Avalon Healthcare - Tacoma
Inspection history, citations, penalties and survey trends for this long-term care facility in Tacoma, Washington.
- Location
- 7411 Pacific Avenue, Tacoma, Washington 98408
- CMS Provider Number
- 505183
- Inspections on file
- 34
- Latest survey
- March 6, 2026
- Citations (last 12 mo.)
- 107 (2 serious)
Citation history
Health deficiencies cited at Avalon Healthcare - Tacoma during CMS and state inspections, most recent first.
A newly admitted hospice resident arrived restless, non-verbal, and repeatedly attempting to get out of bed, yet staff did not obtain vital signs, perform an admission nursing or skin assessment, complete a pain assessment, or develop a baseline care plan. RNs and CNAs reported placing the bed against a wall, using pillows and a floor mattress, and assigning staff to sit with the resident due to agitation and fall risk, but there was no documentation of 1:1 monitoring, consent for bed positioning, or details of care provided and the resident’s response. The electronic record contained only a brief nursing note describing restlessness and the hospice nurse’s involvement leading to transfer back to the hospital, and medical records staff confirmed no additional documentation existed, which the DON acknowledged did not meet expectations for new admissions.
The facility did not adequately assess or care plan for residents with Substance Use Disorder, failing to implement or document individualized interventions, education on facility policies, or increased monitoring as required. Several residents with SUD histories experienced emergencies or exhibited ongoing substance use behaviors without appropriate care plan interventions or documentation.
The facility failed to create personalized discharge plans for four residents, leading to potential delays and unmet care needs. One resident faced insurance and funding barriers for a planned discharge to Hawaii, while another needed stair training before returning home. A third resident left against medical advice, and a fourth was unsure of discharge barriers. Weekly meetings were held, but documentation was lacking in individual files.
The facility failed to provide adequate hydration to residents, as observed when multiple residents did not have water pitchers at their bedside, contrary to their care plans. Interviews revealed that residents often had to request water, and staff acknowledged a shortage of water pitchers, which had not yet been resolved.
Two residents did not receive scheduled bathing due to outdated shower schedules and lack of coordination among staff. One resident, alert and oriented, relied on bed baths from their wife, while the other, with cognitive impairment, received only a bed and sponge bath. Staff interviews revealed the shower schedule was outdated and did not include the residents' room, leading to missed bathing opportunities.
Two residents suffered second-degree burns due to the facility's failure to implement a hot food and beverage policy. A resident with cognitive impairment was served hot coffee without a secured lid, leading to a spill and burns. Another resident with impaired mobility was given hot soup without a temperature check, resulting in burns. The facility's documentation showed inconsistencies in monitoring beverage temperatures, contributing to the incidents.
The facility failed to maintain appetizing food temperatures, as evidenced by resident complaints and improper food handling practices. A resident reported receiving cold eggs, while another noted inconsistent temperatures of hot and cold items. Observations revealed improper temperature measurement by a cook and unrefrigerated watermelon cups during meal service, contrary to the dietary manager's expectations.
The facility did not follow up on concerns raised by the resident council about care issues, such as missing laundry items, noise during sleep hours, long call light wait times, and staff turning off call lights without assisting residents. These concerns were documented in the council minutes but not reflected in the Grievance Log, indicating a lack of follow-up. A Recreation Assistant confirmed that grievances were documented and given to the Administrator but were not usually discussed in subsequent meetings.
A facility failed to provide weekend access to personal funds for a resident, who had communication challenges and whose money was held in a trust. The Business Office Manager confirmed that funds were only accessible during weekday business hours, with no posted information about after-hours availability.
The facility did not provide quarterly personal fund statements to a resident, impacting their ability to know the amount of money held in trust. The Business Office Manager, new to the role, admitted to not recalling when statements were last issued, confirming that no statement was provided in September.
The facility failed to maintain a clean and sanitary environment, with unsanitary bathroom conditions, insufficient housekeeping, and unresolved maintenance issues. Residents reported persistent problems with clogged toilets, inadequate cleaning, and unpleasant odors. The facility was understaffed in housekeeping, and maintenance issues, such as a hot pipe and fly infestation, were not promptly addressed.
The facility failed to implement comprehensive care plans for three residents, resulting in unmet needs and inadequate care. One resident did not receive necessary heel protectors, another had improper catheter care due to a lack of leg bag maintenance instructions, and a third resident's frequent refusal of showers was not documented or addressed in their care plan.
The facility failed to update care plans for two residents after significant health events and did not conduct a timely care conference for another resident. One resident experienced a fall without a subsequent care plan update, while another had a dental issue not reflected in their care plan. Additionally, a resident admitted with acute respiratory failure did not have a care conference within the required timeframe.
The facility failed to provide adequate care for a resident with skin issues, including a lack of documentation and unclear treatment orders. Another resident on anticoagulant therapy was not monitored for adverse side effects, and two residents did not receive proper bowel management, with no documentation of bowel movements or initiation of bowel protocols. Staff interviews confirmed these deficiencies did not meet expectations.
The facility failed to provide non-pharmacological interventions before administering pain medications to three residents, as required by their care plans. Additionally, a resident on Keppra for epileptic syndrome did not receive necessary lab tests to monitor medication levels, placing them at risk for unnecessary medications and diminished quality of life.
The facility failed to provide prescribed therapeutic diets, as observed on a specific date when regular and therapeutic diet menu items were not prepared or served correctly. The cook served all residents the same portion sizes, and some menu items were missing or substituted without proper communication or adjustment, as confirmed by the Dietary Manager.
The facility failed to implement an effective Antibiotic Stewardship Program, as evidenced by the lack of tracking and trending of antibiotic use and failure to report to QAPI for three months. A resident was prescribed an antibiotic despite lab results showing resistance, with no documentation of provider notification. The Regional Nurse Consultant confirmed the absence of required documentation.
The facility failed to educate and offer influenza and pneumococcal vaccines to two residents. One resident, with heart failure, kidney disease, and diabetes, refused the vaccines without documented education on their risks and benefits. Another resident, with acute kidney failure and morbid obesity, had no record of being educated or offered the influenza vaccine. The administrator expected residents to be informed about vaccine risks and benefits before offering.
The facility failed to educate and document the offer of COVID-19 vaccines for two residents. One resident, with heart failure, kidney disease, and diabetes, refused the vaccine without documented education on its risks and benefits. Another resident, with acute kidney failure and morbid obesity, also lacked documentation of vaccine education or an offer. The Regional Nurse Consultant confirmed the absence of documentation, highlighting a deficiency in the facility's vaccination process.
The facility failed to provide non-disposable cups during meals, affecting residents' dining experience across four halls. Staff interviews revealed a shortage of non-disposable cups, leading to the use of plastic cups. The Regional Nurse Consultant noted that more cups had been ordered, but staff were not informed.
A facility failed to honor a resident's right to choose life-saving interventions. Despite being capable of making decisions, a POLST form was not completed for the resident, who was then transitioned to DNR/DNI status without their input. Staff interviews revealed that the POLST form should have been reviewed upon admission and quarterly, but this was not done, leading to a deficiency in respecting the resident's autonomy.
A resident with osteomyelitis and diabetes reported missing pajama bottoms to the Housekeeping Manager, who failed to follow up or initiate a grievance due to a lack of awareness. The grievance was not documented, and the Interim DON confirmed that a grievance should have been initiated if the issue was unresolved.
A facility failed to provide a resident with written notification of the reason for transfer to the hospital. The resident, who had hypertension and chronic embolism, was discharged with an anticipated return, but there was no documentation of a written notice. The Social Services Director acknowledged the inconsistency in providing such notices.
The facility failed to provide a bed hold notice for two residents during their hospitalization, as required by regulations. One resident with hypertension and chronic embolism, and another with Crohn's disease, were not informed about their right to hold their bed. The Social Services Director and Interim Administrator acknowledged the oversight, which could impact the residents' quality of life.
