Aurora Valley Care
Inspection history, citations, penalties and survey trends for this long-term care facility in Spokane, Washington.
- Location
- 414 S University Rd, Spokane, Washington 99206
- CMS Provider Number
- 505114
- Inspections on file
- 53
- Latest survey
- April 1, 2026
- Citations (last 12 mo.)
- 47
Citation history
Health deficiencies cited at Aurora Valley Care during CMS and state inspections, most recent first.
The facility failed to maintain clean and sanitary resident rooms and shared bathrooms, resulting in dirty, sticky, and debris-covered floors, dried urine and foul odors in shared bathrooms, and damaged flooring in resident rooms. A nonverbal resident with a leg fracture had a persistently sticky and dirty floor despite concerns raised by a collateral support person, while two cognitively intact residents reported chronically dirty, urine-stained, and malodorous shared bathrooms and damaged, dirty room floors. Observations confirmed extensive dried urine, dirt, hair, and debris under bariatric commodes, foul odors extending into rooms, peeling duct tape over a floor hole, and cracked flooring embedded with dirt. Staff reported confusion between housekeeping and nursing regarding responsibility for cleaning urine spills, and the Administrator stated an expectation that rooms and bathrooms be cleaned at least daily or as needed.
A resident admitted with a repaired mid-spine fracture, ankylosing spondylitis, and chronic respiratory failure reported that provider-ordered medications were not available for several days after admission. Review of the MAR showed multiple missed doses of enoxaparin, mirtazapine, cyclobenzaprine, pregabalin, sildenafil, and a Butrans patch. The DON reported the facility was using a new pharmacy and was unsure why the medications were missed, while stating the expectation that resident-specific medications be available for administration on the day of admission.
A resident who required extensive assistance with toileting was found in a urine-soaked bed after returning from the emergency room. The resident did not use the call light for help, and a Nursing Assistant did not provide care, assuming no assistance was needed. The LPN responsible did not ensure the resident's needs were met, and the Director of Nursing stated that residents should be checked every two hours.
A resident with right-sided hemiplegia and hemiparesis required assistance with eating, particularly when in bed, due to severe osteoarthritis and a torn rotator cuff. Despite this, the care plan inaccurately stated they could eat independently, leading to inadequate care. Staff communication about the resident's needs was not documented in the care plan, resulting in a lack of guidance for proper care.
A resident with a history of anxiety, mild dementia, and stroke was identified with moderate depression symptoms, but the facility failed to seek timely mental health services. The resident exhibited refusals of care, including medication and repositioning, leading to deteriorating health and worsening wounds. Despite an order for a behavioral health evaluation, the facility did not follow through, and staff were unaware of the need for such an evaluation. The resident's family expressed concerns about the decline, resulting in a hospital evaluation request.
A resident with ill-fitting dentures causing an open sore did not receive timely follow-up for necessary dental services. Despite a dental exam indicating the need for a denture adjustment, no further action was documented. Staff interviews confirmed the lack of follow-up, and the resident was later discharged to the hospital.
The facility failed to address substance use disorders in the care plans of two residents, leading to potential accident hazards. One resident was hospitalized after being found intoxicated following a fall, while another resident with opioid dependence had no safety interventions in place. The administrator acknowledged the need for care planning and monitoring, but this was not implemented.
A resident with Wernicke's Encephalopathy and adult failure to thrive was neglected in terms of incontinence and hygiene care, leading to their removal from the facility AMA. Family members repeatedly found the resident in unsanitary conditions, but staff failed to document or address these concerns adequately. The facility's management was unaware of the situation, highlighting a communication breakdown.
A facility failed to report allegations of potential neglect to the State Agency. A resident left the facility AMA after their family raised concerns about neglect, including the resident being undressed and having urine everywhere. Despite being aware of these concerns, the Social Services Director and Resident Care Manager did not report them to the Administrator or the State Agency, and no report was submitted.
During a COVID-19 outbreak, the facility failed to follow quarantine and isolation precautions, affecting several residents and involving improper PPE use by a staff member. Residents with COVID-19 had open doors against CDC guidelines, and a staff member did not wear the required PPE in a quarantine room. Interviews revealed a lack of documentation and communication regarding precautions.
A resident with end-stage renal disease, diabetes, and seizures experienced vomiting and missed seizure medication doses, but the medical provider was not notified. Staff interviews revealed a lack of communication and documentation regarding the resident's condition changes, leading to a seizure and hospital transport.
The facility failed to implement effective discharge planning for three residents, resulting in unsafe discharges and unmet care needs. One resident was discharged without proper documentation of their urinary status, another left AMA multiple times due to inadequate monitoring of behaviors, and a third resident discharged AMA without proper education on risks. The facility's discharge planning process was insufficient, leading to these deficiencies.
The facility failed to adequately address the risks of elopement and substance use for residents with substance use disorders. A resident with severe cognitive impairment and a history of substance abuse frequently left the facility without staff knowledge and was found with drug paraphernalia. Another resident, initially unresponsive, had an incomplete care plan that did not address elopement or substance use risks. A third resident, with moderate cognitive impairment and alcohol abuse history, had a care plan that failed to address substance use disorder. Staff were unsure of processes for dealing with substance use emergencies.
A resident with an indwelling urinary catheter due to acute urinary retention was not properly assessed or managed by the facility. The facility failed to follow its policy requiring comprehensive assessment and medical justification for catheter use. Despite hospital orders for continued catheter use and a urologist follow-up, the facility did not schedule the appointment and canceled the consult without proper documentation. Staff interviews revealed a lack of clarity and communication regarding catheter management, leading to the resident's discharge with the catheter still in place.
A resident experienced ongoing mouth pain due to the facility's failure to schedule a dental appointment for necessary extractions. Despite being cognitively intact and requesting the appointment, the resident's pain persisted, reaching severe levels. Staff responsible for scheduling acknowledged the oversight, and the DON confirmed the need for the appointment.
The facility failed to ensure timely physician visits for several residents, with gaps exceeding the required intervals. This deficiency was identified through interviews and record reviews, revealing that residents with various diagnoses, including depression, stroke, and diabetes, did not have documented physician visits within the mandated timeframes. The facility's recent switch to a new provider group contributed to the lack of proper tracking and documentation.
A LTC facility failed to administer medications as ordered for three residents, leading to significant medication errors. One resident missed multiple doses due to unavailability and dialysis scheduling conflicts. Another resident missed doses while at dialysis, and a third experienced a delay in receiving a post-surgery antibiotic due to communication issues with an oral surgeon's office.
The facility failed to ensure proper hand hygiene and PPE use during medication administration and wound care, and did not implement Enhanced Barrier Precautions for residents at risk of infection. A resident with MRSA was not placed on EBP, and another resident on EBP did not receive care in accordance with these precautions. Additionally, the facility's water management plan was outdated and inadequately maintained.
The facility failed to provide a dignified dining experience by not offering clothing protectors per residents' preferences, leading to food stains on their clothing. Despite residents being cognitively intact and expressing a preference for clothing protectors, the facility removed them to transition to a fine dining experience. Staff interviews confirmed that residents preferred the protectors, and their removal resulted in soiled clothing, contradicting the facility's policy on dignity.
The facility failed to obtain consent for psychotropic medications before administration for three residents, including one with moderate cognitive impairment and another who was severely cognitively impaired. Staff interviews confirmed that consents should be obtained before the first dose and when doses change, but this was not done for medications like Seroquel and Effexor.
The facility failed to issue a Skilled Nursing Facility Advance Beneficiary Notice (SNFABN) to two residents, one of whom received it 19 days late and another who did not receive it at all. This oversight was due to the Business Office Manager missing a resident and not following the established process, as acknowledged by the Executive Director.
The facility failed to maintain the privacy of residents' mail, as several residents reported receiving opened mail. A cognitively intact resident and others confirmed that their mail was opened before delivery. Staff interviews indicated that mail was sorted by a Business Office Manager, who was on leave during the investigation, leading to confusion about which mail was for residents. The Executive Director acknowledged the issue and confirmed that residents' mail should remain unopened.
A resident with diabetes and quadriplegia reported their cell phone stolen and had not received reimbursement, despite being told it was in process. The facility's logs showed no record of the missing phone, and the Executive Director admitted to not submitting the reimbursement request timely.
The facility failed to complete and implement PASARR for two residents. One resident, admitted with depression, did not receive recommended behavioral health services, and another was admitted without a PASARR completed prior to admission. These oversights risked the residents' mental health and quality of life.
