showing late entries. The administration acknowledged that late medications were not initially counted as errors in their QAPI program.
The facility failed to ensure residents were free from significant medication errors, with numerous instances of late insulin administration and improper documentation. Residents experienced late or missed doses, and staff lacked competency in medication administration, particularly through feeding tubes. The facility's leadership was unaware of medication error trends, and there was a lack of documentation and investigation of errors, contributing to ongoing issues in medication management.
The facility failed to secure medications for four residents, leaving them at bedside, and did not discard expired medications in three medication carts. A resident reported receiving incorrect medication, and the Director of Nursing confirmed only one resident was on a self-medication program, not including those observed. Expired medications were found in multiple carts, with staff expected to check and dispose of them, but this was not done. This was a repeat deficiency.
The facility failed to provide palatable and appropriately heated meals, affecting several residents and the Resident Council. Residents reported receiving cold and unappetizing food, with some meals not aligning with dietary needs. The Resident Council noted ongoing issues with cold food, especially for those eating in their rooms, and a lack of resolution despite repeated complaints. A test tray confirmed the unpalatability of meals, marking a repeat deficiency from a previous survey.
The facility failed to meet residents' nutritional needs and preferences, with multiple reports of incorrect meal orders and missing items. A resident did not receive a prescribed nutritional shake due to communication lapses, while another consistently received unwanted food items. Observations revealed systemic issues in meal plating accuracy.
The facility failed to provide nutritional snacks and meals at non-traditional times, affecting four residents. A resident with low blood sugar was given unsuitable snacks, while another found their meals cold after dialysis with no way to reheat them. Two residents were unaware of available snacks until recently, despite one having severe malnutrition. The administrator and DON were informed of these issues.
The facility failed to ensure compliance with infection control guidelines, as staff did not adhere to proper hand hygiene and PPE protocols during resident care. Observations revealed that staff did not change gloves or perform hand hygiene between tasks, and entered rooms with contact isolation signs without wearing necessary PPE. These actions were observed during wound care and resident transfers, leading to non-compliance with infection control protocols.
The facility failed to maintain operational call lights, affecting multiple residents. A resident reported a non-functioning call light leading to delayed care, while another's spouse had to visit the facility due to a lack of response. Maintenance logs showed numerous unresolved call light issues, and audits focused on response rather than functionality.
The facility failed to provide required training on topics such as culture change, resident needs, and emergency preparedness to five staff members, as identified in the facility assessment. Education logs confirmed the absence of training, and interviews revealed a lack of awareness and alignment between the facility's assessment and training policy.
Two residents in an LTC facility reported feeling intimidated and disrespected by staff, leading to discomfort and fear. One resident was told to soil their brief and wait for assistance, while another experienced dismissive behavior during a room change request and a shower. Both residents expressed feelings of vulnerability and embarrassment due to staff actions.
A resident's representative's request for a care meeting was not honored, leading to a delay and unprofessional conduct by staff. The meeting, initially scheduled for 10:00 AM, did not occur until 11:30 AM. The representative faced dismissive behavior from an LPN and combative interaction with the DON, who suggested the resident move to another facility.
A facility failed to involve a resident in care planning, as the resident expressed they had never attended a care conference and were not informed about their care plan. Despite being alert and oriented, the resident required total assistance, and the facility's policy mandates resident participation in care planning. Staff indicated that care conferences were conducted based on family preference, but no specific care conference notes were available, only progress notes. This issue was a repeat deficiency.
A resident with acute cystitis and ESBL was involuntarily secluded in their room, contrary to their care plan and preferences for group activities. Staff interviews revealed a lack of direct engagement and reliance on second-hand information, with isolation precautions not aligning with CDC guidelines.
The facility failed to provide required written notices to two residents and their representatives during hospital transfers, and did not notify the state Ombudsman. One resident was hospitalized twice without receiving discharge rights information, and another was transferred without a notice of discharge. Staff were unclear about responsibilities for completing these notices, risking inappropriate transfers and lack of information on residents' rights.
A facility failed to provide a written bed-hold notice to a resident or their representative during two hospital transfers, as required by policy. The resident, who had no cognitive impairment, and their family member confirmed they did not receive or sign any paperwork regarding the bed-hold policy. The facility's administrator acknowledged the oversight, noting that the admission director or nurse should have completed the bed-hold process.
The facility failed to complete and document PASRR evaluations for two residents, one with mental health and substance abuse disorders and another with bipolar disorder. The necessary Level II assessments were either not conducted or not integrated into the residents' care plans, risking inadequate mental health care.
A resident with Multiple Sclerosis experienced a deficiency in care plan implementation and documentation. The care plan included ROM exercises and a bed cradle, but staff were unaware of the instructions, and there was no documentation of exercises being performed. The resident expressed interest in exercises, but the bed cradle was not in use, and staff were unaware of the resident's refusal to use it.
The facility failed to provide adequate bathing care for two residents, leading to hygiene issues and dissatisfaction. One resident experienced discomfort due to improper bathing techniques and missed baths due to refusals not being re-offered. Another resident faced inconvenient bathing times, resulting in refusals. Staff were unaware of these issues, indicating a lack of adherence to care plans.
Failure to Revise Care Plans to Reflect Resident Needs and Preferences
Penalty
Summary
The deficiency involves the facility’s failure to revise and individualize comprehensive care plans to reflect residents’ current needs and preferences, as required by its own care planning policy. For one resident with hemiplegia, hemiparesis following cerebrovascular disease, and mononeuropathy of the upper limb, the admission MDS showed intact cognition and upper extremity impairment. This resident reported having bilateral shoulder surgery and an inability to tolerate blood pressure measurements on the upper arms due to pain, and stated a preference for BP measurements on the forearms. The resident reported having informed multiple nursing staff of this preference, but staff continued to place the cuff on the upper arms. Review of the resident’s care plan and Kardex showed no interventions or instructions regarding forearm BP cuff placement. A NAC confirmed they were unaware of the preference until the resident told them directly and that this instruction was not documented in the Kardex. The RN/Unit Manager, who stated they were responsible for revising and reviewing care plans when there were changes, also confirmed they were not aware of the resident’s preference and that it should have been updated in the care plan. Another resident, readmitted with hemiplegia and hemiparesis following a nontraumatic subarachnoid hemorrhage, contracture of the left hand, and weakness, was cognitively intact and required maximum assistance for bed mobility per a quarterly MDS. This resident stated they were supposed to get out of bed for two hours every day, but some NACs were not aware of this care requirement. Review of the resident’s March 2026 MAR/TAR showed an order to document the time the resident got up and the time they returned to bed daily. The report states that, overall, the facility failed to revise care plans accurately to reflect residents’ needs for three of four residents reviewed for care plan revision, placing them at risk for unidentified and unmet care needs and a diminished quality of life.
Failure to Implement Restorative Nursing and Splint/Brace Programs After Therapy Discharge
Penalty
Summary
The deficiency involves the facility’s failure to provide restorative nursing services, including range of motion (ROM) exercises and splint/brace assistance, to maintain or prevent decline in mobility and contractures for two residents with significant motor impairments. The facility’s undated Restorative Nursing Services policy stated that residents would receive restorative care as needed to achieve and maintain optimal functioning and that residents may initiate a restorative program upon discharge from rehabilitative care. Despite this, surveyors found that residents with documented hemiplegia, hemiparesis, weakness, and contractures were not placed on restorative programs and had no restorative interventions documented in their electronic health records (EHRs). Resident 1 was admitted with hemiplegia and hemiparesis following cerebrovascular disease, a left lower leg fracture, and weakness, and the admission MDS showed intact cognition, moderate assistance needs for bed mobility and transfers, and one-sided upper and lower extremity impairment. During observation, the resident was seen lying in bed with a bent inward left forearm and hand and reported no longer receiving therapy or nursing-assisted exercises. The care plan initiated in January showed no restorative services, and the care plan history and EHR contained no restorative nursing interventions. However, the PT discharge summary from February documented that restorative ROM and transfer programs had been established and trained, including PROM to the left upper and lower extremities and stand-by assist with transfers, and the OT discharge summary recommended a splint/brace to prevent contracture. The OT stated that the splint/brace was not tried due to lack of time before insurance was discontinued, and both the Director of Rehab and the MDS coordinator confirmed there was no restorative referral in the EHR and they were unaware of the recommendations. Resident 2 was readmitted with hemiplegia and hemiparesis following a nontraumatic subarachnoid hemorrhage, a left-hand contracture, and weakness, and the quarterly MDS showed intact cognition, maximum assistance needs for bed mobility, total assistance for transfers, bilateral upper and lower extremity impairment, and no therapy or restorative programs. The resident reported that therapy had been discontinued months earlier and that no restorative staff were assisting with exercises. The care plan and EHR showed no restorative services. OT evaluation documented left upper extremity ROM impairment, a left-hand contracture, and prior use of a left orthotic to manage flexion tone, and the OT discharge summary recommended restorative care and assistance with donning/doffing the orthotic. The PT discharge summary recommended restorative programs if Medicaid Part B services did not continue. The Director of Rehab confirmed therapy was discontinued and that restorative nursing programs were recommended, but both the Director of Rehab and the MDS coordinator stated there were no restorative referrals in the EHR after readmission, and the MDS coordinator confirmed the resident had no restorative programs since readmission.