A resident's smoking status was inaccurately recorded in their medical records, as the MDS indicated no tobacco use despite the resident smoking under supervision. Staff interviews confirmed the MDS was incorrectly coded.
A facility failed to update the PASRR for a resident who was newly diagnosed with significant mental illness, including major depressive disorder and psychotic disorder with hallucinations. Despite the facility's policy to review PASRRs quarterly and submit new ones as needed, the resident's PASRR was not updated to reflect these new diagnoses.
The facility failed to accurately complete PASRR assessments for two residents, one with osteomyelitis and anxiety, and another with schizophrenia and anxiety. The assessments were either incomplete or not properly reviewed, signed, and dated, as confirmed by the Social Services Director.
The facility failed to provide necessary ADL assistance for two residents, leading to deficiencies in dressing and nail care. One resident, requiring substantial assistance, was not offered the option to get dressed and lacked proper clothing. Another resident, with schizophrenia and anxiety, showed signs of poor hygiene, with no documentation of bathing activities or refusals. Staff interviews revealed a lack of documentation and interventions for frequent shower refusals, placing both residents at risk for poor hygiene and diminished quality of life.
A resident with a fracture, diabetes, and muscle weakness was not provided with individualized activities, leading to a lack of engagement. The resident expressed a desire to get out of bed and watch TV, but no assistance was provided, and the TV was non-functional. Observations showed the resident remained in bed without engagement, and activity documentation was lacking. Staff interviews revealed a lack of awareness about the resident's needs and responsibilities for activity documentation.
A resident with diabetes and peripheral vascular disease was admitted with pressure ulcers, but the facility failed to thoroughly assess, document, and care plan necessary interventions. A provider order for skin prep was unclear and not followed, and the resident's skin care did not meet expectations, leading to a deficiency in pressure ulcer care.
The facility failed to provide appropriate ROM care for two residents, leading to a lack of documentation and unaddressed care plans. One resident's PROM exercises ceased, resulting in increased finger bending, while another resident's request for a restorative program went unfulfilled after discharge from physical therapy.
A resident with vascular dementia experienced a fall due to a failed independent transfer, and the facility did not complete a fall risk assessment or update the care plan. The planned intervention to mark a parking spot for optimal wheelchair transfers was not implemented, and the resident was later on alert for an unwitnessed fall. The Interim DON acknowledged the failure to meet expectations.
A facility failed to implement fluid restrictions, monitor weights accurately, and obtain ordered labs for a resident with diabetes, dysphagia, hyperkalemia, and chronic kidney disease. The resident's care plan lacked interventions for fluid restrictions, and there were discrepancies in weight documentation. A Regional Nurse Consultant acknowledged the failure in practice and inadequate nutritional services.
The facility failed to provide proper respiratory care for two residents, leading to deficiencies. One resident, with acute respiratory failure, had inconsistent oxygen therapy and lacked documented oxygen saturation checks. Another resident, also with respiratory failure, was observed without the prescribed continuous oxygen therapy, despite care plans indicating otherwise. These discrepancies highlight a failure to follow professional standards and provider orders.
A facility failed to act on a pharmacist's medication regimen review recommendations in a timely manner for a resident, leading to a missing record of patch removal on the MAR. The oversight was acknowledged by a Regional Nurse Consultant, who stated it did not meet expectations.
A facility failed to conduct the AIMS assessment for a resident prescribed Seroquel, an antipsychotic. Despite a provider's request and a pharmacy consultation highlighting the lack of documentation, the assessment was not completed. The Interim DON acknowledged the failure to meet expectations for timely AIMS testing.
The facility failed to properly store and label medications in a medication cart, with several medications found expired or lacking proper dating. An LPN acknowledged the oversight, and a Regional Nurse Consultant confirmed the storage did not meet expectations.
A resident with anxiety, depression, and incomplete paraplegia requested a dental appointment after losing a filling, but the facility failed to update the care plan or ensure a referral was made. Despite a nurse's assurance of a referral, no action was taken, leaving the resident to manage their dental issue without proper support.
Failure to Assess and Document Care for Newly Admitted Hospice Resident
Penalty
Summary
The deficiency involves the facility’s failure to provide care and treatment to a newly admitted resident in accordance with professional standards of practice, including assessment, basic care tasks, and pain management. The resident was admitted for end-of-life care with multiple diagnoses and arrived at the facility appearing restless, under distress, non-verbal, and repeatedly attempting to get out of bed. A collateral contact reported that the resident had been calm and able to go out in a wheelchair while in the hospital, but shortly after admission to the facility the resident was groaning, restless, and appeared significantly different. Staff C, an RN, stated the resident was very restless on admission, that they were concerned about falls and placed a mattress on the floor next to the bed, and had a CNA sit with the resident. Staff D, a CNA, recalled the resident as very restless, confused, not making eye contact, repeatedly removing their hospital gown, and trying to get up, with staff trading off to sit with the resident to prevent self-injury. Staff F, an RN manager on duty, reported working remotely to enter medications into the medical record and being informed that the resident was very agitated and crawling out of bed, and then learning that the hospice nurse had arrived and the resident was sent back to the hospital. Record review showed the resident was in the facility for approximately 2.5 hours, and the electronic chart contained only a single nursing note and a later social services note about a declined bed hold. The nursing note documented the resident’s arrival time, restlessness, distress, attempts to get off the stretcher and out of bed, assignment of a CNA to sit with the resident, and that the hospice nurse contacted the hospice physician, who ordered the resident sent to the hospital. There was no documentation of vital signs, weight, admission nursing assessment, skin assessment, pain assessment, baseline care plan, consent for positioning the bed against the wall, or documentation of 1:1 monitoring or the specific care provided and the resident’s response. Staff C acknowledged that no assessment or vital signs were obtained due to the resident’s restlessness, and Staff E confirmed there were no additional documents beyond what was in the electronic record. The DON confirmed that the absence of these assessments and documentation did not meet the facility’s expectations for care of newly admitted residents.
Failure to Assess and Care Plan for Residents with Substance Use Disorder
Penalty
Summary
The facility failed to adequately assess residents with a history of Substance Use Disorder (SUD) for associated risks, develop comprehensive individualized care plans, and implement interventions to ensure their safety. For five sampled residents with SUD, the facility did not consistently perform or document risk assessments, provide education on facility policies regarding substance use, or increase monitoring as care planned. In several cases, residents with known SUD histories were not given individualized care plans addressing their specific risks, and interventions such as increased monitoring or education were either not implemented or not documented. One resident with a history of polysubstance abuse and homelessness experienced repeated late-night visits from outsiders and was later found unresponsive in their room alongside a visitor, requiring emergency intervention with Narcan and hospitalization. Despite care plan interventions calling for increased monitoring and assessment, there was no documentation that these actions were carried out. Another resident with opioid abuse and polysubstance use was administered Narcan after being found drowsy and unresponsive, but their care plan did not address SUD-related risks, and there was no evidence of education on facility policies regarding substance use. Other residents with SUD histories were noted to leave the facility unsupervised, associate with individuals known for drug use, and return with signs of substance use, yet their care plans lacked specific interventions for SUD risk management. Staff interviews revealed a lack of standardized assessment tools for SUD, inconsistent care planning practices, and failure to educate residents on facility policies regarding substance use. Admission staff did not review facility rules or policies on drug use with residents, and there was no documentation that residents were informed of expectations regarding substance use and possession of illegal substances. The facility's own policy required individualized, resident-centered interventions for SUD, but these were not consistently implemented or documented for the affected residents.