The facility failed to follow care plan interventions for three residents, leading to unmet care needs and discomfort among others. A resident with paralysis was not assisted into a wheelchair as planned, with no documentation of attempts or refusals. Two residents with cognitive impairments engaged in public displays of affection and entered each other's rooms, contrary to their care plans, causing discomfort among other residents. Staff interviews revealed inconsistencies in following these care plans.
Two residents in an LTC facility were not provided with adequate assistance for activities of daily living. One resident, with multiple health issues, received insufficient showers and nutritional support, leading to weight loss and hygiene concerns. Another resident, with amputations and necrosis, reported receiving only one shower in 45 days, with no documentation of scheduled showers. Staff interviews revealed a lack of awareness and communication regarding care plans and resident needs.
A resident with severe cognitive impairment and physical limitations was not provided with activities that matched their interests, leading to social isolation. Despite expressing interest in various activities, the resident was mainly left to watch TV in their room, as staff failed to assist them in attending activities or provide reading materials.
The facility failed to implement a bowel management protocol for two residents, leading to extended periods without bowel movements. One resident, with cognitive impairment and a history of stroke, did not receive prescribed laxatives for six days. Another resident, on opioid medication, experienced multiple periods without bowel movements, with no documentation of offered or refused medications. Staff interviews revealed non-compliance with the protocol.
A resident, who was cognitively intact, informed staff of the need for a vision appointment, which was not scheduled. The resident experienced eye pain and required retinal surgery, but due to communication lapses, the necessary follow-up was not arranged. Staff responsible for appointments acknowledged the oversight, and the DON confirmed the process could have been improved.
A resident with obstructive uropathy was admitted with a urinary catheter, which was supposed to be removed for bladder training as per hospital orders. Despite the resident's cognitive ability to communicate and express discomfort, the catheter was not removed, leading to increased risk of infection. Facility staff confirmed the oversight.
A resident with bipolar disorder and substance abuse in remission missed a crucial behavioral health appointment due to the facility's failure to provide transportation. The appointment was essential for medication review, and the resident was unable to reschedule due to a no-show fee. The facility did not place the appointment on the calendar in time to arrange transportation, despite the resident notifying staff a week in advance.
A facility failed to maintain a medication error rate below five percent, resulting in a 9.38 percent error rate. Two residents received incorrect insulin administration due to staff not following proper procedures, such as cleaning the pen tip and priming the insulin pen. Additionally, one resident did not use their inhaler as documented. The Director of Nursing confirmed the errors.
The facility failed to properly store and handle medications, including controlled substances and expired medications, in two medication rooms and a cart. An insulin pen had conflicting expiration dates, and a refrigerator lock was not engaged, leaving Lorazepam unsecured. Expired medications and unlabeled tablets were found in a medication cart. Staff interviews revealed lapses in securing the emergency kit and removing expired medications.
The facility did not ensure the Dietary Manager had the necessary Food Service Manager certification, as revealed in interviews and record reviews. The Dietary Manager admitted to lacking the certification, and the RD was only part-time. The Executive Director and DON acknowledged these issues, which did not meet regulatory requirements, potentially affecting the nutritional services provided to residents.
The facility failed to provide meals at a safe and appetizing temperature, affecting several residents. Issues included cold food due to a broken plate warmer, lack of fresh fruits and vegetables, and limited meal substitutions. Residents with various medical conditions expressed dissatisfaction with the dining experience. Staff interviews revealed challenges in obtaining necessary ingredients and concerns about reheating food due to cross-contamination.
A resident with end-stage renal disease, diabetes, and heart disease did not receive evening meals on days they returned late from dialysis appointments. Despite requests, the facility failed to hold meals, providing only a sack lunch during appointments. Staff interviews revealed a lack of communication and adherence to meal-holding procedures, risking the resident's nutritional health.
A resident under hospice care did not receive bathing services for over seven weeks due to a scheduling error and lack of communication between the facility and hospice provider. The resident, who required maximum assistance with personal hygiene, was mistakenly removed from the hospice's bath aide schedule. Facility staff believed hospice was providing the baths, but records confirmed the last bath was given over seven weeks prior. The facility's leadership acknowledged the oversight.
The facility failed to ensure a safe discharge for a resident who left AMA without notifying APS, despite safety concerns involving the resident's spouse. Another resident experienced delays in discharge planning, despite expressing a desire to move to another state. Staff interviews revealed lapses in following discharge procedures and timely planning.
A resident in an LTC facility experienced verbal abuse and psychosocial harm due to a roommate's aggressive behavior. Despite being aware of the situation, staff delayed moving the resident to a different room, leading to the resident feeling unsafe and discharging against medical advice. The roommate, with a history of stroke and dementia, exhibited frequent verbally aggressive behaviors, which were not adequately addressed by the facility.
A resident with severe cognitive impairment experienced multiple falls due to the facility's failure to implement and document effective fall prevention strategies. Despite being at high risk, the facility did not consistently revise care plans or add new interventions after falls, leading to repeated incidents. Staff interviews indicated awareness of the need for prompt intervention, but actions did not reflect this understanding.
A resident with PTSD and a history of domestic violence was admitted to a facility without a proper trauma-informed care plan. The care plan lacked specific interventions to address the resident's trauma history, and the resident was placed with a verbally aggressive roommate, leading to a distressing incident. Staff interviews revealed a lack of awareness and documentation of the resident's trauma history and potential triggers.
A facility failed to implement a person-centered care plan for a resident with dementia, leading to increased agitation and combativeness. Despite the resident's history of stroke and dementia, the care plan lacked individualized non-pharmacological interventions. Staff interviews revealed frequent verbal outbursts and the absence of effective behavioral interventions, with pain management not adjusted. The facility's inaction resulted in unmet needs and diminished quality of life for the resident.
The facility failed to report several incidents of potential abuse and misappropriation to the State Survey Agency. A resident with a history of verbal aggression verbally abused their roommate, and another resident with cognitive impairment physically aggressed towards their roommate. Additionally, a resident's missing wallet was not reported as potential misappropriation. These incidents were not documented or reported as required.
Two residents were discharged AMA without proper documentation or valid reasons. One resident, admitted for wound care and antibiotics, was discharged without completing treatment, and their PICC line was removed without a provider order. Another resident, with a history of stroke and overdose, left during an outing and did not return. The facility failed to document the AMA process or send medications with the residents.
The facility failed to consistently monitor a resident's tolerance to dialysis treatments and collaborate with the dialysis center. The resident, who had end-stage renal disease, had significant gaps in the documentation of dialysis communication forms, vital signs, and weights from February to April 2024. The Director of Nursing confirmed that the required dialysis physician orders were only sporadically present, making it difficult to determine if the resident was being adequately monitored.
The facility failed to ensure accurate submission of direct care staffing information to CMS for Q3 2023. The Human Resources Manager did not include agency staff and incorrectly calculated nurse hours, leading to reported staffing levels lower than required. The Administrator, in training at the time, was unsure if the data was reviewed before submission.
The facility failed to timely assess fall risk and implement safety interventions for two residents, leading to repeated falls without appropriate preventive measures. Staff interviews revealed missing information on required assistance levels and delayed initiation of fall care plans.
Failure to Maintain Clean and Sanitary Resident Rooms and Shared Bathrooms
Penalty
Summary
The facility failed to maintain a clean and sanitary, safe, and comfortable environment for multiple residents, resulting in dirty and malodorous resident rooms and shared bathrooms. One resident with a developmental disability and nonverbal status was observed to have a room with a sticky floor, black scuff marks, droplets of a clear red liquid, and scattered paper towel pieces, hair, and dust, after a collateral contact reported that the resident’s floor had been sticky and dirty on an almost daily basis despite notifying nursing staff. The resident’s electronic medical record showed they had been admitted after a right upper leg fracture and required support from a collateral contact due to being nonverbal. Two cognitively intact residents reported that their shared bathrooms were often dirty with dried urine and foul odors, and that their room floors were damaged and dirty. Observations confirmed that the shared bathrooms contained bariatric commodes covering the toilets, with dried yellow urine, dirt, hair, and other debris extending from wall to wall under and around the toilets, along with a strong foul odor that extended into the residents’ rooms. One resident’s room had a floor hole patched with duct tape that was peeling and dirty, and another resident’s room had cracked flooring with dirt embedded in the cracks, along with scuff marks and general debris on the floors. Nursing assistants reported that the housekeeping supervisor had been sick and that there was a language barrier with some housekeeping staff, leading to a misunderstanding about whether housekeeping or nursing staff were responsible for cleaning urine spills in the bathrooms, while the Administrator stated the expectation that resident rooms and bathrooms be cleaned at least daily or as needed to maintain a sanitary environment.