Failure to Provide Complete Instructions, Medications, and Wound Care Preparation at Discharge
Penalty
Summary
The deficiency involves the facility’s failure to ensure a safe and adequately prepared discharge for a resident with multiple medical needs. The resident was admitted with diagnoses including diabetes, a right foot wound, and depression, and had moderate cognitive impairment per the Minimum Data Set. The resident was discharged home with family, but review of the electronic health record showed the discharge instructions and discharge summary were incomplete. The discharge packet did not contain discharge instructions, a discharge summary, or physician orders for wound care to the resident’s right foot. There was no documentation that wound care training had been provided to the resident or family prior to discharge. Further review of the resident’s records showed that the document titled “Medications discharged with Resident” did not list blood pressure, antidepressant, or insulin medications. The discharge packet also lacked documentation that wound care supplies, blood pressure medication, antidepressants, and insulin were sent with the resident. In interviews, the resident’s family contact stated they were not educated on wound care and did not receive wound care supplies or insulin. Social services staff and the nurse manager acknowledged that the discharge instructions and summary were incomplete and that there were no wound care orders, no documentation of wound care training, and no documentation of the necessary medications being provided at discharge. The DON confirmed that the discharge packet was missing the required discharge documents, medication listings, wound care orders, and documentation of wound care supplies and training, despite facility expectations that discharged residents receive these items.
Failure to Ensure Scheduled Hemodialysis Leading to Resident Harm
Penalty
Summary
The facility failed to ensure that a resident with end stage renal failure received scheduled hemodialysis (HD) treatments as ordered. The resident was admitted and readmitted with a diagnosis requiring regular HD, but missed all scheduled treatments since admission. Interviews with collateral contacts and the resident revealed that the facility did not notify the resident’s representatives about missed HD sessions, nor did they attempt to accommodate the resident’s need for a closer HD center or a bed during treatment, despite repeated requests. The resident was unable to tolerate sitting for extended periods due to weakness and repeatedly communicated these needs to facility staff, but no action was taken to change the HD center or transportation arrangements. Facility staff, including the physician assistant, social worker, business office manager, and unit manager, were unaware that the resident had missed all HD treatments until notified by the HD center or after the resident was hospitalized. There was no documentation of the resident’s preferences, reasons for missed appointments, or any risk and benefit discussions with the resident or their representative. Additionally, there was no evidence of notification to the provider, resident representative, or facility management regarding missed HD treatments, nor was there documentation of ongoing monitoring or medical management for the resident’s condition due to missed treatments. Review of the resident’s care plan and progress notes showed a lack of interventions addressing the resident’s preferences, coordination with the HD center, or follow-up for missed treatments. The care plan did not include a focus area for missed HD treatments, and progress notes failed to document arrangements for rescheduled sessions or monitoring of the resident’s condition. The resident ultimately experienced harm, requiring hospitalization in the intensive care unit for volume overload and heart failure, conditions attributed to missed HD treatments.
Failure to Provide Safe Discharge Planning and Documentation
Penalty
Summary
The facility failed to ensure proper preparations were made for a safe discharge for one resident who left the facility against medical advice. According to the facility's policy, nursing services and/or social services are responsible for obtaining discharge orders, arranging recommended services and equipment, preparing medications for discharge, and providing the resident or representative with required documents such as a discharge summary and plan. However, review of the resident's electronic health record showed that no discharge instructions or discharge summary were completed at the time of discharge. Interviews with facility staff confirmed that discharge instructions and summaries are typically completed in the electronic health record, but in this case, none were present. Additionally, no arrangements for home health services or equipment needs were made prior to the resident's departure. The lack of discharge planning and documentation was only identified after the surveyor brought it to the facility's attention.
Failure to Maintain Full-Time DON Coverage
Penalty
Summary
The facility failed to designate and ensure a full-time Registered Nurse (RN) to serve as the Director of Nursing (DON) as required. Upon entry, the receptionist confirmed that there was no current DON, and a review of the facility's key personnel list also showed the absence of a full-time DON. The Administrator stated that the previous DON had been terminated the previous week and that a corporate nurse was temporarily covering the DON position as needed, but not on a full-time basis. In a follow-up interview, the Administrator confirmed that the facility still did not have a full-time DON, although an offer had been made to a potential candidate. The corporate nurse continued to provide coverage, but not in a full-time capacity.
Failure to Protect Resident from Abuse and Neglect
Penalty
Summary
The facility failed to protect a resident from abuse and neglect by not following its own policies after an allegation of sexual assault. The resident, who had moderate cognitive impairment, hemiplegia, hemiparesis, and required substantial assistance with toileting, reported an allegation of sexual assault. Despite the facility's policy requiring immediate assessment, notification, and protection, there was no documentation of a thorough assessment or skin check following the allegation. Additionally, the resident was not offered an emergency room evaluation after the report. The staff member accused in the allegation was not immediately suspended as required. Documentation showed that the staff member continued to work a full shift after the allegation was reported, and the suspension form was not reviewed with the employee until several days later. The investigation summary was unsigned and completed days after the incident, and staff statements were not obtained promptly. The facility also failed to ensure that interventions, such as female care only and care in pairs, were consistently implemented, as male staff continued to provide care and document treatments for the resident. A new skin tear was later discovered on the resident's labia, but there was no documentation of a thorough skin check or investigation into this injury of unknown origin. The injury was not reported to the state, and no further documentation or follow-up was found in the resident's record. Staff interviews confirmed that required reporting and investigation steps were not taken, and interventions to prevent further abuse were not consistently followed.
Failure to Report and Investigate Injury of Unknown Origin in Resident with Recent Abuse Allegation
Penalty
Summary
The facility failed to report to the state survey agency an allegation of injury of unknown origin in a vulnerable area for a resident with a recent history of alleging sexual assault. The resident, who had moderate cognitive impairment and required substantial to maximum assistance with toileting, was found to have a new skin tear around her left labia, as documented in a nursing progress note. There was no further documentation regarding this injury, and no investigation was initiated or reported to the appropriate authorities. Interviews with facility staff revealed that the former DON was unaware of the injury and stated it should have been reported and investigated, especially given the resident's recent allegation of sexual assault. The LPN/Nurse Manager acknowledged being notified of the injury but did not report or investigate it. The Administrator also confirmed that this was the first time they were made aware of the incident and that it should have been reported and investigated. No investigation was conducted, and the incident was not reported to the state survey agency.
Failure to Investigate Sexual Assault Allegation and Protect Resident
Penalty
Summary
The facility failed to thoroughly investigate an allegation of sexual assault involving a resident with moderate cognitive impairment and significant physical limitations, including hemiplegia and hemiparesis. The resident reported to a therapist that a male CNA straddled them and reached into their pants with an ungloved hand. The facility's investigation did not include interviews or witness statements from the resident or staff who worked directly with the resident at the time of the alleged incident. Additionally, the investigation summary was unsigned, and there was no documentation of a thorough skin check or alert monitoring for psychosocial harm following the allegation. The staff member accused was not immediately suspended as required; instead, they continued to work a full shift after the allegation was reported. The suspension form was completed by the administrator without the staff member's knowledge or signature, and the staff member was not informed of the suspension until several days later. The staff member also stated that they were not interviewed or asked for a statement regarding the incident until after their scheduled days off, and only then received the suspension form. Further, there was no documentation that the resident's power of attorney or physician was notified of the allegation. A new skin tear was later found on the resident's labia, but this injury was not reported or investigated, and no thorough skin check was documented. The nurse manager acknowledged that the injury should have been reported and investigated due to its location and the recent allegation, but this did not occur. The investigation lacked critical elements such as timely suspension of the accused staff, comprehensive interviews, and proper documentation of resident assessment and notifications.
Insufficient Nursing Staff Resulting in Delayed Care and Medication Administration
Penalty
Summary
The facility failed to provide sufficient nursing staff on both the first and second floors, resulting in delays in medication administration, untimely responses to residents' call lights, and inadequate supervision of nursing assistants. Observations and interviews revealed that nurses were responsible for covering multiple medication carts and had more residents assigned than they could manage, leading to late medication passes. The electronic Medication Administration Record (eMAR) frequently showed residents' medications as late, and staff reported being unable to complete their duties on time due to being short-staffed. Multiple staff members stated that when only two nurses were present on a unit, they could not provide timely care, supervise aides, or monitor residents' conditions adequately. Residents reported consistently receiving their medications late and experiencing long wait times for assistance after activating their call lights. Some residents stated they had to wait up to an hour or more for help, and in some cases, had to walk to the nurses' station themselves. Grievance forms and interviews with residents and family members corroborated these issues, with reports of residents having to yell for help, waiting extended periods for pain medication, and staff acknowledging the ongoing staffing shortages. Review of facility assignment sheets over a one-month period confirmed that numerous shifts on both floors operated with only two nurses, and nurses were often required to share medication carts. The staffing coordinator indicated that nurse shifts were being cut due to a lower census, but the remaining residents, particularly those in rehab, required more assistance. Despite staff raising concerns to management and the staffing coordinator, no additional support was provided, and the staffing shortages persisted, directly impacting the timeliness and quality of resident care.
Failure to Provide Patient-Centered Discharge Planning and Communication
Penalty
Summary
The facility failed to ensure that discharge planning was patient-centered and involved both the resident and their representatives, as required by policy. For two residents reviewed, there was no evidence that the interdisciplinary team developed or documented a discharge plan that addressed the residents' goals, needs, or referrals to local agencies. Additionally, there was a lack of direct communication with the residents and their families regarding the discharge process, timeline, and preparation, despite facility policy requiring such involvement and documentation at least twenty-four hours prior to discharge. One resident, who was cognitively intact, and their family reported not receiving any information about discharge planning throughout the stay. The resident repeatedly asked staff for updates but was only informed of the discharge on the day it was to occur, leaving insufficient time to arrange transportation. Documentation in the electronic health record did not show any follow-up or involvement of the resident or family in the discharge planning process after an initial note, nor did it reflect any multidisciplinary team discussions or communication about the discharge timeline. Another resident, who was moderately cognitively impaired, also lacked documented discharge planning or communication with the family. The care plan indicated a need for 24/7 care at home, but there was no evidence that the discharge plan was reviewed or updated as the resident's cognitive status declined. Staff interviews confirmed that there was no documentation of communication with the resident or family, no record of team discussions, and no evidence that the family was prepared or received caregiver training prior to discharge.