Failure to Develop Personalized Discharge Plans
Penalty
Summary
The facility failed to develop personalized discharge plans for four residents, which led to a risk of delayed discharge and unmet care needs post-discharge. For Resident 4, the facility did not have an active discharge plan despite the resident's goal to return to the community. The resident's stepdaughter was involved in discussions about a potential discharge to Hawaii, but there were barriers such as funding and insurance issues. The facility's Social Services Director acknowledged that discharge planning information was not documented in the resident's record, and the stepdaughter was unaware of the discharge status. Resident 1 also lacked an active discharge plan, despite expressing a desire to return home to live with their wife and cats. The resident faced barriers such as limited use of their right side and the need for stair training, which had not been addressed. Similarly, Resident 3's discharge plan was incomplete, and the resident left the facility against medical advice. The facility's staff acknowledged that there should have been a discharge care plan in place. Resident 5 expressed a desire to return home but was unsure of the barriers to discharge. The facility held weekly meetings to discuss discharge planning, but documentation was not included in the residents' individual files. The lack of personalized discharge plans for these residents indicates a failure to meet their identified needs, goals, and preferences, as required by regulations.
Deficiency in Resident Hydration Due to Inadequate Water Provision
Penalty
Summary
The facility failed to ensure that residents received drinks consistent with their needs and preferences, leading to a deficiency in maintaining resident hydration. Observations on March 11, 2025, revealed that 11 out of 13 sampled residents did not have water pitchers at their bedside, which is contrary to their care plans. For instance, Resident 5 was observed without a water pitcher, despite a care plan intervention to offer fluids at bedside and every meal. Similarly, Resident 4 reported not receiving enough to drink and noted that the facility ran out of orange juice, which was part of their care plan intervention to have commonly used items like ice water within reach. Interviews with residents and staff highlighted systemic issues in providing adequate hydration. Residents such as Resident 7 and Resident 9 expressed that they had to request water, and it was not routinely provided. Staff interviews revealed that there was a shortage of water pitchers, and the facility had ordered more to address this issue. However, the Food Service Manager admitted that the plan to distribute water pitchers had not yet been implemented. This lack of consistent access to water placed residents at risk of insufficient fluid intake, as evidenced by the observations and resident statements.
Failure to Provide Scheduled Bathing for Residents
Penalty
Summary
The facility failed to ensure that activities of daily living (ADLs) related to bathing and showers were provided for two dependent residents, Resident 1 and Resident 5. Resident 1, who was alert and oriented, required partial/moderate assistance for bathing and was scheduled for showers twice a week. However, documentation showed that Resident 1 only received a shower once since admission, with refusals and missed opportunities noted without proper documentation. Resident 1 reported not having a shower since admission and relied on bed baths provided by their wife. Similarly, Resident 5, with cognitive impairment, required supervision or touching assistance for bathing. The documentation indicated that Resident 5 received a bed bath and a sponge bath but was not offered a shower on scheduled days, with refusals and missed opportunities also noted. The deficiency was attributed to the facility's failure to update and maintain accurate shower schedules for the residents. Staff interviews revealed that the shower schedule was outdated and did not include the room where Residents 1 and 5 resided, as it had been converted from office space to a resident room. Staff members acknowledged the oversight, noting that the shower schedule in the binder and electronic medical record did not match, leading to the residents not being scheduled for showers. This lack of coordination and communication among staff resulted in the residents not receiving the necessary bathing care as per their care plans.
Failure to Implement Hot Food and Beverage Policy Results in Resident Burns
Penalty
Summary
The facility failed to implement a hot food and beverage policy, resulting in two residents suffering second-degree burns. Resident 1, who had moderate cognitive impairment and required setup assistance, was served hot coffee without a secured lid, which spilled in their lap, causing burns. The facility's investigation revealed that the coffee was served at a temperature higher than the policy's limit, and the resident's personal coffee mug was not properly closed, leading to the spill. Resident 2, who was alert and oriented but had impaired mobility, was served hot soup that was not temperature-checked before being given to them. The soup spilled in their lap, causing burns to their thighs and groin. The CNA responsible for serving the soup was from a staffing agency and was unaware of the need to check the temperature, which was a contributing factor to the incident. The facility's documentation showed inconsistencies in monitoring and recording beverage temperatures, with some entries missing or exceeding the policy's temperature limits. The lack of adherence to the hot food and beverage policy and inadequate staff training on temperature checks contributed to the incidents, placing residents at risk for burns and injuries.
Deficiency in Food Temperature Management
Penalty
Summary
The facility failed to provide food at appetizing temperatures, which was identified during a review of kitchen services. This deficiency was highlighted by resident complaints and observations made by surveyors. Resident 44 expressed dissatisfaction with receiving cold eggs, while Resident 35 noted that hot items were not sufficiently hot and cold items were served at room temperature on multiple occasions. During an observation of lunch tray preparation, Staff U, a cook, was seen taking temperatures of food on the steam table by poking holes through foil coverings, which is not the correct method for accurate temperature measurement. Additionally, Staff X, a dietary aide, was observed preparing watermelon cups that were left unrefrigerated for the duration of the meal service, contrary to the facility's expectations as stated by Staff V, the dietary manager.
Failure to Address Resident Council Concerns
Penalty
Summary
The facility failed to address concerns raised by the resident council regarding resident care, as evidenced by the review of the resident council meeting minutes from September 2024. The concerns included issues with missing laundry items, loud talking during sleep hours, long call light wait times, and staff entering resident rooms and turning off call lights without providing assistance. Despite these concerns being documented in the resident council minutes, there were no corresponding entries in the Grievance Log from March 2024 to September 2024, indicating a lack of follow-up on these issues. During an interview, the Recreation Assistant, Staff P, confirmed that concerns voiced by residents were documented on a grievance form and given to the Administrator for follow-up, but they were unaware of any subsequent actions taken and noted that grievances were not typically discussed in the following month's meeting.
Lack of Weekend Access to Resident Funds
Penalty
Summary
The facility failed to provide residents with access to their personal funds on weekends, which was identified during a survey. This deficiency was observed in the case of Resident 10, who was admitted to the facility on an unspecified date. The electronic health record indicated that Resident 10 was rarely understood, suggesting potential communication challenges. During an interview, a collateral contact confirmed that the facility held Resident 10's money in a trust. Further interviews with the Business Office Manager revealed that residents could only access their funds between 8:00 AM and 4:30 PM from Monday to Friday. Additionally, there was no posted information in the facility indicating that money was available after business hours, contributing to the deficiency.
Failure to Provide Personal Fund Statements
Penalty
Summary
The facility failed to provide quarterly personal fund statements to residents with personal fund accounts, specifically affecting one resident who was reviewed for personal funds. Resident 10, who was admitted to the facility and was rarely understood according to their electronic health record, did not receive statements regarding their personal funds held in a trust by the facility. During an interview, a collateral contact for Resident 10 expressed that they were unaware of the amount of money in the trust due to the lack of statements. The Business Office Manager, Staff Q, acknowledged that residents were supposed to receive personal fund statements at the beginning of each month but admitted they could not recall when the last statements were provided, as they were new to the position and still learning the process. It was confirmed that residents did not receive a statement in September.
Facility Fails to Maintain Sanitary and Safe Environment
Penalty
Summary
The facility failed to maintain a clean and sanitary environment, as evidenced by multiple observations of unsanitary bathroom conditions across several rooms. Toilets were found with brown stains, broken tiles, and in some cases, were clogged or backed up, forcing residents to use alternative facilities. Residents reported that these issues had persisted for some time, and staff interviews confirmed that maintenance problems were known but not adequately addressed. The lack of timely cleaning and repair contributed to an undignified living environment for the residents. Housekeeping services were insufficient, with reports of rooms not being cleaned daily and debris accumulating on floors. Interviews with residents and staff revealed that the facility was understaffed in housekeeping, leading to inadequate cleaning routines. The facility had only one housekeeper for a shift, and the absence of weekend coverage exacerbated the situation. The lack of regular vacuuming and carpet cleaning contributed to unpleasant odors and a generally unclean environment. The facility also had maintenance issues, such as a hot pipe in the dining room with inadequate insulation, posing a safety risk. Staff interviews indicated that the maintenance reporting system was not effectively utilized, and there was no permanent maintenance staff on-site. The presence of flies in the facility was attributed to an open door, and this issue, along with others, was not promptly addressed. These deficiencies in maintenance and housekeeping compromised the residents' right to a safe and comfortable environment.