Missed Ordered Medications Due to Unavailable Pharmacy Services
Penalty
Summary
The facility failed to provide pharmaceutical services to meet the needs of a resident by not ensuring ordered medications were available and administered as prescribed. The resident, who was cognitively intact, had been admitted with diagnoses including surgical repair of a mid-spine fracture, ankylosing spondylitis, and chronic respiratory failure. In a telephone interview, the resident reported that provider-ordered medications were not available for several days after admission. Review of the resident’s electronic medical record and MAR showed multiple missed doses of several medications during the admission period. Record review on specific dates in February showed missed doses of enoxaparin on two evenings, mirtazapine on one evening, cyclobenzaprine on one evening and the following morning, pregabalin on one evening and the following morning, and sildenafil at multiple scheduled times over two days. Additionally, a Butrans patch ordered for pain control was missed at a scheduled noon administration later in the month. In an interview, the DON stated the facility had a new pharmacy and that they were unsure why the resident’s medications were missed when the resident first admitted, and further stated the expectation that resident-specific, provider-ordered medications should be available for administration the same day of admission.
Failure to Assist Resident with Toileting Needs
Penalty
Summary
The facility failed to provide necessary care and services to a dependent resident who required assistance with toileting. Resident 1, who was cognitively intact and required extensive assistance for bathroom use, was found by Staff C, an LPN, lying in a urine-soaked bed and clothing. This occurred after the resident returned from the emergency room and was transferred back into bed with a transfer sheet still under them. The resident did not use their call light to request assistance during the night shift, and Staff E, a Nursing Assistant, did not provide any care, assuming the resident did not need help. The facility investigation revealed that Staff D, another LPN assigned to the resident, was not interviewed or followed up with regarding the incident. Staff D's medication administration record showed a code indicating that tasks were not completed. Interviews with the resident and staff indicated that the resident typically received assistance before midnight and in the early morning but did not on this occasion. The Director of Nursing stated that residents should be checked every two hours during the night, and it was the responsibility of the night shift nurse to ensure all ADL tasks were completed by the nursing assistant.
Failure to Update Care Plan for Resident's Eating Assistance Needs
Penalty
Summary
The facility failed to revise and implement a comprehensive care plan for a resident who had specific needs related to their ability to eat. The resident, who was admitted with right-sided hemiplegia and hemiparesis following a stroke, malnutrition, and wounds on their left foot, was documented in the care plan as being able to eat independently. However, progress notes from nursing staff indicated that the resident required assistance with eating, particularly when in bed, due to their inability to raise their left arm high enough and lower their head without pain. This discrepancy between the care plan and the resident's actual needs placed the resident at risk of receiving inappropriate and inadequate care. Interviews with staff revealed that the occupational therapist had verbally communicated the resident's need for assistance when eating in bed to the Resident Care Manager, but this information was not documented in the resident's care plan. Additionally, the care plan did not include the resident's diagnoses of severe osteoarthritis and a torn rotator cuff in the left shoulder, which contributed to their difficulty in feeding themselves while in bed. The lack of updated and accurate information in the care plan failed to provide staff with the necessary guidance to meet the resident's individualized needs and preferences.
Failure to Address Behavioral Health Needs
Penalty
Summary
The facility failed to meet the behavioral health needs of a resident who was identified as having symptoms of moderate depression. Despite a depression screening indicating moderately severe depression symptoms, the facility did not seek mental health services in a timely manner. The resident's medical record showed a history of anxiety, mild dementia, and a stroke, with additional diagnoses including malnutrition and osteomyelitis. The resident exhibited refusals of care, including medication and repositioning, which were documented in nursing progress notes. These refusals were not addressed with person-centered interventions by the interdisciplinary team. The resident's condition deteriorated, with documented weight loss, poor food intake, and worsening wounds. Despite an order for a behavioral health evaluation due to labile behaviors, the facility did not follow through with the evaluation or referral. The resident's care plan was updated to reflect resistive behaviors but lacked interventions for the diagnosed mild dementia, positive depression screen, or the ordered mental health evaluation. Interviews with staff revealed a lack of awareness and communication regarding the need for a behavioral health evaluation. The resident's family expressed concerns about the resident's physical and mental decline, leading to a request for hospital evaluation. The facility's failure to address the resident's behavioral health needs and implement appropriate interventions contributed to the resident's declining condition and quality of life. The lack of timely mental health services and communication among staff and with the resident's family were significant factors in the deficiency.
Failure to Follow Up on Dental Services for Resident
Penalty
Summary
The facility failed to follow up on necessary dental services for a resident who had ill-fitting dentures causing an open sore. The resident, who was admitted with conditions including right-sided weakness and paralysis after a stroke, severe malnutrition, dysphagia, and chronic ulcers, complained of mouth pain and refused to remove their upper denture. A dental appointment was initially scheduled but was canceled and rescheduled. A dental exam revealed an open sore and the need for a denture adjustment, but no further documentation was found regarding the adjustment or monitoring of the sore. Interviews with staff revealed that a request for a denturist appointment was made, but there was no follow-up on the request. The Director of Nursing confirmed the lack of follow-up, and the Administrator acknowledged that the appointment was not pursued further. The resident was eventually discharged to the hospital, and the staff member responsible for the follow-up was no longer employed at the facility.
Failure to Address Substance Use Disorders in Resident Care Plans
Penalty
Summary
The facility failed to identify, evaluate, and implement safety interventions for residents with substance use disorders, leading to potential accident hazards. Resident 1 was admitted with a diagnosis of COVID-19 and an unspecified alcohol-induced disorder, yet their care plan did not include interventions for substance use disorder. This oversight resulted in an incident where Resident 1 was found intoxicated after a fall, with a blood alcohol level of 297 mg/dL, necessitating hospitalization for observation. Similarly, Resident 2, admitted with ankylosing spondylitis and opioid dependence, did not have a care plan addressing their substance use disorder. The facility did not identify or analyze risks associated with their condition, nor were any safety interventions implemented. During an interview, the facility's administrator acknowledged the need for care planning and monitoring for residents with substance use disorders, but this was not reflected in the care plans of the affected residents.
Neglect of Resident's Incontinence and Hygiene Needs
Penalty
Summary
The facility failed to protect a resident from neglect, specifically in addressing concerns related to incontinence and personal hygiene. The resident, who was admitted with diagnoses of Wernicke's Encephalopathy and adult failure to thrive, was found by family members to be frequently naked, wet with urine, and surrounded by urine-soaked bedding and floors. Despite these observations, the facility did not document or address these issues adequately, leading to the resident's removal from the facility against medical advice. Interviews with staff revealed that the concerns were known but not properly communicated or documented. Staff C, the Resident Care Manager, and Staff D, the Social Services Director, were aware of the family's complaints but failed to escalate the issue to the facility Administrator or discuss it in the Interdisciplinary Team meetings. Staff C admitted to witnessing the unsanitary conditions but did not create any documentation or implement effective interventions. The facility's lack of response to the family's repeated concerns and the absence of a documented care plan to address the resident's incontinence and hygiene needs contributed to the neglect. The Administrator was unaware of the situation until after the resident's removal, indicating a breakdown in communication and oversight within the facility's management structure.
Failure to Report Allegations of Neglect
Penalty
Summary
The facility failed to report allegations of potential neglect to the State Agency immediately as required, concerning a resident who left the facility Against Medical Advice (AMA). The resident's family had raised concerns during a care conference that the resident was always naked, not dressed, and had urine everywhere. Despite being aware of these concerns on several occasions, including during a care conference, the Social Services Director and the Resident Care Manager did not report the concerns to the Administrator or the State Agency. The Director of Nursing was informed, but no report was made to the State Agency. A record review confirmed that no report of possible neglect was submitted by the facility regarding the care of the resident.