Medication Error Rate Exceeds Regulatory Threshold Due to Late Administration
Penalty
Summary
The facility failed to maintain a medication error rate below five percent, as required, resulting in a 27 percent error rate. This was identified through observation, interview, and record review, where 8 medication errors were found out of 29 opportunities. The errors occurred because two nurses administered medications outside of the scheduled administration times. Specifically, medications scheduled for administration at 7:00 AM or 8:00 AM were given significantly later, with times ranging from 9:04 AM to 9:58 AM. The medications involved included Levothyroxine, Acetaminophen, Diclofenac gel, Diamox, Dorzolamide-timolol, Protonix, and Hydrocortisone cream. The report details that the facility did not have a policy specifying the acceptable window for medication administration when medications were ordered at a specific time. Staff interviews confirmed that the expected practice was to administer medications within one hour before or after the scheduled time, but this was not consistently followed. The lack of adherence to scheduled medication times led to the identified errors for multiple residents, as observed and documented by surveyors.
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.
Lack of Qualified Infection Preventionist During Outbreak
Penalty
Summary
The facility failed to ensure the designation of a qualified Infection Preventionist (IP) responsible for the infection control program, which is crucial for early detection, analysis, and management of healthcare-associated infections. During a viral respiratory disease outbreak, it was found that Staff B, who was acting as the IP, had not received the necessary training or certification for the role. Interviews with Staff C, the Unit Manager, and Staff A, the Administrator, confirmed that Staff B was hired for the IP/Staff Development Coordinator role but had not been enrolled in a certification program. A review of the facility's key personnel list revealed no staff was officially designated as the IP, placing residents and staff at risk for transmission of infectious diseases.
Failure to Notify Emergency Contact of Resident Hospitalization
Penalty
Summary
The facility failed to notify the responsible party for a resident who was hospitalized, which was a requirement according to the facility's policy. The policy stated that a nurse should inform the resident's representative when the resident is transferred to a hospital. In this case, the resident was admitted to the facility with a son listed as the primary emergency contact and a significant other as the secondary contact. However, when the resident was sent to the hospital due to unclear speech and changes in neurological function, there was no documentation that any family or responsible party was notified. Interviews and record reviews revealed that the family was unaware of the resident's hospitalization. A family member stated that they were not informed and discovered the resident's absence when visiting the facility the day after the transfer. The facility's visitor log confirmed that the significant other visited the facility after the resident had been hospitalized. The administrator acknowledged that the primary emergency contact should have been notified, but there was no documentation to confirm that this was done.
Director of Nursing Lacked Active License
Penalty
Summary
The facility failed to ensure that the Director of Nursing (DON), identified as Staff B, had an active professional license, which placed all residents at risk of substandard quality of care. Staff B was hired as the new DON and was responsible for supervising the nursing department and overseeing resident care. Multiple staff members, including an LPN and a unit manager, confirmed that Staff B was the current DON and that they would seek guidance from Staff B for nursing concerns. However, a review of the Washington State Provider Credential Search website revealed that Staff B's Registered Nurse license was suspended and expired. The facility's administrator, Staff A, was aware of the suspension of Staff B's license, yet Staff B continued to serve in the role of DON.
Incomplete Background Check for DON
Penalty
Summary
The facility failed to complete a background check prior to the employment of a staff member, identified as Staff B, who was hired as the Director of Nursing. This oversight was discovered during a review of the facility's policy on abuse, which mandates screening potential employees for a history of abuse, neglect, or mistreatment by completing a background check. Staff B's employment file indicated a hire date, but the background check was incomplete due to missing information. Despite this, Staff B was observed interacting with surveyors and moving unaccompanied in resident areas. The facility's administrator, Staff A, acknowledged the incomplete background check and confirmed that there was no evidence of Staff B being supervised or accompanied by another staff member since their hiring. This failure placed residents at risk of interactions with unqualified staff, potentially leading to abuse, neglect, and exploitation.
Failure to Verify DNS Credentials and Background
Penalty
Summary
The facility's governing body failed to ensure compliance with its abuse policy by not verifying that the Director of Nursing (DNS) had a completed background check and an active professional license before employment. The employment records showed that the DNS was hired without these verifications. During an interview, the Human Resources staff revealed that the background check for the DNS was incomplete, requiring additional information, and that the DNS's Registered Nurse license was suspended. Despite being aware of these issues, the Administrator stated that the decision to hire the DNS was made by the governing body.
Ineffective Administration and Unaddressed Resident Concerns
Penalty
Summary
The facility failed to administer services effectively and efficiently, impacting residents' optimal physical, mental, and psychosocial well-being. The administration did not ensure thorough investigations of all allegations, nor did they maintain systems to prevent repeat citations. This included issues documented in Resident Council meeting minutes regarding long call light wait times, which were not addressed. The administrator was responsible for the day-to-day functions and implementing operational policies but failed to put corrective actions in place to sustain these systems. The facility's last annual recertification Statement of Deficiencies showed repeat deficiencies in several areas, including resident rights, grievances, and abuse prevention. The administration did not implement an Abuse Prohibition policy effectively, leading to delayed investigations and failure to protect residents. The administrator acknowledged that the Director of Nursing Services completed investigations for abuse allegations, but they were responsible for reviewing them. Despite receiving monthly Resident Council Minutes, the administrator did not address the repeated concerns about call light wait times.
Governing Body's Lack of Oversight Leads to Repeated Deficiencies
Penalty
Summary
The governing body of the facility failed to provide adequate oversight and monitoring of the appointed Administrator, resulting in a lack of clinical systems related to various critical areas such as Abuse/Neglect, Resident Rights, Grievances, Pressure Ulcers, Infection Control and Prevention, Social Services, Nutrition, Care Planning, Accidents and Supervision, Transfer and Discharge, Staffing, Medication Safety, Range of Motion program, and Infection Control Practices. This lack of oversight led to repeated deficiencies in these areas, as noted in the facility's last annual recertification Statement of Deficiencies. The governing body also failed to ensure the Administrator had sufficient staff to meet the residents' needs, including personal care, grooming, restorative care, and an effective call light system. Interviews and record reviews revealed that the governing body did not actively participate in the Quality Assurance Performance Improvement (QAPI) program, as evidenced by their absence from QAPI meetings and lack of communication with the Administrator. The Administrator reported that the governing body, consisting of the Chief Nursing Operator, Chief Operating Officer, Regional Director of Operations, and Regional Director of Clinical Services, did not engage in the facility's operations or provide necessary support. The facility's assessment and QAPI minutes lacked signatures or reviews from the governing body, indicating a disconnect between the governing body and the facility's management. This failure to engage and support the facility's operations placed residents at risk for suboptimal care and services.
Failure to Address Resident Council Concerns
Penalty
Summary
The facility failed to adequately respond to and resolve concerns raised by the Resident Council over several months, leading to unmet care needs and diminished quality of life for residents. The administration did not investigate or address issues reported during Resident Council meetings from May to August 2024. These issues included slow response times to call lights during the night shift, incorrect food orders, and a lack of staff presence at nursing stations. Despite these concerns being documented in various forms and logs, there was no evidence of follow-up or resolution. Interviews with Resident Council representatives revealed ongoing issues with night shift staffing and call light response times, as well as problems with food service accuracy. Resident 50 reported that overnight call light response times were excessively long, and there was a shortage of night shift staff. Resident 19 noted that residents were not receiving the food they requested, and the facility was not adhering to the menu. These concerns were echoed in the Resident Council meeting minutes, yet there was no documentation of any actions taken to address them. The facility's grievance and concern reporting logs did not reflect the issues raised by the Resident Council, and there was a lack of documentation regarding the investigation or resolution of these grievances. Staff interviews confirmed that the concerns were known to the administration, but no steps were taken to address them. This systemic failure to act on resident grievances placed all residents at risk for unmet care needs and a diminished quality of life.
Failure to Address and Document Resident Grievances
Penalty
Summary
The facility failed to recognize, record, and promptly resolve grievances for five residents, which placed them at risk for anxiety, undue stress, and a diminished quality of life. Resident 98 experienced multiple unresolved issues, including a malfunctioning air mattress, a non-working call light, and missing medications. Despite reporting these issues to staff and leaving messages for maintenance, no grievances were logged, and the maintenance director was unaware of the mattress issue. Resident 98 also faced delays in room relocation and was not informed about the grievance process. Resident 2 reported missing bed pads, and Resident 37 reported a missing tee shirt, both of which were not logged as grievances. Resident 43's favorite pajamas went missing, and they were not informed about the grievance process. Resident 255 reported missing ice packs and covers, but these concerns were also not documented in the grievance log. Interviews with staff revealed a lack of awareness and understanding of the grievance process, with some staff unaware of how to report or track missing items. The facility's grievance policy encourages staff to guide residents on filing grievances, but this was not effectively implemented. The administrator and director of nursing were unsure why grievances were not created for Resident 98's concerns. The facility's grievance log showed no entries for the missing belongings of Residents 2, 37, 43, and 255, indicating a systemic failure to address and document resident grievances as required by the facility's policy and regulatory standards.