Deficiencies in Care Plan Implementation for Residents
Penalty
Summary
The facility failed to develop and implement comprehensive and person-centered care plans for three residents, leading to unmet needs and inadequate care. Resident 309, who was admitted with a fracture of the left femur, diabetes, and muscle weakness, required heel protector boots to prevent skin impairment. However, observations over several days showed the resident lying in bed without the boots or any alternative measures to offload pressure from the heels. Staff interviews revealed that the boots were unavailable, and a temporary solution using a pillow was suggested but not documented in the care plan. Resident 20, with a diagnosis of obstructive uropathy and a urinary tract infection, had an indwelling catheter and preferred using a leg bag. The care plan lacked specific instructions for the care and maintenance of the leg bag, leading to observations of the resident with a discolored urine bag positioned incorrectly. Staff interviews indicated a lack of awareness and documentation regarding the resident's use of a leg bag. Resident 39, diagnosed with schizophrenia and anxiety, was observed with poor personal hygiene, and the care plan did not document the resident's frequent refusal of showers. Staff interviews confirmed that refusals were not documented, and the care plan lacked interventions for managing these refusals.
Care Plan and Conference Deficiencies
Penalty
Summary
The facility failed to revise and update the care plans for two residents and did not conduct a care conference for another resident, leading to deficiencies in care. Resident 1, who was admitted with vascular dementia and absence of the larynx, experienced a fall on 09/06/2024. However, the facility did not complete a fall risk assessment or update the care plan following the incident. The Interim Director of Nursing Services acknowledged that the care plan should have been updated to reflect new interventions after the fall. Resident 30, who was readmitted with anemia and anxiety disorder, reported a dental issue where a filling had fallen out, affecting their ability to chew. Despite a provider's note indicating the need for dental follow-up and monitoring for infection, the care plan was not updated to include these concerns. Additionally, Resident 209, admitted with acute respiratory failure and chronic kidney disease, did not have a care conference within the required timeframe. The Social Services Director confirmed that a care conference should have been held within 72 hours of admission, but this did not occur.
Deficiencies in Skin Care, Anticoagulant Monitoring, and Bowel Management
Penalty
Summary
The facility failed to accurately assess, monitor, document, care plan, and provide necessary care for a resident with multiple skin issues. Resident 209, who had diabetes, peripheral vascular disease, and a history of toe amputation, was admitted with various skin conditions, including a hemodialysis fistula, moisture-associated skin damage, and fragile skin. Despite these conditions, the facility did not document measurements for the skin issues, nor did they have orders to wrap the resident's foot or monitor the fistula. The care plan lacked interventions for these issues, and the treatment orders were unclear and not followed as documented in the medication administration record. The facility also failed to monitor and document adverse side effects for a resident on anticoagulant therapy. Resident 21, who had heart failure, diabetes, and venous hypertension, was on blood-thinning medication but had no documentation of monitoring for adverse side effects for 30 days. Interviews with staff revealed that the lack of documentation did not meet expectations, indicating a failure in monitoring the resident's condition as required. Additionally, the facility did not consistently monitor and document bowel movements for two residents, nor did they implement the bowel program when needed. Resident 31, with epileptic syndrome and dementia, had no documented bowel movements for several days, and no as-needed medications were administered for constipation. Similarly, Resident 44, who was on medications causing constipation, had multiple days without documented bowel movements, and the bowel protocol was not initiated. Staff interviews confirmed that the facility's actions did not meet the expected standards for bowel management.
Failure to Provide Non-Pharmacological Interventions and Conduct Lab Testing
Penalty
Summary
The facility failed to provide non-pharmacological interventions for three residents before administering as-needed pain medications, as required by their care plans. Resident 17, who was admitted with hypertension and chronic embolism, received tramadol without any documented non-pharmacological interventions. Similarly, Resident 24, with diagnoses including high blood pressure and intervertebral disc degeneration, was given oxycodone outside the prescribed pain level parameters, and non-pharmacological interventions were not documented. Resident 46, diagnosed with skin infection, diabetes, and opioid use, received narcotic pain medication multiple times without the required non-pharmacological interventions being documented. Additionally, the facility failed to conduct necessary laboratory testing for Resident 31, who was prescribed Keppra for epileptic syndrome. Since admission, no lab tests were performed to check the resident's Keppra blood levels, which should have been done every six to twelve months according to the Advanced Registered Nurse Practitioner. This oversight placed the resident at risk of receiving unnecessary medications and a diminished quality of life.
Failure to Provide Prescribed Therapeutic Diets
Penalty
Summary
The facility failed to prepare and provide the menu items included in regular or therapeutic diets for all residents, which compromised the required nutritive value for each meal. On 10/07/2024, the lunch menu for residents on regular diets was supposed to include glazed baked ham, maple roasted sweet potatoes, spinach, a white roll, and chocolate chess pie. However, observations revealed that no white rolls or glazed baby carrots were prepared for meal service. Additionally, during the lunch tray preparation, all residents were served the same portion sizes regardless of their dietary needs. Staff U, the cook, admitted to not having glazed carrots and not providing white rolls with the meal. Furthermore, when spinach ran out, green beans were served to the remaining residents on the last hall. Staff V, the Dietary Manager, confirmed that the expectation was for therapeutic diets and resident preferences to be followed according to the tray card, and all menu items should have been prepared or communicated if unavailable for necessary adjustments.
Failure in Antibiotic Stewardship Program Implementation
Penalty
Summary
The facility failed to implement an effective Antibiotic Stewardship Program, which is crucial for promoting appropriate antibiotic use, reducing unnecessary antibiotic use, and decreasing the development of adverse side effects and antibiotic resistance. This deficiency was identified for one resident and involved the facility's failure to complete tracking and trending of antibiotic use and report these findings to the Quality Assurance and Performance Improvement (QAPI) program for three consecutive months. The facility's policy required that infections, antibiotic usage, sensitivity, and resistance patterns be tracked and reported to QAPI monthly, but this was not done for June, July, and August 2024. Resident 20 was admitted with diagnoses of obstructive uropathy and a urinary tract infection and was prescribed ceftriaxone sodium. However, laboratory results showed that the bacterium causing the infection was resistant to ceftriaxone. There was no documentation in the electronic health record that the provider was notified of these results, which is a critical step in ensuring appropriate antibiotic use. During an interview, the Regional Nurse Consultant confirmed the lack of documentation for tracking and trending being brought to QAPI and stated that staff should notify the provider and change the antibiotic if the organism is resistant.
Failure to Educate and Offer Vaccinations
Penalty
Summary
The facility failed to offer, educate, and obtain consent for influenza and/or pneumococcal vaccines for two of five sampled residents. Resident 18, who was admitted with diagnoses of heart failure, kidney disease, and diabetes, refused the influenza and pneumococcal vaccinations. However, there was no documentation indicating that the resident was educated on the risks and benefits of these vaccines prior to refusal. Similarly, Resident 50, admitted with acute kidney failure and morbid obesity, had no documentation in their electronic health record showing that they were educated on the risks and benefits of the influenza vaccine or that it was offered to them. During an interview, the facility's administrator stated that it was expected that residents be educated on the risks and benefits of available vaccines before they are offered.
Failure to Educate and Document COVID-19 Vaccine Offer
Penalty
Summary
The facility failed to offer, educate, and obtain consent for COVID-19 vaccines for two residents, identified as Residents 18 and 50, during a review of immunizations. Resident 18, who was admitted with diagnoses of heart failure, kidney disease, and diabetes, had refused the COVID vaccination. However, there was no documentation indicating that the resident was provided with education on the risks and benefits of the vaccine prior to making this decision. Similarly, Resident 50, admitted with acute kidney failure and morbid obesity, also lacked documentation in their electronic health record (EHR) regarding education on the risks and benefits of the COVID vaccine or an offer to receive it. During an interview, the Regional Nurse Consultant confirmed the absence of documentation for both residents, indicating a failure in the facility's process to ensure informed decision-making regarding COVID-19 vaccinations.