Failure to Follow COVID-19 Precautions and PPE Protocols
Penalty
Summary
The facility failed to adhere to quarantine and isolation precautions during a COVID-19 outbreak, affecting four out of five residents and involving improper use of personal protective equipment (PPE) by one staff member. Observations revealed that residents with current COVID-19 infections had their room doors open, contrary to CDC guidelines that require doors to be closed if safe. Specifically, two residents with Aerosol Precaution signs had their doors wide open, with no documented safety reasons for this. Additionally, a staff member was observed in a quarantine room wearing only a surgical mask instead of the required N95 respirator, eye protection, gown, and gloves, while interacting with a resident who was not wearing any PPE. Interviews with staff members highlighted a lack of communication and documentation regarding quarantine precautions. A physical therapy assistant was unaware of the need for PPE when working with a resident in a quarantine room, and a registered nurse confirmed the absence of precaution orders in the electronic medical records for the involved residents. The facility's administrator and director of nursing acknowledged the need for closed doors for COVID-19 positive residents and confirmed that quarantine precautions should be documented in the residents' care plans and electronic health records.
Failure to Notify Medical Provider of Resident's Condition Change
Penalty
Summary
The facility failed to assess and respond to a change in condition for a resident, leading to a deficiency in quality of care. The resident, who had diagnoses of end-stage renal disease, diabetes, and seizures, was admitted to the facility and was on a medication regimen to prevent seizure activity. The resident tested positive for COVID-19 and experienced vomiting and a seizure, but the medical provider was not notified in a timely manner. Staff interviews revealed that the resident had vomited and missed doses of seizure medication, but this information was not communicated to the medical provider or documented in the provider medical book. Staff E, a Resident Care Manager, noted that they were unaware of the resident's vomiting and missed medication until after the resident had a seizure and was transported to the hospital. Staff D, another Resident Care Manager, also stated they were not informed of the resident's condition changes and missed medication doses. The Nurse Practitioner confirmed they were not notified of the resident's vomiting and missed medication, which should have prompted a notification to the medical provider. This lack of communication and documentation placed the resident at risk for medical complications and unmet care needs.
Inadequate Discharge Planning Leads to Unsafe Discharges
Penalty
Summary
The facility failed to implement an effective discharge planning process for three residents, leading to unsafe discharges and unmet care needs. Resident 4 was admitted with urinary retention and an indwelling catheter, requiring a urologist appointment for further management. Despite the resident's condition and the need for follow-up, the facility discharged Resident 4 without proper documentation of their urinary status or a provider order for discharge. Additionally, the resident's report of feeling feverish on the day of discharge was not communicated to the receiving facility. Resident 1, who had severe cognitive impairment and a history of substance abuse, left the facility against medical advice (AMA) multiple times. The facility failed to adequately monitor and manage the resident's behaviors, including drug use and elopement. The AMA discharge form was not properly completed, lacking the resident's signature and documentation of the risks associated with leaving the facility. Resident 5, who was cognitively intact and independent with activities of daily living, chose to discharge AMA due to boredom and restlessness. The facility did not document any discharge barriers or provide adequate education on the risks of leaving AMA. The AMA form was incomplete, missing information on potential complications and the facility's release from liability. The facility's failure to properly assess and document discharge needs and plans resulted in unsafe discharges for all three residents.
Failure to Address Substance Use and Elopement Risks
Penalty
Summary
The facility failed to identify, evaluate, and implement safety interventions for residents with substance use disorders, leading to potential risks of elopement and substance use within the facility. Resident 1, with severe cognitive impairment and a history of substance abuse, was admitted with a desire to leave the facility and exhibited exit-seeking behavior. Despite being identified as at risk for elopement, the baseline care plan did not address these risks adequately. Resident 1 frequently left the facility without staff knowledge, was found with drug paraphernalia, and exhibited signs of substance use, yet interventions were not effectively implemented to mitigate these risks. Resident 2, admitted with a history of psychoactive substance abuse and other medical conditions, was initially unresponsive and dependent on staff for activities of daily living. However, as Resident 2's condition improved, the care plan failed to address the risk of elopement or substance use within the facility. The assessments and care plans were incomplete, lacking critical information on substance use disorder and elopement risk, leaving Resident 2 vulnerable to potential hazards. Resident 3, with moderate cognitive impairment and a history of alcohol abuse, was identified as at risk for elopement and had a wanderguard bracelet placed. However, the care plan did not address the substance use disorder or the risk of substance use while in the facility. The facility's staff, including nursing assistants and social service directors, were unsure of the processes for dealing with substance use emergencies and were not adequately trained to recognize signs of substance use, contributing to the facility's failure to provide a safe environment for residents with substance use disorders.
Deficiency in Urinary Catheter Management
Penalty
Summary
The facility failed to accurately assess and manage the urinary status of a resident, identified as Resident 4, who was admitted with an indwelling urinary catheter due to acute urinary retention. The facility's policy required a comprehensive assessment and medical justification for the continued use of an indwelling catheter, which was not adequately followed. Resident 4's medical records showed inconsistencies in catheter care documentation, with omissions noted on specific dates, and a lack of a urinary toileting program attempt despite the resident's ability to perform most activities of daily living independently. Resident 4 was admitted to the facility with a history of urinary tract infections and acute cystitis, and had a urinary catheter placed in the hospital due to urinary retention. Despite the hospital's discharge orders for continued catheter use until a urologist could evaluate the situation, the facility did not ensure a follow-up appointment with a urologist was scheduled. Furthermore, the facility's nursing staff canceled the urologist consult without proper documentation or provider orders, and Resident 4 was discharged back to their previous living setting with the catheter still in place. Interviews with facility staff revealed a lack of clarity and communication regarding Resident 4's catheter management. Staff members were unable to locate provider orders for catheter discontinuation or urologist consultation, and there was no documentation of monitoring for urinary retention or routine catheter care. The Director of Nursing acknowledged the oversight in monitoring and follow-up, and the facility's failure to adhere to its own policies and procedures for catheter management and resident assessment.
Failure to Schedule Dental Appointment for Resident
Penalty
Summary
The facility failed to schedule a necessary dental appointment for a resident, identified as Resident 59, who was experiencing ongoing mouth pain. The resident was cognitively intact and capable of making decisions regarding their care, with a diagnosis that included cavities. A dental care plan dated January 2, 2024, indicated that Resident 59 had broken teeth and required nursing staff to coordinate dental care arrangements. A dental visit on May 15, 2024, documented that the resident requested to have all their teeth extracted due to pain, and several teeth were extracted during that visit. However, a referral for the extraction of the remaining teeth was not documented, nor was there any evidence that the remaining teeth had been extracted. Interviews with the resident and staff revealed that the resident had communicated their need for a dental appointment to have their teeth extracted, but the appointment was not scheduled. The resident reported severe pain, rating it a 10 on a scale of 1-10, and continued to experience significant discomfort. Staff J, responsible for making appointments and arranging transportation, acknowledged that the appointment request had been missed. Staff I and the Director of Nursing confirmed that an appointment should have been made for the resident, indicating a lapse in the facility's coordination of necessary dental services.
Failure to Ensure Timely Physician Visits
Penalty
Summary
The facility failed to ensure that physician visits were conducted every 30 days for the first three months after admission and then every 60 days as required for eight of the fourteen sampled residents. This deficiency was identified through interviews and record reviews, revealing that several residents did not have documented physician visits within the required timeframes. For instance, Resident 12, who was admitted with depression and stroke, had no physician visits documented in their Electronic Medical Record (EMR). Similarly, Resident 21, with diagnoses including diabetes and depression, had no physician visit notes during their five months in the facility. Other residents, such as Resident 15, Resident 24, and Resident 42, also experienced significant gaps between physician visits, exceeding the mandated intervals. The facility's Executive Director and Medical Records staff acknowledged the issue, noting that the facility had recently switched to a new provider group, which may have contributed to the lack of proper tracking and documentation of physician visits. The staff were unsure of the follow-up procedures if a resident was not seen, indicating a lapse in the system to ensure compliance with the required visit schedule.
Medication Administration Failures in LTC Facility
Penalty
Summary
The facility failed to ensure that residents received their medications as ordered, leading to significant medication errors for three residents. Resident 42, who had diagnoses including end-stage kidney disease, seizures, and diabetes, missed multiple doses of medications such as levetiracetam, Advair, erythromycin, and others due to unavailability or absence during dialysis appointments. The staff did not coordinate medication administration times with dialysis schedules, resulting in missed doses when the resident was out of the facility. Resident 36, also requiring dialysis, missed doses of several medications including acetaminophen, atorvastatin, apixaban, and others. These omissions occurred on days when the resident was at dialysis, and the facility did not send medications with the resident or adjust administration times to accommodate the dialysis schedule. This lack of coordination and planning led to repeated medication omissions. Resident 80, who had recently undergone oral surgery, experienced a delay in receiving an antibiotic prescribed to prevent infection. The facility did not obtain the medication until three days after the surgery due to communication issues with the oral surgeon's office. Staff failed to promptly secure the necessary orders and medication, which could have been addressed by contacting the facility's provider for immediate assistance.