Failure to Address Resident Grievances on Staffing and Food Services
Penalty
Summary
The facility failed to protect residents from abuse and neglect by not adequately addressing grievances related to nursing care, staffing, and food services over a four-month period. The administration selectively addressed grievances and neglected to investigate or resolve concerns about nursing staffing and food service, which were repeatedly raised by the Resident Council. This lack of action and documentation led to an unknown number of residents being deprived of necessary nursing care and food service support. Interviews with Resident Council representatives revealed ongoing issues with slow call light response times during the night shift and dissatisfaction with the food service program, as residents were not receiving the foods they requested. Despite these concerns being documented in Resident Council meeting minutes and grievance forms, there was no evidence of follow-up or resolution by the facility administration. The grievance forms lacked specific resident identifiers, and the facility's grievance reporting logs did not reflect the concerns raised in the Resident Council meetings. Staff interviews confirmed that the facility administration, including the Director of Activities and the Administrator, were aware of the grievances but failed to take action. The Director of Activities admitted to not documenting grievances in the Resident Council minutes and not completing grievance forms for certain concerns. The Administrator acknowledged that the grievances regarding call light response times were not investigated or logged. This systematic failure to address and document resident grievances placed all residents at risk for ongoing neglect and unmet needs.
Failure to Implement Abuse and Neglect Policies
Penalty
Summary
The facility failed to ensure systems were in place for staff to follow and implement abuse and neglect policies and procedures for reporting, investigation, and protection for three residents. Resident 15, who was cognitively intact and had a right above-knee amputation, reported being left on a bedside commode for 45 minutes, causing discomfort and pain. Despite informing a nurse, the incident was not logged in the concern and incident reporting logs, and the administrators were unaware of the allegation. An occupational therapist noted the resident's hesitance to participate in toilet training due to the incident, but the concern was not escalated appropriately. Resident 84, with no cognitive impairment, expressed fear and intimidation by a nursing assistant who discouraged them from calling for assistance during the night, suggesting they soil their brief instead. The resident reported feeling scared and intimidated, leading to reluctance in seeking help at night. Although the resident communicated their concerns to a staff member, the issue was not reported to the appropriate authorities, and the staff member involved was eventually removed from the facility. Resident 50 alleged being left in the bathroom for over an hour with the call light on, but the facility delayed reporting the incident to the state agency. Additionally, the Resident Council had repeatedly raised concerns about long call light response times and staffing issues during night shifts, but these were not logged or investigated by the facility. Interviews with staff revealed a lack of understanding and adherence to reporting requirements, contributing to the facility's failure to address and document these concerns adequately.
Inadequate Investigations into Resident Complaints and Incidents
Penalty
Summary
The facility failed to conduct thorough investigations into multiple allegations of abuse, neglect, and other incidents involving residents. For Resident 15, the investigation into their complaint of being left on a commode for an extended period was inconsistent and lacked a clear timeline. Conflicting statements from staff were not adequately addressed, and the investigation did not include all relevant staff members' accounts. Similarly, Resident 78's grievances about dehydration, a fall, and a choking incident were not properly escalated or investigated, with missing documentation and staff statements. Resident 84 reported feeling intimidated by a staff member who allegedly instructed them to soil their brief instead of providing timely assistance. The investigation into this incident was incomplete, lacking statements from key staff and failing to address all aspects of the resident's concerns. Additionally, Resident 454's complaint about delayed pain medication was not thoroughly investigated, with discrepancies in medication administration records not being resolved. The facility also failed to properly investigate a fall involving Resident 46, with missing staff statements and inadequate questioning of relevant personnel. The report highlights systemic issues in the facility's response to incidents, including late medication administration for multiple residents and unaddressed concerns raised by the Resident Council regarding call light response times. Investigations were often incomplete, lacking necessary documentation, witness statements, and analysis. The facility's failure to log and investigate Resident Council concerns further exemplifies the lack of thoroughness in addressing resident grievances and potential neglect.
Incomplete Resident Assessments in LTC Facility
Penalty
Summary
The facility failed to ensure that the Resident Assessment Instrument (RAI) included thorough summaries of the Care Area Assessments (CAA) for four residents, which are essential for analyzing and planning individualized care. The RAI, which consists of the Minimum Data Set (MDS), the CAA process, and the RAI Utilization Guidelines, is designed to assess a resident's needs, strengths, goals, and preferences. However, the CAAs for Residents 14, 43, 88, and 98 did not contain comprehensive assessments, including input from the residents on their actual or potential problems or needs. This omission placed the residents at risk of not receiving appropriate services based on their individualized needs. Specifically, Resident 88, who was admitted with surgical amputation and subsequent infection, had CAAs that lacked comprehensive assessments in areas such as dehydration, urinary incontinence, nutrition, and functional ability. Similarly, Resident 98, admitted with a deep tissue injury, had CAAs that did not thoroughly assess nutritional status and pressure ulcers. Resident 43, with diagnoses including type 2 diabetes, chronic kidney disease, and atrial fibrillation, also had incomplete CAAs regarding nutritional status. During a Quality Assurance Performance Improvement meeting, it was revealed that the facility had not identified CAAs as an issue, and there was no performance improvement plan in place to address this deficiency.
Deficiency in Comprehensive Person-Centered Care Planning
Penalty
Summary
The facility failed to develop and implement comprehensive person-centered care plans for three residents, which placed them at risk of not receiving services that would meet their desires or wants, potentially decreasing their quality of life. Resident 24, who was admitted with sciatica and shoulder pain, did not have a care plan that included their goals or nonpharmacological interventions for pain management. Resident 98, admitted with a right heel deep tissue injury, had a care plan that incorrectly identified them as being at risk for a pressure ulcer rather than having one, and it lacked the resident's wishes or goals for discharge. Resident 43, with diagnoses including type 2 diabetes, bipolar disorder, and dementia, had a care plan that did not contain comprehensive person-centered information or measurable objectives for dementia care. Interviews with facility staff revealed a lack of awareness and performance plans regarding care planning issues. Staff A, the Administrator, indicated that care plans could be updated by MDS nurses and unit managers but was not aware of any existing care plan issues. This deficiency was noted as a repeat issue from a previous survey conducted in December 2023, indicating ongoing non-compliance with care planning requirements as per WAC Reference: 388-97-1020(1)(2).
Medication Administration Deficiencies
Penalty
Summary
The facility failed to adhere to professional standards of practice in medication administration for four residents, leading to potential medication errors. Resident 78, who was re-admitted with a gastrostomy tube and an NPO (nothing by mouth) order, continued to have medications ordered to be given orally. This discrepancy was observed when a Licensed Practical Nurse (LPN) administered Baclofen via the G tube, despite the Medication Administration Record (MAR) indicating oral administration. The LPN acknowledged that the orders should have been updated to reflect the change in administration route following the resident's hospitalization. Additionally, the facility was found to have issues with pre-signing medication administration records. For Residents 58, 2, and 5, an agency LPN signed the MAR indicating that Humalog insulin was administered at a specific time, although the insulin was actually administered later. The LPN admitted to signing the MAR ahead of time to avoid the appearance of late administration in the electronic chart, acknowledging that this practice was unsafe. These actions were contrary to the facility's policy, which requires signing the MAR only after medication administration.
Failure to Monitor and Treat Pressure Ulcers
Penalty
Summary
The facility failed to monitor and provide necessary treatment and services consistent with professional standards of practice for three residents reviewed for pressure ulcers. Resident 98, who was admitted with a right heel deep tissue injury, experienced issues with their air mattress, which frequently malfunctioned, leaving them lying on the metal frame. Despite multiple reports to staff and maintenance, the issue was not addressed promptly, and the resident's care plan did not reflect the actual skin impairment or include necessary interventions like an air mattress or heel protectors. Additionally, there were inconsistencies in the application of prescribed treatments, such as Betadine and dressings, due to staffing issues. Resident 14, admitted with no skin issues, developed pressure ulcers on their backside and heels while at the facility. Observations revealed that heel protectors were not consistently used, and the resident experienced significant pain from the sores. The care plan did not document the development and treatment of the pressure ulcers or the use of foam boots and a specialized mattress. Furthermore, there was no incident report for the development of the pressure sores, indicating a lack of proper documentation and follow-up. Resident 43, who had an open area on admission, was observed with a non-functioning specialized air mattress, which was not addressed by staff. The care plan included the use of a low air loss mattress, but there was no directive in the medication administration record for its use. Staff were unaware of the mattress's non-functioning status, and there was a lack of familiarity with the resident's care needs. This deficiency was noted as a repeat issue from a previous survey, highlighting ongoing problems with equipment maintenance and care plan implementation.
Failure to Provide Restorative Care for Residents with Limited ROM
Penalty
Summary
The facility failed to provide restorative and rehabilitative treatment and services for four residents with limited range of motion (ROM) and mobility issues. Resident 2, a long-term resident with spinal stenosis and weakness, was supposed to receive active and passive ROM exercises as per their care plan. However, there was no documentation or exercise instruction sheet available, and the resident reported not receiving any exercises. Staff acknowledged that the restorative program tasks were missing from the system and that there was no structured restorative program in place. Resident 88, who had a right foot ulcer and toe amputations, was initially receiving physical and occupational therapy, but these services were discontinued due to insurance issues. The resident expressed a desire for therapy to regain strength, but no exercises were being conducted. The facility administrator admitted to not having a budget for restorative care until recently, and there was a delay in implementing a new restorative program after therapy discharge recommendations. Resident 41, who had a hip fracture, was not enrolled in a restorative nursing program despite having received therapy. The resident was not trained on a home exercise program, and there was no documentation of such a program being provided. Similarly, Resident 46, diagnosed with multiple sclerosis and malnutrition, was not on a restorative program despite being at risk for loss of ROM. Staff were unable to find documentation of ROM exercises, and the resident expressed interest in doing exercises. The facility lacked a restorative nursing program, relying instead on the activity department for exercises, which was insufficient to meet the residents' needs.