Failure to Provide Non-Disposable Cups During Meals
Penalty
Summary
The facility failed to ensure a dignified dining experience for residents by not providing non-disposable cups during meals across four sampled halls. Observations on multiple occasions revealed that staff were using plastic cups to serve beverages such as juice and milk to residents. This practice was consistent across the 100, 200, 300, and 400-halls, indicating a widespread issue within the facility. Interviews with staff members, including Certified Nursing Assistants (CNAs), revealed that the use of plastic cups was due to a shortage of non-disposable cups. Staff O mentioned the lack of sufficient non-disposable cups, while Staff N admitted to not checking the kitchen for additional supplies. Staff M, a recently hired CNA, confirmed that they were trained to use plastic cups. The Regional Nurse Consultant, Staff B, acknowledged that more cups had been ordered, but the floor staff had not been informed, leading to the continued use of disposable dishware.
Failure to Honor Resident's Right to Choose Life-Saving Interventions
Penalty
Summary
The facility failed to honor a resident's right to choose the level of life-saving interventions, specifically for Resident 39. The resident was admitted with diagnoses including pulmonary emboli, schizophrenia, and anxiety. Despite being deemed capable of making decisions during the admission assessment, a POLST form, which details the resident's wishes for life-saving measures, was not completed or reviewed with the resident. Instead, a provider note indicated a decision was made to transition the resident to a DNR/DNI status without the resident's input, citing their inability to make complex decisions. Interviews with facility staff revealed that the POLST form should have been reviewed and completed upon admission and then reviewed quarterly. Staff C, the Social Services Director, acknowledged that the POLST form was not completed as required. Staff B, the Regional Nurse Consultant, confirmed that the facility's protocol in the absence of a decision-maker would default to full code, which was not followed in this case. The lack of a completed POLST form and the resident being listed as DNR/selective treatment did not meet the facility's expectations.
Failure to Address Resident Grievance on Missing Property
Penalty
Summary
The facility failed to initiate and resolve a grievance for a resident regarding missing personal property. The resident, who was admitted with osteomyelitis and diabetes, reported missing black pajama bottoms to the Housekeeping Manager. Despite being informed, the Housekeeping Manager did not follow up or initiate a grievance, as they were unaware of their ability to do so. The grievance was not documented in the facility's Grievance Log, and the Interim Director of Nursing Services confirmed that a grievance should have been initiated if the issue could not be resolved immediately.
Failure to Provide Written Notification for Hospital Transfer
Penalty
Summary
The facility failed to provide written notification of the reason for transfer to the hospital to a resident or responsible party for one of the sampled residents reviewed for hospitalization. Resident 17, who was admitted to the facility with diagnoses including hypertension and chronic embolism, was able to make their needs known. The electronic health record indicated a discharge with anticipated return, but there was no documentation showing that the resident was provided a written notice for the reason of transfer. During an interview, the Social Services Director admitted that they did not consistently provide residents with written notice for the reason of transfer to the hospital.
Failure to Provide Bed Hold Notice for Hospitalized Residents
Penalty
Summary
The facility failed to provide a bed hold notice at the time of transfer to the hospital for two residents, which is a requirement under WAC 388-97-0120 (4). Resident 17, who was admitted with conditions including hypertension and chronic embolism, was hospitalized and later readmitted to the facility. However, there was no documentation in the electronic health record (EHR) indicating that a bed hold was offered to this resident. During an interview, the Social Services Director acknowledged the absence of documentation and confirmed that a bed hold should have been offered. Similarly, Resident 109, who was admitted with Crohn's disease, experienced a complication that necessitated hospitalization. The resident was readmitted to the facility after the hospital stay, but again, there was no documentation in the EHR that a bed hold was offered. The Social Services Director admitted to not offering a bed hold to Resident 109, and the Interim Administrator stated that it was their expectation that a bed hold should have been offered. This oversight placed the residents at risk of not being informed about their right to hold their bed during hospitalization, potentially affecting their quality of life.
Inaccurate Assessment of Resident's Smoking Status
Penalty
Summary
The facility failed to accurately assess a resident's smoking status, which led to inaccurate data in the resident's medical records. The resident, who was admitted with diagnoses including stroke, heart failure, and respiratory failure, was noted in the admission minimum data set (MDS) as not using tobacco. However, during an interview, the resident stated they smoked outside in the designated smoking area under staff supervision. This was corroborated by an observation of the resident smoking in the courtyard. Interviews with the Clinical Reimbursement/MDS Nurse and the Regional Nurse Consultant confirmed that the MDS was incorrectly coded and should have indicated tobacco use.
Failure to Update PASRR for Resident with New SMI Diagnosis
Penalty
Summary
The facility failed to obtain an updated preadmission screening and resident review (PASRR) for a resident who was newly diagnosed with significant mental illness (SMI). Resident 16 was admitted with a diagnosis of chronic obstructive pulmonary disease and initially had no significant mental illness according to the PASRR dated 10/20/2022. However, the resident later received diagnoses of major depressive disorder and psychotic disorder with hallucinations on 11/20/2023 and 04/24/2024, respectively. Despite these new diagnoses, the most recent PASRR dated 10/18/2023 still showed no SMI, and no further assessment was conducted. During an interview, the Social Services Director acknowledged that the facility's policy required reviewing PASRRs on admission and quarterly, and submitting a new one if needed, but this was not done for Resident 16.
Inaccurate PASRR Assessments for Two Residents
Penalty
Summary
The facility failed to ensure accurate completion of Pre-Admission Screening and Resident Review (PASRR) assessments for two residents, which could lead to unidentified mental health care needs. Resident 46 was admitted with osteomyelitis and anxiety, but their PASRR showed no serious mental illness indicators checked. The Social Services Director (SSD) acknowledged that the PASRR should have been reviewed, corrected, signed, and dated. Similarly, Resident 39, admitted with schizophrenia and anxiety, had a PASRR that was not signed or dated. The SSD confirmed that this PASRR should have been reviewed, signed, and dated, as per facility policy.
Failure to Provide Necessary ADL Assistance for Two Residents
Penalty
Summary
The facility failed to provide necessary assistance for activities of daily living (ADL) for two residents, leading to deficiencies in dressing and nail care. Resident 309, who required substantial assistance with lower body dressing due to a fracture, diabetes, and muscle weakness, was observed lying in bed in a facility-issued nightgown over several days. Interviews with staff revealed that Resident 309 was not offered the option to get dressed, and there was a lack of documentation regarding any refusals or interventions. Staff also noted that the resident did not have any clothes, which contributed to the failure to dress the resident. Resident 39, diagnosed with schizophrenia and anxiety, was observed with oily hair and dirty fingernails, indicating poor hygiene. The resident required supervision during bathing, but there was no documentation of bathing activities or refusals in the electronic health record (EHR) for the past 30 days. Interviews with staff indicated that Resident 39 frequently refused showers, but these refusals were not documented, nor were interventions developed to address the frequent refusals. The lack of documentation and failure to provide necessary ADL assistance placed both residents at risk for poor hygiene and diminished quality of life.