Infection Control and Water Management Deficiencies
Penalty
Summary
The facility failed to ensure proper hand hygiene and use of personal protective equipment (PPE) during medication administration and wound care, as well as failed to implement Enhanced Barrier Precautions (EBP) for residents at risk of infection. During a medication pass observation, Staff F, an Infection Preventionist/Registered Nurse, did not perform hand hygiene or wear gloves while administering insulin to Resident 78, who required assistance with activities of daily living due to diabetes. This oversight was contrary to the facility's hand hygiene policy, which mandates handwashing before handling medications and after contact with a resident's skin. Resident 12, who was colonized with MRSA and had weeping leg wounds, was not placed on EBP, despite the risk of infection transmission. The resident expressed concerns about their MRSA status and the lack of precautions taken. Observations revealed that Resident 12's room lacked signage and PPE supplies necessary for EBP, and the resident's soiled stockings indicated inadequate infection control measures. Staff interviews confirmed that Resident 12 should have been on EBP due to their draining wounds, but this was not implemented. Resident 17, who had pressure sores and was on EBP, did not receive care in accordance with these precautions. Staff EE and Staff FF provided personal and wound care without wearing the required PPE, despite the presence of an EBP sign outside the resident's room. Staff interviews revealed a lack of awareness and understanding of EBP requirements, leading to non-compliance with infection control protocols. Additionally, the facility's water management plan was outdated and inadequately maintained, with missing test results and unclear procedures, further compromising resident safety.
Failure to Provide Dignified Dining Experience
Penalty
Summary
The facility failed to ensure a dignified dining experience for several residents by not providing clothing protectors according to their preferences. This deficiency was observed in four residents who were cognitively intact and had varying levels of assistance required for eating. The facility's policy on resident rights emphasized treating each resident with respect and dignity, which was not upheld in this instance. Resident 1, who required no assistance with eating, reported that the Executive Director removed all clothing protectors, leading to the use of bath towels instead. Resident 6, who needed setup/clean-up assistance, was observed with food stains on their clothing and expressed dissatisfaction with the lack of clothing protectors. Similarly, Resident 9, who also required setup/clean-up assistance, was found with food spills on their clothing and stated that they had requested a clothing protector but were denied. Resident 45, who needed similar assistance, was seen with food debris on their clothing and expressed that it was from their breakfast. Interviews with staff revealed that the removal of clothing protectors was intended to transition to a fine dining experience using cloth napkins, as directed by Staff A. However, this change was not communicated effectively to the residents, leading to misunderstandings and dissatisfaction. Staff members acknowledged that residents preferred clothing protectors and that their removal resulted in residents' clothing being soiled, which contradicted the facility's policy of promoting residents' dignity and self-worth.
Failure to Obtain Consent for Psychotropic Medications
Penalty
Summary
The facility failed to obtain consent for psychotropic medications prior to administration for three residents, which is a requirement to ensure residents and their representatives are fully informed of the risks and benefits of medications. Resident 21, who had moderate cognitive impairment and diagnoses including diabetes, brain dysfunction, and depression, was prescribed Seroquel on 06/13/2024 without prior consent, despite having been on the medication previously and it being discontinued earlier. Resident 19, who was alert and had diagnoses including diabetes, anxiety, and bipolar depression, began taking Effexor XR on 10/06/2024, but consent was only documented 19 days later. Staff interviews confirmed that consents should be obtained before the first dose and when doses change. Resident 333, who was severely cognitively impaired with diagnoses including traumatic brain injury and depression, was prescribed Effexor and Seroquel on 06/14/2024. The consent for Seroquel was signed three days after the medication was started, and there was no consent for Effexor. Staff interviews, including with the Director of Nursing, confirmed that consents for psychotropic medications should be obtained when the medication is ordered, and acknowledged the absence of the required consents.
Failure to Provide Required Beneficiary Notices
Penalty
Summary
The facility failed to provide a Skilled Nursing Facility Advance Beneficiary Notice (SNFABN) to two residents, which is required to inform them of the estimated costs of services that may no longer be covered by Medicare Part A. Resident 46, who was cognitively intact and required assistance with activities of daily living, did not receive the SNFABN until 19 days after their last covered day. Resident 62, who was independent with activities of daily living but had severely impaired cognition, did not receive a SNFABN at all. This oversight placed both residents at risk of being unable to make informed financial and care decisions regarding their continued stay. Interviews with facility staff revealed that the Business Office Manager, Staff N, was responsible for issuing the SNFABNs. Staff N admitted to missing Resident 62 and failing to issue the notice as required. The Executive Director, Staff A, acknowledged the failures and stated that the process of issuing SNFABNs the day after a resident's Medicare Part A coverage ended was not followed. The deficiency was identified as a failure to comply with the requirements for providing beneficiary notices, as referenced by WAC 388-97-0300(1)(e)(5)(6).
Failure to Ensure Privacy of Residents' Mail
Penalty
Summary
The facility failed to ensure the privacy of residents' mail, affecting six residents who were part of the sample reviewed for privacy. Resident 1, who was cognitively intact and able to direct their care, reported during a Resident Council interview that their mail was consistently opened before delivery. Other residents, including Residents 29, 42, 45, and 47, confirmed similar experiences of receiving opened mail. Resident 19 specifically mentioned that their mail from the Department of Social and Health Services (DSHS), behavioral health, and welfare was opened, and they had discussed this issue with Staff N, the Business Office Manager. Staff interviews revealed that the mail was initially handled by Staff P, the Receptionist, who passed it to Staff N for sorting before returning it for delivery. Staff P confirmed that mail from DSHS addressed to residents had been opened. Staff N was unavailable for interview due to being on leave. The Executive Director, Staff A, acknowledged that mail should be delivered unopened and attributed the issue to confusion over which mail was intended for residents versus the facility. Staff A affirmed that residents have a right to privacy with their mail and that the facility requires permission to open it.
Failure to Reimburse Resident for Lost Property
Penalty
Summary
The facility failed to protect a resident's property from loss and did not reimburse the resident in a timely manner for the loss of a cell phone. Resident 19, who has diagnoses including diabetes and quadriplegia and is cognitively intact, reported that their cell phone was stolen in November 2023. Despite being informed by the Executive Director, Staff A, that reimbursement was in process, the resident had not received the reimbursement check and had to purchase a new cell phone using their own funds. Interviews and record reviews revealed that there were no entries in the missing property logs or grievance logs regarding the resident's cell phone. Staff L, Director of Social Services, indicated that missing property forms were submitted to Staff A. Staff A acknowledged that they were aware of the missing cell phone several months prior but had not submitted the reimbursement request. They admitted that the reimbursement should have been processed within five business days, acknowledging the delay in resolving the issue.
Failure to Complete and Implement PASARR for Residents
Penalty
Summary
The facility failed to ensure that Preadmission Screening and Resident Reviews (PASARR) were completed or implemented as required for two residents. Resident 12, who was admitted with a diagnosis of depression, had a PASARR Level I screen indicating mental illness and functional limitations, necessitating a Level II review. Despite a Level II Notice of Determination recommending specialized behavioral health services, these services were not documented or provided. Interviews revealed that Resident 12 had not seen a behavioral health provider since admission, and an appointment was only scheduled after the deficiency was identified. Resident 21 was admitted without a PASARR completed prior to admission, contrary to requirements. The PASARR Level I was completed five days after admission by the facility's social services staff, as no earlier form was found. The Director of Social Services indicated that the PASARR should have been completed by the hospital, but it was not done before the resident's admission. This oversight in both cases placed the residents at risk for a decline in their mental health and a decrease in their quality of life.