Inadequate Weight Monitoring and Nutritional Support
Penalty
Summary
The facility failed to ensure adequate weight monitoring and timely evaluation of weights for several residents, leading to significant weight loss and poor nutrition. For instance, one resident with severe protein-calorie malnutrition experienced a weight loss of 16 pounds over 60 days, which was not identified until the day of discharge. The resident reported not receiving bedtime snacks and was unaware of available snacks until the day before discharge. The Registered Dietitian (RD) did not evaluate the resident due to missing weight records, and the Director of Nursing acknowledged the lack of weight monitoring. Another resident, who required enteral feeding due to adult failure to thrive and other medical conditions, experienced significant weight loss. The resident reported being unable to swallow and expressed concerns about not receiving tube feeding as scheduled. The RD worked remotely and did not visit the facility, leading to missed weights and inadequate monitoring of the resident's nutritional needs. The facility's staff acknowledged the lack of weight monitoring and the RD's absence from Quality Assurance Performance Improvement meetings. Additional residents also experienced significant weight loss without proper monitoring or intervention. One resident lost 13.6% of their body weight in less than 30 days, but there was no documented re-weight or notification to the dietitian. Another resident experienced a 13.8% weight loss in one week, with no re-weights or documentation of refusal to be weighed. The facility's failure to provide prescribed nutritional supplements and sack lunches for residents attending dialysis further contributed to the nutritional deficiencies observed.
Staffing Shortages Lead to Delays and Inadequate Care
Penalty
Summary
The facility failed to provide sufficient nursing staff and adequate supervision, resulting in several deficiencies in resident care. Residents reported long wait times for call light responses, with delays sometimes extending up to an hour or more, particularly during night shifts and weekends when agency staff were more prevalent. This staffing shortage also led to issues such as missed bathing schedules, cold food, and inaccurate medical records. The Resident Council had repeatedly raised concerns about these issues, but the administration did not investigate or resolve them. Resident 5, who required substantial assistance due to hemiplegia, experienced significant delays in receiving care, including waiting up to six hours for assistance with incontinence care, which led them to call 911. The resident also reported inadequate bed baths and missed nutritional supplements, with documentation showing inconsistencies in the administration of these supplements. The facility's records indicated that Resident 5 was not bathed according to their care plan, and refusals were not documented or followed up with alternative offers. Other residents echoed similar concerns, with reports of extended wait times for call light responses and inadequate staffing levels affecting their care. Resident 15, for example, was left on a bedside commode for 45 minutes, causing discomfort due to their poor sitting balance. The facility's staffing records confirmed a lack of registered nursing staff on several night shifts, and the administrator acknowledged the ongoing recruitment efforts but had not assessed the impact of these staffing shortages on resident care.
High Medication Error Rate Due to Incorrect Administration Practices
Penalty
Summary
The facility failed to maintain a medication error rate of less than five percent, resulting in a 68.97% error rate. This was due to multiple instances of incorrect medication administration, including wrong doses, incorrect routes, and late administration times. Specifically, Resident 43 did not receive their 8:00 AM medications on time, and when administered, the wrong dose of Calcium Carbonate Antacid was given. Resident 75 received medications outside the prescribed time window, and Resident 78 was given Baclofen via a gastrostomy tube despite the order stating it should be administered orally. Staff interviews revealed a lack of adherence to the facility's medication administration policy, which requires medications to be given within one hour before or after the scheduled time. Staff members admitted to prioritizing certain medications when running late and acknowledged not seeking assistance from unit managers. Additionally, there was a practice of signing the Medication Administration Record (MAR) before actually administering the medications to avoid showing late administration in the electronic chart. The facility's administration acknowledged that late medication administration was not counted as a medication error in their Quality Assurance and Performance Improvement (QAPI) program. They also noted that late medications were logged as errors only after being cited in a survey. The report indicates that this is a repeat citation, suggesting ongoing issues with medication administration practices at the facility.
Significant Medication Errors in LTC Facility
Penalty
Summary
The facility failed to ensure that residents were free from significant medication errors, as evidenced by numerous instances of late medication administration and improper documentation. The report highlights that seven out of ten residents experienced significant medication errors, particularly with insulin administration, which was not given within the required one-hour window before or after the scheduled time. This resulted in multiple medication errors, with some doses being administered hours late or in close succession, leading to potential adverse effects on residents' health. Additionally, there was a lack of documentation regarding physician notification for these errors, indicating a systemic issue in medication management practices. Resident 5, who has diabetes, depression, anxiety, and a communication deficit, experienced numerous late insulin administrations over several months, with no documentation of physician notification for these errors. The resident's family member reported instances of low blood sugar and double dosing of sedative medications, which were not adequately addressed by the facility. Similarly, Resident 78, who has stiff person syndrome, reported missed medications and improper administration through a feeding tube, with staff lacking the necessary competency to perform the task correctly. The facility's failure to document and investigate these errors further exacerbated the situation. The report also notes that the facility's Director of Nursing (DON) and Administrator were unaware of the medication error trends and had not been conducting root cause analyses or reporting errors as required. The facility's incident reporting logs showed minimal logged medication errors, despite the numerous errors observed. This lack of oversight and accountability contributed to the ongoing medication management issues, which were not being adequately monitored or addressed by the facility's leadership.
Medication Security and Expired Medications Deficiency
Penalty
Summary
The facility failed to ensure medications were secured for four residents, as observed with medications left at their bedside. Resident 453 had Normal Saline Spray, Artificial tears, and a Proair inhaler on their overbed table, and reported receiving incorrect medication from a nurse. Resident 47 had Timolol eye drops on their overbed table, Resident 454 had a bottle of medicated Metholatum Gold Bond Powder on their nightstand, and Resident 78 had an unlabeled orange-colored bottle with Lidocaine on their nightstand, which was brought from home by their son. The Director of Nursing Services confirmed that only one resident was on a self-medication program, and it was not any of these residents. Additionally, the facility failed to discard expired medications in three of four medication carts reviewed. The Yellow Medication Cart on the first floor contained four expired bottles of medications, the [NAME] Medication Cart had one expired medication, and the Pink Medication Cart on the second floor had two expired medications. Staff interviews revealed that nurses were expected to check expiration dates before opening containers and dispose of expired medications, but this was not done. This issue was noted as a repeat deficiency from a previous survey.
Deficiency in Food Service Quality
Penalty
Summary
The facility failed to ensure that food and drink were served at a palatable and safe temperature, affecting six residents and the Resident Council. Multiple residents reported receiving cold meals, with some stating that their food was not served according to their preferences. Resident 84 expressed dissatisfaction with the temperature and type of food served, noting that their preferences were often ignored. Resident 98, who has diabetes, reported receiving meals high in carbohydrates and lacking in appropriate dietary management. Resident 95 and Resident 75 also reported receiving cold and unappetizing meals, with Resident 75 noting an improvement after raising concerns. The Resident Council highlighted ongoing issues with cold food, particularly for those eating in their rooms. They reported that food often arrived cold and that there was no way to reheat it. The council had repeatedly communicated these concerns to the kitchen staff without any resolution. Staff HH, who facilitates Resident Council meetings, confirmed that the facility does not provide microwaves for reheating food, and Staff B, the Director of Nursing, suggested that residents should inform staff if they receive cold food. A test tray evaluation conducted by surveyors confirmed the residents' complaints, revealing that the meal provided was not palatable. While the temperature of the meal components was within standards, the chicken cutlet was dry and flavorless, the zucchini was mushy, and the fruit cocktail was served uncovered. This deficiency was noted as a repeat issue from a previous survey conducted in December 2023, indicating a persistent problem with food service quality in the facility.
Deficiencies in Food Service and Meal Accuracy
Penalty
Summary
The facility failed to ensure that residents' menus and individual food plans met their nutritional needs and preferences, affecting five residents and the Resident Council. Residents reported not receiving the foods they ordered, with tray cards often not matching the meals served. Resident 50 and Resident 19 expressed dissatisfaction with the availability of alternative foods and the accuracy of their meal orders. The Resident Council had previously raised concerns about missing items and incorrect orders, but the facility administrator could not provide information on how these issues were resolved. Resident 5 experienced ongoing issues with receiving the correct food items, including a prescribed nutritional shake that was not provided with meals as ordered. Despite a physician's order for Glucerna with meals, the dietary manager was unaware of this requirement due to a lack of communication from nursing staff. Additionally, Resident 5's meal tray did not match the menu, leading to further dissatisfaction and the need for family intervention to provide the necessary nutritional supplements. Resident 81 also faced issues with meal accuracy and quality, receiving items they did not order and finding the food unappetizing or improperly prepared. Despite a documented preference for green bananas and a dislike for yogurt, Resident 81 consistently received these items, which they returned uneaten. The dietary manager acknowledged the need to reassess Resident 81's preferences. Observations of the tray line process revealed multiple errors in meal plating, indicating systemic issues in the facility's food service operations.