Failure to Implement Individualized Activities for Resident
Penalty
Summary
The facility failed to implement individualized activities for a resident, identified as Resident 309, who was reviewed for activities. Resident 309 was admitted with diagnoses including a fracture of the left femur, diabetes, and muscle weakness, and was capable of communicating their needs. Despite this, the resident expressed a desire to get out of bed and get dressed, but reported that no assistance was provided to do so. Additionally, the resident's television was not functioning, preventing them from watching TV, which was noted as a preferred activity in their care plan. Observations over several days showed Resident 309 remained in bed wearing a facility-issued nightgown, either looking at the ceiling or with eyes closed, indicating a lack of engagement in activities. The activity flowsheets for September and October 2024 showed no documented group, one-on-one, or independent activities for the resident. Interviews with staff revealed a lack of awareness regarding the resident's television status and responsibilities for documenting activities. Staff members, including a CNA and a Recreation Assistant, were either unaware of the television's functionality or had not interacted with the resident to facilitate activities.
Deficiency in Pressure Ulcer Care for a Resident
Penalty
Summary
The facility failed to adequately assess, document, and care plan necessary interventions for a resident with pressure ulcers, leading to a deficiency in pressure ulcer care. The resident, who was admitted with conditions including diabetes, peripheral vascular disease, and pressure ulcers in the sacral region and buttocks, did not receive a thorough admission assessment. The admission evaluation noted a deep tissue injury (DTI) to the sacrum, but no measurements were documented for this or other skin issues. Additionally, the care plan did not reflect the resident's current skin impairments or specify interventions for the DTI. A provider order was issued six days after admission for skin prep and gauze application to the buttocks, intended to prevent skin breakdown. However, this order was unclear, and the treatment was not provided as prescribed. The Regional Nurse Consultant confirmed that the necessary measurements and documentation for the DTI were not completed, and the resident's skin care did not meet expectations. This lack of comprehensive assessment and monitoring placed the resident at risk for unmet treatment and services.
Failure to Provide ROM Care for Two Residents
Penalty
Summary
The facility failed to provide appropriate care and services for two residents, Resident 27 and Resident 30, in maintaining or improving their range of motion (ROM) and mobility. Resident 27, who was admitted with diagnoses including anxiety, depression, and spinal cord injury with paralysis, reported that their passive range of motion (PROM) exercises had stopped about three months prior, leading to increased bending of their fingers towards their palms. The care plan for Resident 27 included PROM to all extremities, but there was no documentation found in the electronic health record (EHR) to confirm that these exercises were being performed. Staff interviews confirmed the absence of documentation for Resident 27's PROM program. Similarly, Resident 30, who was readmitted with diagnoses including anxiety, depression, and incomplete paraplegia, had requested to be placed on a restorative program after being discharged from physical therapy with recommendations for a restorative ROM program. However, no such program was provided, and there was no documentation in the EHR to indicate that a ROM program was set up for Resident 30. Staff interviews confirmed the lack of documentation and the ongoing efforts to establish the program. These deficiencies placed both residents at risk for worsening mobility and diminished quality of life.
Failure to Implement Fall Prevention Measures
Penalty
Summary
The facility failed to implement an identified intervention related to falls for a resident diagnosed with vascular dementia and absence of larynx. The resident was admitted with the ability to make needs known. The care plan, initiated in July 2024, included a goal to prevent injury from falls, with an intervention to review and update the fall risk assessment quarterly, post any fall, and as needed. However, after a fall on September 6, 2024, the facility did not complete a fall risk assessment nor update the care plan. The incident report from September 3, 2024, identified the root cause of the fall as a failed independent transfer due to the resident's self-transfers and vision deficits. The plan was to identify the best wheelchair position for transfers and mark a parking spot on the floor for optimal transfers. Despite this, an observation of the resident's room showed no parking spot on the floor. Additionally, a progress note from October 5, 2024, indicated the resident was on alert for an unwitnessed fall. During an interview, the Interim Director of Nursing Services acknowledged that the expected interventions and care plan updates were not met.
Failure to Implement Fluid Restrictions and Monitor Nutrition
Penalty
Summary
The facility failed to implement fluid restrictions, accurately monitor and document weights, and obtain ordered labs for Resident 209, who was reviewed for nutrition. Resident 209 was admitted with diagnoses including diabetes, dysphagia, hyperkalemia, and chronic kidney disease. The resident was supposed to be on a high protein dysphagia diet with nectar thick liquids and a 2000 ml fluid restriction, but the order did not include fluid restrictions. The care plan also lacked interventions for fluid restrictions, and there were no documented lab results despite orders for several tests. The resident's weights showed discrepancies, with significant fluctuations noted, and the nutritional evaluation indicated that the weights were incorrect. The resident was at nutritional risk due to advanced age, therapeutic diet, altered textures, wounds, diuretic use, and current diagnoses. Staff B, a Regional Nurse Consultant, acknowledged the failure in practice regarding fluid restrictions and the lack of a good system for lab orders, stating that the nutritional services did not meet expectations.
Deficiencies in Respiratory Care for Two Residents
Penalty
Summary
The facility failed to provide respiratory care consistent with professional standards for two residents, leading to deficiencies in their care. Resident 209, who was admitted with acute respiratory failure and other conditions, was observed receiving oxygen therapy inconsistently. Despite having a provider order to check oxygen saturation as needed, there was no documentation of these checks in the treatment administration record. Additionally, a provider note indicated the need for continuous pulse oximetry monitoring, but staff were not informed of this plan, resulting in unmet care needs. Similarly, Resident 55, admitted with diagnoses including stroke and acute respiratory failure, was observed multiple times without the prescribed continuous oxygen therapy. The provider order and care plan specified oxygen delivery at two liters per minute via nasal cannula, but this was not reflected in the resident's care. The medication administration record inaccurately documented that Resident 55 was receiving oxygen therapy, highlighting a discrepancy between the care plan and actual practice.
Failure to Act on Pharmacist's Recommendations for Medication Administration
Penalty
Summary
The facility failed to act on the consultant pharmacist's medication regimen review (MRR) recommendations in a timely manner for one resident, identified as Resident 24, who was reviewed for unnecessary medication use. The resident was admitted with diagnoses including chronic obstructive pulmonary disease, high blood pressure, and intervertebral disc degeneration. The MRR dated 09/18/2024 noted an irregularity in the electronic medication administration record (MAR) for the Salon pas lidocaine patch, which was missing a space for nurses to record patch removal. This irregularity was not addressed until 10/04/2024, 17 days after the pharmacist's recommendation. During an interview, Staff B, a Regional Nurse Consultant, acknowledged that the recommendation to record the patch removal was missed and not corrected in a timely manner, which did not meet the facility's expectations. This oversight placed the resident at risk for experiencing adverse side effects, medical complications, and a decreased quality of life, as the facility did not adhere to the pharmacist's recommendations promptly.
Failure to Conduct AIMS Assessment for Resident on Antipsychotic Medication
Penalty
Summary
The facility failed to conduct the Abnormal Involuntary Movement Scale (AIMS) assessment for a resident who was prescribed Seroquel, an antipsychotic medication. The resident, who had diagnoses including hypertension and chronic embolism, was admitted to the facility and had an order for Seroquel 25 milligrams to be administered daily at bedtime. Despite a provider note requesting the AIMS test on August 27, 2024, and a pharmacy consultation noting the absence of AIMS testing documentation within the last six months, the assessment was not completed. During an interview, the Interim Director of Nursing Services acknowledged that the AIMS testing was not conducted timely, which did not meet the facility's expectations.
Medication Storage and Labeling Deficiency
Penalty
Summary
The facility failed to ensure proper storage and labeling of medications in one of the two medication carts, specifically the 100-hall medication cart. During an observation, artificial tears eye drops were found without an expiration date, Vitamin D3 125 mcg was expired as of September 2024, glargine insulin had an open date of August 29, 2024, indicating it was expired, Lispro insulin lacked an open date, and aspirin 81mg was expired as of August 2024. This oversight was confirmed during an interview with a Licensed Practical Nurse (LPN), who acknowledged that medications should be dated when opened and monitored for expiration dates. Additionally, a Regional Nurse Consultant confirmed that the medication storage did not meet expectations.