Failure to Follow Care Plan Interventions for Residents
Penalty
Summary
The facility failed to ensure care plan interventions were followed for three residents, leading to unmet care needs and discomfort among other residents. Resident 54, who had a stroke and paralysis, required substantial assistance with activities of daily living and was dependent on staff for bed mobility and transfers. Despite a care plan and physical therapy recommendation to assist Resident 54 into a wheelchair daily, there was no documentation of attempts or refusals, and the resident was frequently observed lying in bed. Staff interviews revealed inconsistencies in following the care plan, with one staff member stating the resident often refused assistance, but these refusals were not documented. Additionally, the facility did not adhere to care plan interventions for Residents 39 and 67, who were romantically involved and had severe cognitive impairments. Their care plans required staff to ensure public displays of affection were appropriate and to prevent them from entering each other's rooms. However, observations and interviews indicated that these interventions were not consistently followed, as the residents were seen entering each other's rooms and engaging in public displays of affection, causing discomfort among other residents. Staff interviews highlighted a lack of consistent supervision and adherence to the care plans.
Deficiencies in ADL Assistance for Two Residents
Penalty
Summary
The facility failed to provide adequate assistance with activities of daily living (ADLs) for two residents, leading to deficiencies in their care. Resident 60, who had diagnoses including adult failure to thrive, osteoporosis, and hypothyroidism, was not provided with the necessary showers, assistance, cueing, supplements, and referrals to promote their nutrition. The resident was mildly cognitively impaired and required maximum assistance with showering and toileting hygiene. Despite being incontinent, Resident 60 received only one shower in a 30-day period, and there was a persistent smell of urine in their room. The resident also experienced significant weight loss, and there were multiple instances where they were not assisted or cued during meals, leading to uneaten food and inadequate nutritional intake. The facility also failed to ensure that Resident 60 received the prescribed high protein/high calorie drinks, with 11 out of 100 opportunities missed due to the drinks being out of stock. Additionally, a referral to a dental or ENT provider was recommended by the speech therapist due to the resident's jaw pain, but no such appointment was made. Interviews with staff revealed a lack of awareness and communication regarding the resident's care plan, dietary needs, and the necessity for regular toileting and hygiene assistance. Resident 75, who had necrosis/gangrene of the fingers and amputations of both legs, was also not provided with the scheduled showers. Despite being alert and able to communicate their needs, Resident 75 reported receiving only one shower since their admission 45 days prior. The facility's records showed no documentation of showers or refusals, and staff interviews confirmed that the resident's bathing schedule was not followed. The lack of showers contributed to hygiene issues, as evidenced by the presence of stains on the resident's clothing and bedding.
Failure to Provide Resident-Centered Activities
Penalty
Summary
The facility failed to provide an ongoing program of activities that met the interests of a resident with severe cognitive impairment and physical limitations. The resident, who had a history of stroke and hemiplegia, expressed interest in activities such as reading, listening to music, being around animals, being outdoors, practicing religion, and engaging in favorite activities. Despite these preferences, the care plan only documented independent leisure activities like watching TV and spending time with visitors, along with 1 to 1 visits with activity staff. However, the resident had not attended any activity programs over the prior quarter, and staff failed to ensure the resident was escorted or transported to activities as needed. Observations revealed that the resident spent most of their time lying in bed, watching TV, or napping, and they reported not receiving assistance to get into their wheelchair to attend activities. The Life Enrichment Director acknowledged that activities for the resident mainly consisted of in-room visits and admitted that pet visits were no longer offered. The director also stated that no reading materials or audiobooks had been provided, despite the resident's interest in reading. The resident had initially refused activities upon admission, leading staff to stop inviting them, although the director recognized that the resident should still be invited to activities.
Failure to Implement Bowel Management Protocol
Penalty
Summary
The facility failed to implement a bowel management protocol for two residents, leading to a deficiency in care. Resident 21, who had diagnoses including diabetes, brain dysfunction, and a history of stroke, was cognitively impaired and required assistance with daily activities, including toileting. Despite having orders for Milk of Magnesia, Bisacodyl suppository, and Fleet enema to manage constipation, the resident did not have a bowel movement for six days, from June 11 to June 16, 2024. The medication administration record showed that the prescribed laxatives were not administered as needed, and there were no entries indicating that the resident was offered or refused the medications. Similarly, Resident 75, who had necrosis/gangrene of the fingers and amputations due to frostbite, was cognitively intact and required assistance with toileting. This resident was on opioid pain medication, which could cause constipation. Despite having orders for Miralax, Senna, Milk of Magnesia, Dulcolax, and Fleet enema, the resident experienced multiple periods without bowel movements, ranging from three to five days, between May 29 and June 21, 2024. The medication administration records indicated that the as-needed medications were not given when required, and there were no corresponding entries documenting that the medications were offered or refused. Interviews with staff revealed a lack of adherence to the bowel management protocol, contributing to the deficiency.
Failure to Schedule Vision Appointment for Resident
Penalty
Summary
The facility failed to schedule a necessary vision appointment for a resident, identified as Resident 59, who was cognitively intact and able to communicate their needs. The resident had informed both the Resident Care Manager and the Transportation staff about their need for a vision appointment approximately a month prior. Despite this, the appointment was not scheduled, placing the resident at risk for worsening vision and decreased quality of life. The resident experienced intermittent eye pain and had previously undergone an eye exam, which indicated the need for retinal surgery. However, due to a communication lapse, where the eye clinic contacted an outdated phone number and subsequently closed the referral after two unsuccessful attempts, the necessary follow-up appointment was not made. Staff T, responsible for scheduling appointments, acknowledged the oversight and the Director of Nursing confirmed that the process could have been handled better.
Failure to Remove Urinary Catheter and Initiate Bladder Training
Penalty
Summary
The facility failed to remove a urinary catheter and provide bladder training as ordered for a resident, which increased the risk of catheter-associated urinary tract infections and diminished quality of life. The resident, who was cognitively intact and able to communicate their needs, was admitted with an indwelling urinary catheter due to obstructive uropathy. A hospital progress note indicated that the catheter was initially placed because the resident was unable to void and needed to be removed for bladder training. Transition of care orders from the hospital also documented the need for bladder training. Despite these orders, the urinary catheter was not removed, and bladder training was not attempted. The resident expressed frustration about the catheter not being removed prior to discharge, and a family member confirmed that the orders for removal were not followed. Interviews with facility staff, including a Licensed Practical Nurse and the Director of Nursing, verified that the catheter should have been removed and bladder training should have been initiated, as per the orders dated 04/22/2024.
Failure to Provide Behavioral Health Services
Penalty
Summary
The facility failed to provide necessary behavioral health care services for Resident 80, who had diagnoses of bipolar disorder and substance abuse in remission. The resident was cognitively intact and capable of making decisions regarding their care. On the day of a scheduled behavioral health appointment, the resident was informed only 15 minutes prior that the facility could not provide transportation, leading to the resident missing the appointment. This appointment was crucial for medication review and adjustment, and the resident expressed significant distress over missing it, as they had no alternative means of transportation and had been waiting for the appointment for a month and a half. Subsequently, the resident was unable to reschedule the appointment due to a no-show fee charged by the behavioral health clinic. Interviews with facility staff revealed that the appointment was not placed on the facility's calendar until three days before the scheduled date, which was insufficient time to arrange transportation. The Social Service Director did not recall being informed about the appointment but did not dispute the resident's claim that they had notified the staff a week in advance. This oversight resulted in the resident missing a critical appointment for their mental health and sobriety management.
Medication Administration Errors in LTC Facility
Penalty
Summary
The facility failed to maintain a medication error rate of less than five percent, resulting in a rate of 9.38 percent. This was identified through observations and interviews involving two residents. Resident 9, who was cognitively intact and had diagnoses including diabetes, chronic pain, and anxiety, did not receive their medications correctly. A Licensed Practical Nurse (LPN) failed to clean the insulin pen tip, did not perform a test dose, and removed the needle too quickly after administering insulin. Additionally, the LPN documented that Resident 9 used their Flovent inhaler, although the resident did not actually use it. Resident 78, also cognitively intact with diagnoses including a broken right upper arm, diabetes, and heart disease, received incorrect insulin administration. A Registered Nurse (RN) did not clean the insulin pen tip or prime the pen before administering the insulin dose. The Director of Nursing Services confirmed that the proper procedures for insulin pen use were not followed by the staff involved.