Failure to Provide Nutritional Snacks and Meals
Penalty
Summary
The facility failed to consistently offer and provide nutritional snacks when ordered or requested for four residents reviewed for dining preferences. Resident 2 reported difficulty in obtaining appropriate snacks, particularly those needed to manage low blood sugar, and was often provided with unsuitable options like potato chips. Resident 50, a representative of the resident council, highlighted that snacks at bedtime were no longer provided, and meals were left cold in their room after returning from dialysis, with no means to reheat or replace them due to the kitchen being closed. Resident 24 expressed satisfaction with a new snack offering card, which allowed them to order snacks like yogurt and pudding, but noted that they had not received bedtime snacks until recently. Resident 84, diagnosed with severe protein-calorie malnutrition, was unaware of available snacks until receiving a laminated list. Both Resident 24 and 84 confirmed they had not received bedtime snacks since admission until the week of the survey. The facility's administrator and director of nursing were informed of these issues, including the inadequacy of dialysis sack lunches.
Infection Control and PPE Compliance Deficiencies
Penalty
Summary
The facility failed to ensure compliance with Infection Prevention and Control Guidelines, as observed in the care of five residents. Staff members did not adhere to proper hand hygiene protocols during wound care and peri care, as evidenced by not changing gloves or performing hand hygiene between tasks. For instance, a registered nurse did not change gloves or perform hand hygiene after removing an old dressing before applying ointment and a new dressing to a resident's wound. Similarly, certified nursing assistants failed to perform hand hygiene between glove changes during peri care. In another instance, a registered nurse was observed using double gloves during wound care, which prevented proper hand hygiene. The nurse used contaminated gloves to handle various items in the resident's room, including opening doors and handling washcloths, without changing gloves or performing hand hygiene. The nurse acknowledged the oversight when questioned about the hand hygiene process during wound care. Additionally, staff members did not follow transmission-based precautions as required. Staff were observed entering rooms with contact isolation signs without wearing the necessary personal protective equipment (PPE), such as gowns and gloves. This included instances where staff entered rooms with enhanced barrier precaution signs without wearing gowns during resident transfers. Staff members were either unaware of the requirements or misunderstood the instructions on the precaution signs, leading to non-compliance with infection control protocols.
Call Light System Deficiency
Penalty
Summary
The facility failed to ensure that call lights were consistently operational and functioning appropriately across two floors, affecting six residents and potentially any resident using a call light. Resident 50 reported that their call light was not responded to for over an hour, and an investigation revealed the call light was not functioning. Resident 98 experienced a delay in care due to a non-working call light from the day of admission until the previous week. Resident 24 and Resident 454 also reported non-functioning call lights, with Resident 454's spouse having to drive to the facility due to the lack of response. Resident 53 was observed calling for help with an activated call light that did not illuminate outside the room. Resident 78 mentioned that their call light was sometimes out of reach, and they heard a neighbor calling for help for over an hour without response. The maintenance log from 09/01/2024 to 11/06/2024 showed 18 work orders related to call light issues, including critical and medium priority problems such as non-working call lights, missing buttons, and lights that would not turn off. Staff J, the Director of Maintenance, stated that call lights were fixed whenever problems arose and that an audit showed all call lights were working 100% as of 11/12/2024. However, the report indicates that the facility was conducting audits of call light response but not specifically of call light function, contributing to the deficiency.
Deficiency in Staff Training and Education
Penalty
Summary
The facility failed to ensure that staff were educated on all required topics identified in the facility assessment, affecting five sampled staff members. The identified trainings that were not provided included culture change/person-centered care, special needs of residents, identification of resident changes in condition, QAPI, emergency preparedness, and dementia care. This lack of training was confirmed through a review of the education logs for Staff DD, CC, EE, K, and X, which showed missing education in these areas. Interviews with Staff V, the Registered Nurse/Staff Development Coordinator, revealed that there were no records to show that the sampled staff had received the missing education. Staff V was unaware of the required education per the facility assessment and relied on a list provided by the corporate office. Additionally, Staff A, the administrator, acknowledged that the list of required education per the facility assessment did not match the in-service training policy, indicating a disconnect between the facility's assessment and the training provided.
Failure to Ensure Dignified and Respectful Treatment of Residents
Penalty
Summary
The facility failed to ensure that staff treated two residents, identified as Residents 84 and 98, with dignity and respect, leading to feelings of intimidation and discomfort. Resident 84, who had no cognitive impairment, reported feeling scared and intimidated by Staff F, a Nursing Assistant Registered (NAR). The resident recounted an incident where Staff F instructed them to soil their brief and wait for assistance, which caused physical discomfort and fear of calling for help at night. Resident 84 expressed that Staff F's behavior was intimidating and reported the issue to an Occupational Therapist, who suggested filing a complaint. Resident 98, also without cognitive impairment, experienced a lack of responsiveness and dismissive behavior from staff. The resident requested a room change due to the current room's depressing environment, but the Director of Nursing dismissed the request. Additionally, during a shower, Staff Q, a Nursing Assistant Certified (NAC), left Resident 98 alone multiple times to use a cell phone, causing the resident to feel cold and nervous. The resident also reported that Staff F dismissed their concerns about discomfort during care and that Staff E, another NAC, was dismissive when the resident needed assistance while eating breakfast. Both residents expressed feelings of vulnerability and embarrassment due to staff behavior. Resident 98 reported an incident where a staff member inappropriately discussed a private matter in front of others, causing further embarrassment. The facility's failure to address these issues resulted in repeated deficiencies, as noted in previous reports.
Failure to Honor Care Meeting Request and Unprofessional Conduct
Penalty
Summary
The facility failed to honor a request from a resident's representative to schedule a care meeting, which placed the resident at risk for unmet needs and hindered the representative's ability to advocate for the resident. The incident involved Resident 5, whose family member, referred to as Collateral Contact 2 (CC2), attempted to set up a care meeting at 10:00 AM, but it did not occur as planned. CC2 reported that when they tried to discuss the issue with Staff X, an LPN/Resident Care Manager, they were met with dismissive behavior, as Staff X extended their arm to indicate they would not engage in conversation. CC2 expressed frustration over the lack of communication and the need for a meeting to address various concerns regarding Resident 5's care. Further interviews and facility notes revealed that the care meeting eventually took place at 11:30 AM, and there were additional issues with Staff B, the Director of Nursing, who was described as combative and suggested that Resident 5 move to another facility. The facility's notes confirmed the rude behavior of Staff X and Staff B and indicated that the Administrator would educate them on customer service. The report highlights the failure to accommodate the representative's request for a timely care meeting and the unprofessional conduct of the staff involved.
Failure to Involve Resident in Care Planning
Penalty
Summary
The facility failed to ensure that residents and/or their representatives were offered the opportunity to participate in care conferences, as evidenced by the case of one resident who was not involved in the development and implementation of their person-centered care plan. The facility's policy requires that residents and their legal representatives be encouraged to attend and participate in care planning, with advance notice provided through various means. However, Resident 46, who was admitted to the facility and assessed to have severe cognitive impairment, expressed during an interview that they had never attended a care conference and were not informed about their care plan. Interviews with staff revealed that although Resident 46 was alert and oriented, they were forgetful and required total assistance with care. The Social Services staff indicated that care conferences were conducted quarterly or annually based on the preference of the resident or their representative, and in this case, the family preferred annual conferences via telephone. However, there were no specific care conference notes for Resident 46, as updates were documented as progress notes. This deficiency was noted as a repeat issue from a previous survey.
Failure to Prevent Involuntary Seclusion of a Resident
Penalty
Summary
The facility failed to ensure a resident's right to be free from involuntary seclusion, affecting one resident who was admitted with acute cystitis and placed on isolation/contact precautions due to ESBL in their urine. The resident, who was cognitively intact, expressed feelings of loneliness and reported being confined to their room by the nursing staff due to their infection. The resident's Minimum Data Set indicated a preference for group activities, yet they were restricted to their room, which was not aligned with their care plan that included self-directed activities. Interviews with facility staff revealed a lack of direct engagement with the resident. The Activities Director provided materials for individual activities but did not conduct an in-person assessment due to the isolation precautions. The Infection Preventionist, who had not met the resident, relied on second-hand information about the resident's incontinence, which was contradicted by documentation showing the resident was continent. The Social Services Director had limited contact with the resident, only during care conferences and discharge planning. The facility's approach to isolation did not align with CDC guidelines, which emphasize hand washing and enhanced barrier precautions rather than confinement.
Failure to Provide Required Transfer/Discharge Notices
Penalty
Summary
The facility failed to provide required written notices to residents and their representatives at the time of transfer or discharge, as well as to notify the state Ombudsman office. This deficiency was identified for two residents who were hospitalized. Resident 78 was admitted to the facility and later transported to the hospital on two occasions. The facility did not provide Resident 78 or their family with any paperwork regarding their discharge rights or information about holding the bed. The medical records lacked discharge or transfer notices for both hospitalizations, and the insurance plan notification was submitted late. Similarly, Resident 14 was transferred to the hospital due to a medical condition but did not receive a notice of discharge/transfer. The facility's staff, including the Social Services Director and nursing staff, were unclear about who was responsible for completing the discharge/transfer notices for residents who were hospitalized. This lack of a clear system for providing required notices placed residents at risk for inappropriate transfers and a lack of information regarding their rights and options.