Failure to Address Dental Needs
Penalty
Summary
The facility failed to assist with scheduling a dental appointment and address the dental needs of a resident, identified as Resident 30, who was reviewed for dental services. Resident 30 had been readmitted to the facility with diagnoses including anxiety, depression, and incomplete paraplegia, and was capable of communicating their needs. The resident reported that they had requested to see a dentist after a filling fell out of their bottom right tooth, which forced them to chew on the left side of their mouth. A nurse had informed the resident that a referral to a dentist had been made, but there were no updates in the resident's care plan regarding their dental needs. A provider's progress note indicated the need for a dental follow-up, but the facility did not meet the expectations of monitoring the resident's dental problems, updating the care plan, or ensuring a referral to a dentist was made.
Latest citations in Washington
Inaccurate PASARR screening affected two residents. One resident with vascular dementia, depression, and adjustment disorder had a PASARR level one that did not reflect mental health diagnoses, and staff stated it was inaccurate. Another resident with PTSD had a PASARR level one that did not include the PTSD diagnosis, with no additional PASARR level one or level two found in the EHR; staff stated the screening was not accurate and should have been repeated.
Undated open meds were found on 2 medication carts, including an open insulin vial and multiple open eye drop bottles with no dates. An LPN and an RN both stated the items should have been dated when opened, and the DON stated open multidose vials or bottles found without a date should be discarded immediately.
A resident with respiratory failure, HTN, and anxiety became SOB and diaphoretic, received a breathing tx, and was sent by EMS to the hospital. The facility could not locate the required SNF/NF to Hospital Transfer form or other transfer records showing what information was communicated to the receiving provider.
Care plans for two residents were not updated to match their current status and care needs. One resident had PTSD and generalized anxiety disorder and was receiving a psychotropic medication, but the care plan listed monitoring for antipsychotic and anticonvulsant meds that were not prescribed and did not include the anxiety diagnosis or related behaviors and interventions. Another resident had new upper and lower dentures, but the oral/dental care plan only noted edentulous status and difficulty chewing, with no mention of dentures or denture-related interventions.
Failure to Provide Individualized Activities: A resident with anxiety, depression, and weakness was cognitively intact but said they could not attend group activities because of leg problems and wanted more in-room activities. The resident mostly stayed in bed watching TV, and staff documentation showed only limited room visits with no consistent activity documentation despite a care plan goal for participation two to three times per week.
Failure to maintain heel offloading for a resident with a reopened DFU. A resident with dementia and dependence for mobility had a left heel wound that had healed and then reopened; the wound care provider recommended heel floating and pressure relieving boots at all times, but observations showed the resident in bed with heels on the mattress and later reclined in a wheelchair with the heel resting on the footrest strap and no boots in place. Staff stated the resident had not refused the boots or heel floating, and the care plan was not updated after the wound reopened.
Failure to Address Hearing and Vision Services for a Resident: A resident with dementia, bilateral hearing loss, and impaired vision was observed without eyeglasses or a hearing device, despite records showing admission with eyeglasses and a personal sound amplifier. The care plan addressed vision only and did not include hearing-related interventions, while staff interviews confirmed the resident’s hearing was strained and that the resident’s device use and vision needs were not fully reflected in the plan of care.
Respiratory care was not provided consistently for two residents receiving O2. One resident with COPD and chronic respiratory failure had an O2 order missing the indication for use and Sats parameters, no MAR documentation of O2 therapy, and inconsistent Sats charting. Another resident with respiratory failure was observed on continuous O2 via NC, but provider orders for O2 therapy and tubing changes were not present after readmission, despite the care plan stating the resident was dependent on O2.
A resident with dementia, hearing loss, and missing lower teeth had an MDS showing obvious or likely cavities or broken natural teeth, and the care plan identified oral/dental health problems with an intervention to coordinate dental care and transportation. Staff stated the resident’s dental needs were captured on the MDS, but no referral was made for dental services or follow-up with the dentist, and the DON said the lack of referral did not meet expectations.
Inaccurate Meal Intake Documentation: A resident with DM, dysphagia, and protein-calorie malnutrition was observed eating less than 25% of a meal, but the POC documented 76-100% intake. The CNA said the resident usually ate only 25-50% of meals and that intake was sometimes documented based on what a coworker reported. The LPN/RCM and DON stated meal intake should be documented accurately.
Inaccurate PASARR Screening for Two Residents
Penalty
Summary
The facility failed to ensure that two residents were screened for additional mental health supports through the PASARR process. Resident 97 was admitted with diagnoses including vascular dementia, depression, and adjustment disorder, and was able to make needs known. Review of the PASARR level one dated 04/10/2026 showed no mental health diagnoses and no need for a PASARR level two, even though the resident’s record included mental health diagnoses. During interview, the Regional Social Services staff and the Administrator stated the PASARR was inaccurate, needed modifications, and did not meet expectations. Resident 6 was admitted with diagnoses including heart failure, respiratory failure, and PTSD, and was able to make needs known. Review of the PASARR level one dated 03/30/2026 showed no serious mental illness indicators marked and no PASARR level two indicated, and the EHR contained no other documented PASARR level one or level two. The Social Services Director stated the hospital-provided PASARR was reviewed for accuracy and, if inaccurate, another level one would be completed, and stated this resident’s PASARR did not include PTSD and should have had another level one completed. The Administrator also stated the PASARR was not accurate and another level one needed to be conducted, but none could be located in the EHR.
Undated Open Medications on Medication Carts
Penalty
Summary
The facility failed to ensure proper storage and labeling of medications for 2 of 3 sampled medication carts reviewed for medication storage and labeling, including carts on the 400 and 500 halls. On the 500 hall medication cart, an open vial of insulin and an open bottle of eye drops were observed with no dates. During interview, an LPN stated that when an insulin vial or bottle of eye drops is opened, it should be dated immediately and said both items should have been dated upon opening; the LPN stated they would dispose of the undated vial and bottle. On the 400 hall medication cart, two open bottles of eye drops were observed with no dates. During interview, an RN stated both bottles should have been dated as soon as they were opened and said they would get new eye drops and dispose of the undated bottles. The DNS/RN stated that if an eye drop was opened it should have been dated immediately and that any open multidose vial or bottle found without a date should be discarded immediately.
Missing Hospital Transfer Documentation
Penalty
Summary
The facility failed to ensure hospital transfer documentation was completed for one resident who was transferred to the hospital after complaining of not being able to breathe and appearing diaphoretic. The resident had diagnoses of respiratory failure, high blood pressure, and anxiety disorder, and was able to make needs known. A breathing treatment was provided, and the provider agreed to send the resident out for further evaluation, after which emergency transportation took the resident to the hospital. Record review found no documentation showing what information was provided or communicated to the receiving facility for the transfer. Staff stated that transfer documentation should have included a SNF/NF to Hospital Transfer form, the resident's face sheet, and the medication and treatment administration records, but they were unable to locate documentation showing these items were completed or sent for the resident's hospital transfer.
Care plans did not reflect current diagnoses, medications, or denture status
Penalty
Summary
The facility failed to ensure that care plans were revised and accurately reflected residents’ current status and care needs for 2 of 21 sampled residents. Resident 6 was admitted with diagnoses including heart failure, respiratory failure, and PTSD, and was able to make needs known. The EHR showed Resident 6 also had generalized anxiety disorder and was receiving a psychotropic medication, but the current care plan dated 05/05/2026 documented monitoring for side effects of antipsychotic and anticonvulsant medications even though Resident 6 was not prescribed those medications. The care plan also identified PTSD but did not include generalized anxiety disorder or behaviors to monitor and interventions related to PTSD or anxiety disorder. Staff F, LPN/CC, stated the care plan did not accurately reflect the resident’s current status or prescribed medications, and Staff B, DNS, stated it did not meet expectations because it did not address the anxiety disorder or target behaviors and interventions. Resident 71 was admitted with diagnoses including PTSD, high blood pressure, and depression and was able to make needs known. Observation on 05/06/2026 showed a denture cup by the sink with the resident’s name on the lid and new upper and lower dentures dated 01/12/26. The resident stated the lower dentures did not fit well and that denture adhesive had been provided, but the dentures still did not fit right and the resident had not told staff yet. The focused oral/dental care plan, initiated on 06/23/2026, identified the resident as edentulous and having difficulty chewing, but did not show that the resident had dentures or include interventions related to denture use or maintenance. Staff E, CNA, stated they had not seen the resident wear dentures and were unaware of the new dentures, Staff C, LPN/CC, stated the care plan should have been updated when the dentures were obtained, and Staff B, DNS, stated the care plan should have reflected the dentures and interventions.