Medication Storage and Handling Deficiencies
Penalty
Summary
The facility failed to ensure proper storage and handling of medications, specifically controlled substances and expired medications, in two medication storage rooms and a medication cart. In the South Medication Room, a Levemir insulin pen was found with a pharmacy label indicating an expiration date of 03/08/2025, while the manufacturer's label showed an expiration date of 11/2023. In the North Medication Room, the refrigerator lock was not engaged, and an emergency kit inside had a broken red tag lock. This kit contained Lorazepam, a schedule IV-controlled substance, which was not secured as required. Additionally, the North Medication Cart contained expired medications, including Acetaminophen and Vitamin B-12 tablets, and unlabeled tablets were found in the cart's drawers. Interviews with staff revealed that the emergency kit was usually locked, but the lock was not replaced after a check on 06/20/2024. The Director of Nursing Services confirmed that the emergency kit should have been double locked and expired medications should have been removed from the cart.
Dietary Manager Lacks Required Certification
Penalty
Summary
The facility failed to ensure that the Dietary Manager possessed the required credentials, specifically a Food Service Manager certification. This deficiency was identified during interviews and record reviews. Staff H, the Dietary Manager, admitted to not having the necessary certification and mentioned plans to take the class. Additionally, the Registered Dietician (RD), Staff K, was only employed part-time at the facility. The Executive Director and Director of Nursing acknowledged that the absence of a full-time RD and the lack of certification for Staff H did not meet regulatory requirements, as per WAC 388-97-1160(1). This situation placed all residents at risk of receiving dietary services that might not meet necessary nutritional requirements or adhere to industry standards.
Deficiency in Meal Temperature and Quality
Penalty
Summary
The facility failed to provide palatable, attractive meals at a safe and appetizing temperature for six of eight sampled residents. The deficiency was identified through observations, interviews, and record reviews. Residents reported that meals were often served cold, and the menu did not always reflect what was actually served. The facility's plate warmer was broken, which contributed to the issue of cold food. Residents expressed dissatisfaction with the lack of fresh fruits and vegetables, and some reported being served canned fruits and vegetables instead. Additionally, there were complaints about the lack of meal substitutions and the inability to reheat food. Several residents, including those with conditions such as rheumatoid arthritis, Parkinsonism, peripheral vascular disease, end-stage renal disease, Crohn's disease, and kidney failure, were affected by the facility's failure to provide meals at the appropriate temperature. These residents were cognitively intact and had varying levels of assistance required for eating and activities of daily living. During interviews, residents expressed dissatisfaction with the dining experience, citing issues such as cold food, lack of menu variety, and unavailability of certain food items like bananas and salads. Staff interviews revealed that the dietary manager was aware of the broken plate warmer and the challenges in obtaining necessary ingredients due to budgetary constraints. The executive director was initially unaware of the extent of the residents' food concerns but acknowledged receiving some complaints about cold food. The facility's inability to reheat food was attributed to concerns about cross-contamination. The dietary manager also mentioned being locked out of ordering certain food items from the supplier's website, which further limited the facility's ability to meet residents' dietary preferences and needs.
Failure to Provide Meals for Resident Attending Dialysis
Penalty
Summary
The facility failed to provide at least three meals daily for a resident who attended outside medical appointments on specific days of the week. The resident, who had diagnoses including end-stage renal disease, diabetes, and heart disease, was cognitively intact and required no staff assistance for activities of daily living. Despite the resident's repeated requests to have their evening meal held for them on days they returned late from dialysis appointments, the facility only complied once. As a result, the resident often went without an evening meal, receiving only a sack lunch during their dialysis appointments, which they consumed before returning to the facility. Interviews with facility staff revealed a lack of communication and adherence to the process of holding meals for residents who are out of the building during regular mealtimes. The Dietary Manager admitted to not communicating with the kitchen staff to hold a meal for the resident, and the Executive Director was unsure if the kitchen staff were following the process of holding a hot meal for residents not present at scheduled mealtimes. This oversight placed the resident at risk for unplanned weight loss and nutritional deficits.
Failure to Ensure Resident Received Bathing Services
Penalty
Summary
The facility failed to communicate effectively with the hospice provider regarding bathing services for a resident, identified as Resident 15, who was under hospice care. This resident, who had severe cognitive impairment and required maximum assistance with personal hygiene, did not receive a shower or sponge bath for over seven weeks due to a scheduling error. The hospice was responsible for providing bathing assistance twice a week, but a mistake led to the cancellation of the resident's bath aide services. The facility's records, including the electronic medical record and paper shower log, showed no documentation of bathing during this period. Interviews with facility staff revealed that there was a misunderstanding about who was responsible for the resident's bathing. Staff members believed hospice was providing the baths, but hospice records confirmed that the last bath was given on a specific date over seven weeks prior. The facility's Executive Director and Director of Nursing acknowledged the oversight and confirmed that the facility did not ensure the resident received adequate bathing and grooming, which was ultimately their responsibility.
Failure in Safe and Timely Discharge Planning
Penalty
Summary
The facility failed to ensure a safe discharge for Resident 56, who was admitted with diagnoses including encephalopathy, bipolar disorder, and adult maltreatment. Despite being cognitively intact and requiring supervision for ADLs, Resident 56 expressed a desire to discharge home with their spouse, against whom there was an open APS investigation and a restraining order. The resident eventually left the facility AMA with a representative, but the facility did not notify APS as required by their policy. Interviews with staff revealed a lack of clarity and adherence to the process for AMA discharges, contributing to the unsafe discharge. For Resident 79, the facility failed to honor discharge preferences in a timely manner. Resident 79, admitted with heart failure, anxiety, and depression, expressed a desire to discharge to another state where a family member worked. Despite this request being made early in their stay, the discharge process was delayed. Staff interviews confirmed that discharge planning should have occurred sooner, indicating a failure in the facility's discharge planning process.
Failure to Protect Resident from Verbal Abuse and Neglect
Penalty
Summary
The facility failed to act promptly after altercations between two residents, leading to one resident experiencing verbal abuse and psychosocial harm. The affected resident, who was cognitively intact and had a complex medical history, reported anxiety, tearfulness, lack of sleep, and expressed fear due to their roommate's aggressive behavior. Despite being aware of the situation, the staff delayed moving the resident to a different room, which resulted in the resident feeling unsafe and ultimately deciding to discharge against medical advice. The roommate, who had a history of stroke and dementia, exhibited moderate cognitive impairment and frequent verbally aggressive behaviors. These behaviors included yelling, cursing, and making threats, which were documented in the resident's care plan. However, the facility did not implement new interventions or adequately address the escalating situation after the incidents occurred, leaving the affected resident vulnerable to further distress. Interviews with staff members revealed that the verbally aggressive behaviors of the roommate were well-known and had been ongoing for some time. Despite this knowledge, the facility's response was insufficient, as they failed to provide immediate safety measures for the affected resident or monitor for potential psychological harm. The lack of timely intervention and appropriate care plan adjustments contributed to the deficiency in protecting residents from abuse and neglect.
Failure to Implement Effective Fall Prevention Strategies
Penalty
Summary
The facility failed to consistently implement interventions to reduce fall hazards, monitor for intervention effectiveness, and modify interventions when necessary for a resident with severe cognitive impairment. This resident, identified as Resident 4, experienced multiple falls within a short period, indicating a lack of effective fall prevention strategies. The facility's policy required revising care plans and implementing new interventions following falls, but this was not consistently done for Resident 4. Resident 4 had a history of falls and was at high risk due to cognitive impairment and overestimating their abilities. Despite this, the facility did not adequately document or implement new interventions after each fall. For instance, after a fall on May 7, 2024, no new interventions were added to the care plan, and a medication review was delayed. Additionally, incident reports for some falls were incomplete or missing, and there was a lack of documentation for 1:1 monitoring, which was supposed to be in place. Interviews with staff revealed a general understanding that new interventions should be implemented promptly after a fall to prevent further incidents. However, the facility's actions did not align with this understanding, as evidenced by the repeated falls and insufficient documentation. The facility's failure to adhere to its fall prevention policy and effectively manage Resident 4's care plan contributed to the resident's repeated falls and potential risk for injury.