Failure to Provide Bed-Hold Notice During Hospital Transfers
Penalty
Summary
The facility failed to provide a written bed-hold notice to a resident or their representative at the time of transfer to the hospital or within 24 hours of the transfer, as required by their policy. This deficiency was identified for one resident who was reviewed for hospitalization. The facility's policy mandates that residents or their representatives be informed in writing about the bed-hold and return policy prior to transfers and therapeutic leaves, and a second written notice should be provided at the time of transfer or within 24 hours in cases of emergency transfer. However, the review of the resident's progress notes and clinical records showed no evidence of a bed-hold notice being provided during two separate hospital transfers. Resident 78, who had no cognitive impairment, was admitted to the facility and later transferred to the hospital on two occasions. During these transfers, neither the resident nor their family member received or signed any paperwork regarding the bed-hold policy. Interviews with the resident, their family member, and the facility's administrator confirmed that the bed-hold notice was not provided as required. The administrator indicated that the admission director is responsible for obtaining bed holds, and if unavailable, the nurse should complete the process and send it with the resident to the hospital.
Failure to Complete and Document PASRR Evaluations
Penalty
Summary
The facility failed to ensure the completion of the Pre-admission Screening and Resident Review (PASRR) process for two residents, which is a federal requirement to ensure individuals with mental disorders or intellectual disabilities receive appropriate care. Resident 74, who was admitted with diagnoses including anxiety, depression, PTSD, and substance abuse disorder, had a Level I PASRR indicating the need for a Level II assessment. However, the facility did not have documentation of a Level II assessment or follow-up, despite a progress note from August indicating the PASRR was under review. Similarly, Resident 43, admitted with type 2 diabetes, chronic kidney disease, and bipolar disorder, required a Level II PASRR evaluation. Although the evaluation was completed before admission, it was not documented in the resident's medical record until after the surveyor's inquiry. Additionally, Resident 43's care plan did not reflect any updates based on the PASRR Level II evaluation, indicating a lack of integration of the assessment into the resident's care plan.
Deficiency in Care Plan Implementation and Documentation
Penalty
Summary
The facility failed to implement, review, and revise care plans for a resident diagnosed with Multiple Sclerosis, who was at risk for loss of range of motion (ROM) due to impaired mobility and weakness. The care plan, last revised in July 2023, included interventions for active ROM exercises for the resident's lower extremities. However, staff interviews revealed that the resident was not on a restorative program, and there was no documentation of ROM exercises being performed. Staff members were unaware of the exercise instructions, and the resident expressed interest in doing ROM exercises but was unsure if they were being done. Additionally, the care plan indicated the use of a bed cradle to prevent the blanket from touching the resident's feet, but observations showed that the bed cradle was not in use. Staff interviews revealed a lack of awareness about the bed cradle's purpose and the resident's refusal to use it. The bed cradle was stored in the resident's bathroom, and the unit manager was not informed of the resident's refusal to use it. The facility's Director of Nursing Services stated that unit managers are responsible for updating care plans, which are usually done quarterly unless there are changes. However, the lack of documentation and communication regarding the resident's care plan and interventions, such as ROM exercises and the use of a bed cradle, contributed to the deficiency identified by the surveyors.
Failure to Provide Adequate Bathing Care for Residents
Penalty
Summary
The facility failed to provide necessary activities of daily living care and services for two residents, specifically in the area of bathing. Resident 5, who was admitted to the facility with no cognitive impairment and required substantial assistance with bathing, reported issues with the bathing process. They experienced discomfort due to the use of the same soapy water for washing and rinsing, leading to itchiness. Additionally, Resident 5 mentioned instances where they refused to bathe due to fatigue and subsequently went without a bath for a week. Documentation showed that Resident 5 was bathed five times in 30 days, with three refusals noted. Staff X, an LPN/RCM, was unaware of the refusals and did not re-offer bathing on subsequent days. Resident 54, also with no cognitive impairment, expressed dissatisfaction with the timing of their baths, stating that staff did not inform them in advance, leading to refusals due to inconvenient timing. The documentation indicated that Resident 54 wanted to be bathed twice a week but had four refusals recorded. Staff X was unable to provide information regarding the refusals or lack of documented bathing for Resident 54. These deficiencies in bathing care were identified as a failure to adhere to the residents' care plans, potentially impacting their hygiene and quality of life.
Latest citations in Washington
Inaccurate PASARR screening affected two residents. One resident with vascular dementia, depression, and adjustment disorder had a PASARR level one that did not reflect mental health diagnoses, and staff stated it was inaccurate. Another resident with PTSD had a PASARR level one that did not include the PTSD diagnosis, with no additional PASARR level one or level two found in the EHR; staff stated the screening was not accurate and should have been repeated.
Undated open meds were found on 2 medication carts, including an open insulin vial and multiple open eye drop bottles with no dates. An LPN and an RN both stated the items should have been dated when opened, and the DON stated open multidose vials or bottles found without a date should be discarded immediately.
A resident with respiratory failure, HTN, and anxiety became SOB and diaphoretic, received a breathing tx, and was sent by EMS to the hospital. The facility could not locate the required SNF/NF to Hospital Transfer form or other transfer records showing what information was communicated to the receiving provider.
Care plans for two residents were not updated to match their current status and care needs. One resident had PTSD and generalized anxiety disorder and was receiving a psychotropic medication, but the care plan listed monitoring for antipsychotic and anticonvulsant meds that were not prescribed and did not include the anxiety diagnosis or related behaviors and interventions. Another resident had new upper and lower dentures, but the oral/dental care plan only noted edentulous status and difficulty chewing, with no mention of dentures or denture-related interventions.
Failure to Provide Individualized Activities: A resident with anxiety, depression, and weakness was cognitively intact but said they could not attend group activities because of leg problems and wanted more in-room activities. The resident mostly stayed in bed watching TV, and staff documentation showed only limited room visits with no consistent activity documentation despite a care plan goal for participation two to three times per week.
Failure to maintain heel offloading for a resident with a reopened DFU. A resident with dementia and dependence for mobility had a left heel wound that had healed and then reopened; the wound care provider recommended heel floating and pressure relieving boots at all times, but observations showed the resident in bed with heels on the mattress and later reclined in a wheelchair with the heel resting on the footrest strap and no boots in place. Staff stated the resident had not refused the boots or heel floating, and the care plan was not updated after the wound reopened.
Failure to Address Hearing and Vision Services for a Resident: A resident with dementia, bilateral hearing loss, and impaired vision was observed without eyeglasses or a hearing device, despite records showing admission with eyeglasses and a personal sound amplifier. The care plan addressed vision only and did not include hearing-related interventions, while staff interviews confirmed the resident’s hearing was strained and that the resident’s device use and vision needs were not fully reflected in the plan of care.
Respiratory care was not provided consistently for two residents receiving O2. One resident with COPD and chronic respiratory failure had an O2 order missing the indication for use and Sats parameters, no MAR documentation of O2 therapy, and inconsistent Sats charting. Another resident with respiratory failure was observed on continuous O2 via NC, but provider orders for O2 therapy and tubing changes were not present after readmission, despite the care plan stating the resident was dependent on O2.
A resident with dementia, hearing loss, and missing lower teeth had an MDS showing obvious or likely cavities or broken natural teeth, and the care plan identified oral/dental health problems with an intervention to coordinate dental care and transportation. Staff stated the resident’s dental needs were captured on the MDS, but no referral was made for dental services or follow-up with the dentist, and the DON said the lack of referral did not meet expectations.
Inaccurate Meal Intake Documentation: A resident with DM, dysphagia, and protein-calorie malnutrition was observed eating less than 25% of a meal, but the POC documented 76-100% intake. The CNA said the resident usually ate only 25-50% of meals and that intake was sometimes documented based on what a coworker reported. The LPN/RCM and DON stated meal intake should be documented accurately.
Inaccurate PASARR Screening for Two Residents
Penalty
Summary
The facility failed to ensure that two residents were screened for additional mental health supports through the PASARR process. Resident 97 was admitted with diagnoses including vascular dementia, depression, and adjustment disorder, and was able to make needs known. Review of the PASARR level one dated 04/10/2026 showed no mental health diagnoses and no need for a PASARR level two, even though the resident’s record included mental health diagnoses. During interview, the Regional Social Services staff and the Administrator stated the PASARR was inaccurate, needed modifications, and did not meet expectations. Resident 6 was admitted with diagnoses including heart failure, respiratory failure, and PTSD, and was able to make needs known. Review of the PASARR level one dated 03/30/2026 showed no serious mental illness indicators marked and no PASARR level two indicated, and the EHR contained no other documented PASARR level one or level two. The Social Services Director stated the hospital-provided PASARR was reviewed for accuracy and, if inaccurate, another level one would be completed, and stated this resident’s PASARR did not include PTSD and should have had another level one completed. The Administrator also stated the PASARR was not accurate and another level one needed to be conducted, but none could be located in the EHR.
Undated Open Medications on Medication Carts
Penalty
Summary
The facility failed to ensure proper storage and labeling of medications for 2 of 3 sampled medication carts reviewed for medication storage and labeling, including carts on the 400 and 500 halls. On the 500 hall medication cart, an open vial of insulin and an open bottle of eye drops were observed with no dates. During interview, an LPN stated that when an insulin vial or bottle of eye drops is opened, it should be dated immediately and said both items should have been dated upon opening; the LPN stated they would dispose of the undated vial and bottle. On the 400 hall medication cart, two open bottles of eye drops were observed with no dates. During interview, an RN stated both bottles should have been dated as soon as they were opened and said they would get new eye drops and dispose of the undated bottles. The DNS/RN stated that if an eye drop was opened it should have been dated immediately and that any open multidose vial or bottle found without a date should be discarded immediately.