Failure to Provide Individualized Activities
Penalty
Summary
The facility failed to provide individualized activities for Resident 5, who was admitted with diagnoses including anxiety disorder, depression, and weakness. The admission MDS dated 01/14/2026 showed the resident was cognitively intact. During interviews on 05/03/2026 and 05/06/2026, Resident 5 stated they could not attend in-person activities because of their legs, wanted more activities to occupy them, mostly stayed in bed watching TV, and did not remember the last time activities staff visited to offer activities. The resident also stated activities staff would need to offer something they were able to do because they had difficulty doing some activities. The activities care plan dated 12/26/2026 showed a goal for Resident 5 to participate in activities two to three times per week. Progress notes documented one visit on 12/22/2026 to provide a welcome packet and encourage participation in daily activities, but no further activity documentation was found in the progress notes. Staff H stated room visits should include puzzles, arts and crafts, visiting, and chatting, and that documentation was placed in tasks, but the task record showed no documentation of activities for the past 30 days. Staff J stated paper documentation existed for room visits and that Resident 5 was on a list for room visits every Monday and Wednesday, while the room visit documentation showed only four visits on 01/26/2026, 02/06/2026, 03/10/2026, and 04/08/2026.
Failure to Maintain Heel Offloading for Reopened DFU
Penalty
Summary
The facility failed to consistently implement pressure reducing strategies for a resident with a left heel diabetic foot ulcer that had reopened. The resident was admitted with diagnoses including left hip fracture with surgical repair, a blood clot of the left lower leg, and dementia, and was dependent on staff for mobility and unable to make needs known. The baseline care plan and care plan both included heel offloading interventions, and the wound care provider initially recommended heel floating with pillows or wedge and pressure relieving boots. The wound later resolved, but a weekly skin assessment documented that the left heel wound reopened and was very painful to touch. After the wound reopened, the contracted wound care provider documented that the DFU to the left heel had reopened and recommended the resident wear pressure relieving boots at all times. The current care plan reviewed after the wound reopened did not include new interventions related to the reopened wound. Observations showed the resident seated in a reclined wheelchair with the left foot/heel resting on the footrest strap and no pressure relieving boots in place, and later lying in bed with both heels directly on the mattress without being floated and without boots. Staff interviews indicated the resident had not refused the boots or heel floating, and the LPN/CC and DON stated the resident should have been assessed and the plan of care updated when the wound reopened.
Failure to Address Resident Hearing and Vision Needs
Penalty
Summary
The facility failed to address one resident’s hearing and vision needs. Resident 112 was admitted with diagnoses including a leg fracture, dementia, and hearing loss in both ears, and was able to make needs known. The record showed the resident lost their glasses and was given readers, but the resident did not wear them because they were concerned that wearing glasses that were not their prescription would further degrade their vision. Observation did not show glasses in the resident’s room, and the resident stated they did not use a hearing aid. The resident was observed to be hard of hearing, requiring an elevated voice and repeated questions to understand. The admission MDS dated [DATE] documented adequate hearing with hearing aid and adequate vision with corrective lenses, while the significant change MDS dated [DATE] documented moderate difficulty hearing without a hearing aid and impaired vision without corrective lenses. The care plan initiated 02/24/2026 addressed impaired vision with interventions to arrange consultation with eye care practitioners as needed and remind the resident to wear glasses, but it did not include a focus area or interventions for hearing loss or use of hearing aids. A resident clothing list showed the resident admitted with one pair of eyeglasses and one Super Ear headset personal sound amplifier, yet observation and interview showed the resident in bed without eyeglasses or a hearing device, with the amplifier stored in the bedside table drawer. Staff interviews confirmed the resident’s hearing was strained, that the hearing device and glasses were not being used, and that the resident’s hearing device use should have been included in the plan of care and the resident should have been referred for eye care assessment.
Respiratory Care Orders and Documentation Not Maintained
Penalty
Summary
The facility failed to provide respiratory care consistent with professional standards of practice for two residents receiving oxygen therapy. One resident with COPD and chronic respiratory failure with hypoxia was observed multiple times lying in bed receiving oxygen at 2 L via nasal cannula. The resident’s oxygen order, dated 02/15/2026, allowed 1 to 4 L per minute continuously via nasal cannula, but it did not include an indication for use or oxygen saturation parameters. The April and May 2026 MARs did not show documentation of oxygen therapy being provided, and the TARs showed only an order to change oxygen tubing if damaged or visibly soiled, not an order for oxygen therapy. Oxygen saturations were not documented consistently daily from 04/01/2026 through 05/04/2026. A second resident with respiratory failure, high blood pressure, and anxiety disorder was observed in the room receiving oxygen at 6 L via nasal cannula on multiple occasions. The resident stated they needed oxygen therapy to breathe, and the care plan identified the resident as dependent on oxygen and to receive oxygen per provider orders. However, provider orders reviewed on 05/04/2026 showed no orders for oxygen therapy or for changing oxygen tubing. Staff stated the oxygen and tubing-change orders had been discontinued when the resident went to the hospital and were not added back to the MAR or TAR when the resident readmitted to the facility.
Failure to Refer Resident With Identified Dental Needs
Penalty
Summary
The facility failed to ensure that Resident 112 received needed dental care. Resident 112 was admitted with diagnoses including a leg fracture, dementia, and hearing loss in both ears. Observation on 05/03/2026 showed the resident had missing lower teeth. The admission MDS, dated [DATE], documented obvious or likely cavities or broken natural teeth, and the care plan dated 02/24/2026 identified oral/dental health problems related to likely cavities or broken teeth with an intervention to coordinate dental care and provide transportation. During interviews, Staff G, Regional Social Services, stated Resident 112's dental needs were captured on the 02/24/2026 MDS and the resident was not referred for dental services. Staff M, Social Services Director, stated residents with dental needs should be referred to social services to be scheduled for assessment by a dental care practitioner, and that Resident 112 should have been referred after the MDS assessment. Staff B, DON, stated residents with identified dental needs should be referred for follow-up with a dentist and that Resident 112 should have been referred to the in-house dental provider; Staff B stated the lack of referral did not meet expectations.
Inaccurate Meal Intake Documentation
Penalty
Summary
The facility failed to accurately document the amount of food eaten for Resident 13, who was admitted with diagnoses including diabetes mellitus, dysphagia, and protein-calorie malnutrition. The quarterly MDS dated 02/12/2026 showed the resident was moderately cognitively impaired. During observation on 05/05/2026 at 12:09 PM, a meal tray was delivered to the resident’s room, set up on a bedside table, and the resident was observed eating slowly, eating less than 25% of the meal, then laying back in bed and closing their eyes while the tray remained in the room. Staff later removed the tray, but the POC documentation for lunch on 05/05/2026 recorded that Resident 13 ate 76-100% of the meal. During interview, the CNA stated the resident typically ate 25-50% of meals and never ate all of the food, and that if they did not pick up a tray they would ask a coworker what the resident ate before documenting it. The CNA stated they were told the resident ate 75-100% of lunch, so that is what was entered. The LPN/RCM stated staff should document meal intake accurately in POC, and the RN/DNS stated it was their expectation that all staff document meal intake accurately.
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