Failure to Provide Trauma-Informed Care for Resident with PTSD
Penalty
Summary
The facility failed to provide trauma-informed care for Resident 3, who was a trauma survivor with a history of domestic violence. The facility's policy required universal screening for trauma and the development of care plans to mitigate potential triggers. However, upon admission, Resident 3's social service admission and discharge evaluation was incomplete, and the care plan did not specify the resident's history of domestic violence or identify potential triggers to prevent re-traumatization. Resident 3, diagnosed with anxiety, depression, and PTSD, was admitted to the facility with a history of verbal abuse from their spouse. Despite this, the care plan only included general interventions related to medication management and psychosocial well-being, without addressing specific trauma-related needs. Shortly after admission, Resident 3 was placed in a room with a roommate known for verbally aggressive behaviors, which led to an incident where the roommate aggressively grabbed Resident 3's arm, causing confusion and distress. Interviews with facility staff revealed a lack of awareness and documentation regarding Resident 3's trauma history and potential triggers. Staff acknowledged that trauma and potential triggers should be listed in the care plan, but Resident 3's care plan lacked such details. Additionally, the facility delayed implementing measures to prevent contact between Resident 3 and their spouse, who was identified as a source of trauma, until several weeks after admission.
Failure to Implement Person-Centered Dementia Care Plan
Penalty
Summary
The facility failed to develop and implement person-centered care plans with individualized interventions for a resident diagnosed with dementia, leading to increased behaviors and diminished quality of life. The facility's policy on dementia care emphasized the need for non-pharmacological approaches and person-centered care plans to address behaviors. However, the care plan for the resident in question was not reviewed or updated, and it lacked individualized non-pharmacological interventions. The resident exhibited increased agitation and combativeness, yet the assessments failed to document effective interventions or behavioral symptoms accurately. The resident, who had a history of stroke and dementia, showed moderate cognitive impairment and fluctuating moods. Despite the resident's increased agitation and combativeness, the care plan did not include specific strategies to address these behaviors. Nursing progress notes documented frequent behaviors such as crying out, panic attacks, anxiety, hallucinations, delusions, and verbal outbursts. These behaviors were often triggered during care or when a peer was present in the resident's room. Staff interviews revealed that the resident's behaviors were known but lacked specific interventions to manage them effectively. Interviews with various staff members, including nursing assistants, registered nurses, and social services, highlighted the resident's frequent verbal outbursts and the absence of effective behavioral interventions. Staff acknowledged that the resident's behaviors could be related to pain, but pain interventions and alternative care options were not adjusted. The facility's failure to implement a person-centered care plan with individualized interventions for the resident's dementia-related behaviors resulted in unmet needs and a diminished quality of life for the resident.
Failure to Report Potential Abuse and Misappropriation
Penalty
Summary
The facility failed to identify and report several incidents of potential abuse and misappropriation of property to the State Survey Agency as required. In the case of Resident 4, who had a history of verbal aggression, there were multiple incidents where they verbally abused their roommate, Resident 3, over TV volume disputes. Despite these incidents being documented in nursing progress notes, they were not reported as potential abuse. Staff interviews revealed a lack of awareness and action regarding these incidents, and the facility's incident log did not reflect these occurrences. Similarly, Resident 6, who had severe cognitive impairment and a history of behavioral issues, was involved in an incident where they became agitated and physically aggressive towards their roommate, Resident 5. This incident was documented in the facility's incident log but was not reported to the State Survey Agency as potential abuse. Staff interviews indicated a lack of awareness of the incident, and the investigation into the incident was incomplete, lacking staff or resident interviews. Additionally, the facility failed to report the potential misappropriation of Resident 2's wallet, which contained important personal items and cash. Despite the missing wallet being reported to the facility's management, it was not documented in the facility's grievance or incident logs, nor was it reported to the State Survey Agency. Staff interviews revealed a lack of awareness of the missing wallet, and the facility's administrator acknowledged the incident but did not consider it potential misappropriation due to the absence of specific allegations of theft.
Inadequate Documentation and Improper Discharge Procedures
Penalty
Summary
The facility failed to ensure that facility-initiated discharges had a valid basis and that the discharge documentation included the required components for two of the three sampled residents. Resident 1, who was admitted for wound care and completion of a six-week course of IV and oral antibiotics for osteomyelitis, was discharged against medical advice (AMA) without proper documentation or a valid reason. The resident was informed that failure to return to the facility by a certain time would result in discharge without a safe discharge plan. The discharge occurred without completing the AMA form, documenting the resident's condition, or notifying the necessary staff. Additionally, the resident's PICC line was discontinued without a provider order, and the resident was discharged with incomplete antibiotic treatment. Resident 2, who had a history of stroke and intentional salicylate overdose, was also discharged AMA without proper documentation or a valid reason. The resident had moderate cognitive impairment and was on mood-stabilizing medications. Despite a planned discharge with home health services, the resident left the facility during a personal outing and did not return. The facility failed to document the reasons for postponing the planned discharge, details of why the discharge was considered AMA, or that the resident had been kept informed. No AMA paperwork was completed, and medications were not sent with the resident. Interviews with facility staff revealed inconsistencies in the discharge process and a lack of adherence to facility policies. Staff acknowledged that residents could leave for personal outings but were encouraged to return by a specific time. However, there was no consistent monitoring of resident sign-outs, and staff were unsure of the AMA discharge process. The facility was able to meet the needs of both residents, yet failed to follow proper procedures for AMA discharges, resulting in inadequate documentation and potential risks to the residents' health.
Failure to Monitor Dialysis Tolerance and Collaborate with Dialysis Center
Penalty
Summary
The facility failed to consistently monitor a resident's tolerance to dialysis treatments and collaborate care with the dialysis center. The resident, who had end-stage renal disease and was dependent on dialysis, had a care plan that required staff to check the dialysis access port post-dialysis and monitor for complications. However, the facility did not consistently complete the dialysis communication forms, which were essential for tracking the resident's pre-dialysis and post-dialysis vital signs and any complications during treatment. Review of the resident's medical records from February to April 2024 showed significant gaps in the documentation of dialysis communication forms, vital signs, and weights. The February Medication Administration Record (MAR) indicated that standard dialysis physician orders were in place only until February 19, 2024, and no monitoring was found from February 20th onwards. In March, there were no standard dialysis physician orders from March 1st to March 14th, and the resident refused dialysis on March 15th without any weight or blood pressure recorded. In April, no standard dialysis physician orders were present until the date of the investigation. The Director of Nursing confirmed that there is a standard physician order set for dialysis-dependent residents and that the facility's expectation was for staff to complete the dialysis communication form each time the resident went to dialysis. However, upon reviewing the MARs, it was evident that the required dialysis physician orders were only sporadically present, making it difficult to determine if the resident was being adequately monitored and tolerating dialysis treatments. This lack of consistent monitoring placed the resident at risk of unrecognized complications and unmet care needs.
Failure to Accurately Submit Direct Care Staffing Information
Penalty
Summary
The facility failed to ensure that direct care staffing information, including data for agency and contract staff, was correctly submitted to the Centers for Medicare and Medicaid Services (CMS) for Quarter 3 of 2023. This failure was identified through a review of the Certification and Survey Provider Enhanced Reports (CASPER) Payroll-Based Journal Staffing Data Report, which showed that the facility reported staffing levels lower than required. During interviews, the Administrator revealed that the Human Resources Manager, who has since been terminated, was responsible for reporting the PBJ data, and the Administrator was supposed to check the data for accuracy before submission. The error occurred because the Human Resources Director did not include agency staff in the numbers and incorrectly calculated nurse hours. The Administrator, who was in training at the time, was unsure if the Interim Administrator had reviewed the data before submission.
Failure to Timely Assess Fall Risk and Implement Safety Interventions
Penalty
Summary
The facility failed to consistently assess fall risk, timely initiate fall care plans, and implement new safety interventions for two residents reviewed for falls. Resident 1, who had a history of falls and was identified as high risk, experienced multiple falls after admission. Despite being identified as high risk, the baseline care plan did not document fall risk or interventions, and no new interventions were implemented after falls occurred on multiple occasions. The facility's incident reports and care plans did not reflect timely or adequate responses to these falls, leading to repeated incidents without appropriate preventive measures being put in place. Resident 2, also identified as high risk for falls, experienced a fall the day after admission. The baseline care plan did not document fall risk or interventions, and the comprehensive care plan addressing falls was not initiated until several days after the fall occurred. Staff interviews revealed that information on required levels of assistance and safety interventions was often missing for new admissions, and there was a lack of immediate initiation of new safety interventions following falls. The facility's policy required residents to be assessed for fall risks on admission, quarterly, after a fall, and with a change of condition. However, the facility did not adhere to this policy, as evidenced by the delayed initiation of fall care plans and the absence of new safety interventions following falls. Staff acknowledged the deficiencies in timely assessment and intervention, and the facility's documentation practices were found to be inadequate in addressing the fall risks of the residents involved.
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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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