Missing Hospital Transfer Documentation
Penalty
Summary
The facility failed to ensure hospital transfer documentation was completed for one resident who was transferred to the hospital after complaining of not being able to breathe and appearing diaphoretic. The resident had diagnoses of respiratory failure, high blood pressure, and anxiety disorder, and was able to make needs known. A breathing treatment was provided, and the provider agreed to send the resident out for further evaluation, after which emergency transportation took the resident to the hospital. Record review found no documentation showing what information was provided or communicated to the receiving facility for the transfer. Staff stated that transfer documentation should have included a SNF/NF to Hospital Transfer form, the resident's face sheet, and the medication and treatment administration records, but they were unable to locate documentation showing these items were completed or sent for the resident's hospital transfer.
Care plans did not reflect current diagnoses, medications, or denture status
Penalty
Summary
The facility failed to ensure that care plans were revised and accurately reflected residents’ current status and care needs for 2 of 21 sampled residents. Resident 6 was admitted with diagnoses including heart failure, respiratory failure, and PTSD, and was able to make needs known. The EHR showed Resident 6 also had generalized anxiety disorder and was receiving a psychotropic medication, but the current care plan dated 05/05/2026 documented monitoring for side effects of antipsychotic and anticonvulsant medications even though Resident 6 was not prescribed those medications. The care plan also identified PTSD but did not include generalized anxiety disorder or behaviors to monitor and interventions related to PTSD or anxiety disorder. Staff F, LPN/CC, stated the care plan did not accurately reflect the resident’s current status or prescribed medications, and Staff B, DNS, stated it did not meet expectations because it did not address the anxiety disorder or target behaviors and interventions. Resident 71 was admitted with diagnoses including PTSD, high blood pressure, and depression and was able to make needs known. Observation on 05/06/2026 showed a denture cup by the sink with the resident’s name on the lid and new upper and lower dentures dated 01/12/26. The resident stated the lower dentures did not fit well and that denture adhesive had been provided, but the dentures still did not fit right and the resident had not told staff yet. The focused oral/dental care plan, initiated on 06/23/2026, identified the resident as edentulous and having difficulty chewing, but did not show that the resident had dentures or include interventions related to denture use or maintenance. Staff E, CNA, stated they had not seen the resident wear dentures and were unaware of the new dentures, Staff C, LPN/CC, stated the care plan should have been updated when the dentures were obtained, and Staff B, DNS, stated the care plan should have reflected the dentures and interventions.
Failure to Provide Individualized Activities
Penalty
Summary
The facility failed to provide individualized activities for Resident 5, who was admitted with diagnoses including anxiety disorder, depression, and weakness. The admission MDS dated 01/14/2026 showed the resident was cognitively intact. During interviews on 05/03/2026 and 05/06/2026, Resident 5 stated they could not attend in-person activities because of their legs, wanted more activities to occupy them, mostly stayed in bed watching TV, and did not remember the last time activities staff visited to offer activities. The resident also stated activities staff would need to offer something they were able to do because they had difficulty doing some activities. The activities care plan dated 12/26/2026 showed a goal for Resident 5 to participate in activities two to three times per week. Progress notes documented one visit on 12/22/2026 to provide a welcome packet and encourage participation in daily activities, but no further activity documentation was found in the progress notes. Staff H stated room visits should include puzzles, arts and crafts, visiting, and chatting, and that documentation was placed in tasks, but the task record showed no documentation of activities for the past 30 days. Staff J stated paper documentation existed for room visits and that Resident 5 was on a list for room visits every Monday and Wednesday, while the room visit documentation showed only four visits on 01/26/2026, 02/06/2026, 03/10/2026, and 04/08/2026.
Failure to Maintain Heel Offloading for Reopened DFU
Penalty
Summary
The facility failed to consistently implement pressure reducing strategies for a resident with a left heel diabetic foot ulcer that had reopened. The resident was admitted with diagnoses including left hip fracture with surgical repair, a blood clot of the left lower leg, and dementia, and was dependent on staff for mobility and unable to make needs known. The baseline care plan and care plan both included heel offloading interventions, and the wound care provider initially recommended heel floating with pillows or wedge and pressure relieving boots. The wound later resolved, but a weekly skin assessment documented that the left heel wound reopened and was very painful to touch. After the wound reopened, the contracted wound care provider documented that the DFU to the left heel had reopened and recommended the resident wear pressure relieving boots at all times. The current care plan reviewed after the wound reopened did not include new interventions related to the reopened wound. Observations showed the resident seated in a reclined wheelchair with the left foot/heel resting on the footrest strap and no pressure relieving boots in place, and later lying in bed with both heels directly on the mattress without being floated and without boots. Staff interviews indicated the resident had not refused the boots or heel floating, and the LPN/CC and DON stated the resident should have been assessed and the plan of care updated when the wound reopened.
Failure to Address Resident Hearing and Vision Needs
Penalty
Summary
The facility failed to address one resident’s hearing and vision needs. Resident 112 was admitted with diagnoses including a leg fracture, dementia, and hearing loss in both ears, and was able to make needs known. The record showed the resident lost their glasses and was given readers, but the resident did not wear them because they were concerned that wearing glasses that were not their prescription would further degrade their vision. Observation did not show glasses in the resident’s room, and the resident stated they did not use a hearing aid. The resident was observed to be hard of hearing, requiring an elevated voice and repeated questions to understand. The admission MDS dated [DATE] documented adequate hearing with hearing aid and adequate vision with corrective lenses, while the significant change MDS dated [DATE] documented moderate difficulty hearing without a hearing aid and impaired vision without corrective lenses. The care plan initiated 02/24/2026 addressed impaired vision with interventions to arrange consultation with eye care practitioners as needed and remind the resident to wear glasses, but it did not include a focus area or interventions for hearing loss or use of hearing aids. A resident clothing list showed the resident admitted with one pair of eyeglasses and one Super Ear headset personal sound amplifier, yet observation and interview showed the resident in bed without eyeglasses or a hearing device, with the amplifier stored in the bedside table drawer. Staff interviews confirmed the resident’s hearing was strained, that the hearing device and glasses were not being used, and that the resident’s hearing device use should have been included in the plan of care and the resident should have been referred for eye care assessment.
Respiratory Care Orders and Documentation Not Maintained
Penalty
Summary
The facility failed to provide respiratory care consistent with professional standards of practice for two residents receiving oxygen therapy. One resident with COPD and chronic respiratory failure with hypoxia was observed multiple times lying in bed receiving oxygen at 2 L via nasal cannula. The resident’s oxygen order, dated 02/15/2026, allowed 1 to 4 L per minute continuously via nasal cannula, but it did not include an indication for use or oxygen saturation parameters. The April and May 2026 MARs did not show documentation of oxygen therapy being provided, and the TARs showed only an order to change oxygen tubing if damaged or visibly soiled, not an order for oxygen therapy. Oxygen saturations were not documented consistently daily from 04/01/2026 through 05/04/2026. A second resident with respiratory failure, high blood pressure, and anxiety disorder was observed in the room receiving oxygen at 6 L via nasal cannula on multiple occasions. The resident stated they needed oxygen therapy to breathe, and the care plan identified the resident as dependent on oxygen and to receive oxygen per provider orders. However, provider orders reviewed on 05/04/2026 showed no orders for oxygen therapy or for changing oxygen tubing. Staff stated the oxygen and tubing-change orders had been discontinued when the resident went to the hospital and were not added back to the MAR or TAR when the resident readmitted to the facility.
Failure to Refer Resident With Identified Dental Needs
Penalty
Summary
The facility failed to ensure that Resident 112 received needed dental care. Resident 112 was admitted with diagnoses including a leg fracture, dementia, and hearing loss in both ears. Observation on 05/03/2026 showed the resident had missing lower teeth. The admission MDS, dated [DATE], documented obvious or likely cavities or broken natural teeth, and the care plan dated 02/24/2026 identified oral/dental health problems related to likely cavities or broken teeth with an intervention to coordinate dental care and provide transportation. During interviews, Staff G, Regional Social Services, stated Resident 112's dental needs were captured on the 02/24/2026 MDS and the resident was not referred for dental services. Staff M, Social Services Director, stated residents with dental needs should be referred to social services to be scheduled for assessment by a dental care practitioner, and that Resident 112 should have been referred after the MDS assessment. Staff B, DON, stated residents with identified dental needs should be referred for follow-up with a dentist and that Resident 112 should have been referred to the in-house dental provider; Staff B stated the lack of referral did not meet expectations.
Inaccurate Meal Intake Documentation
Penalty
Summary
The facility failed to accurately document the amount of food eaten for Resident 13, who was admitted with diagnoses including diabetes mellitus, dysphagia, and protein-calorie malnutrition. The quarterly MDS dated 02/12/2026 showed the resident was moderately cognitively impaired. During observation on 05/05/2026 at 12:09 PM, a meal tray was delivered to the resident’s room, set up on a bedside table, and the resident was observed eating slowly, eating less than 25% of the meal, then laying back in bed and closing their eyes while the tray remained in the room. Staff later removed the tray, but the POC documentation for lunch on 05/05/2026 recorded that Resident 13 ate 76-100% of the meal. During interview, the CNA stated the resident typically ate 25-50% of meals and never ate all of the food, and that if they did not pick up a tray they would ask a coworker what the resident ate before documenting it. The CNA stated they were told the resident ate 75-100% of lunch, so that is what was entered. The LPN/RCM stated staff should document meal intake accurately in POC, and the RN/DNS stated it was their expectation that all staff document meal intake accurately.
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