Avamere At Pacific Ridge
Inspection history, citations, penalties and survey trends for this long-term care facility in Tacoma, Washington.
- Location
- 3625 East B Street, Tacoma, Washington 98404
- CMS Provider Number
- 505264
- Inspections on file
- 34
- Latest survey
- April 24, 2026
- Citations (last 12 mo.)
- 36
Citation history
Health deficiencies cited at Avamere At Pacific Ridge during CMS and state inspections, most recent first.
Medication Refrigerator Temperature Logs Not Consistently Maintained: The facility failed to consistently document refrigerator temperatures in 2 medication rooms where liquid meds and vaccines were stored. In one room, the thermometer read 28 degrees Fahrenheit, outside the required range, and review of the logs showed missing entries and inconsistent twice-daily monitoring. Staff acknowledged the documentation gaps and that the logs were not being maintained as required.
Psychotropic medication monitoring and documentation were incomplete for several residents. One resident received quetiapine without a documented indication or diagnosis, another received Seroquel without orthostatic BP monitoring, and two residents on routine antipsychotics did not have timely AIMS assessments. Staff confirmed the missing diagnosis, BP checks, and AIMS timing did not meet expectations.
Sharps containers on the 200 and 300 hall medication carts were observed with used needles visible and accessible, with needles stacked to the rim and the internal spinning mechanism not visible or not turning properly. The Administrator and RDQA stated that sharps with visible or accessible needles did not meet expectations and that used sharps were to be regularly emptied and fully enclosed at the bottom of the container.
Two residents had PRN acetaminophen given without consistent documentation of NPI attempts before administration. One resident with dementia and a right arm fracture had acetaminophen given multiple times, but the interventions were marked not applicable. Another resident with HTN, anxiety, and osteoporosis received acetaminophen for pain, but not applicable was documented instead of an NPI code, and no NPIs were recorded.
Failure to offer and educate on flu and pneumococcal vaccines for two residents. EHR review showed no documentation that one resident received influenza vaccine education for the season and no documentation that another resident received education on influenza or pneumococcal vaccination after admission. The RDQA stated residents were expected to be offered pneumococcal vaccines on admission and influenza vaccine annually, with risks and benefits explained and consent or declination completed, but this was not done for the two residents.
The facility failed to document COVID-19 vaccine education for two residents reviewed for vaccination status. EHR review showed no evidence that either resident received education on the risks and benefits of the vaccine, and there was no documented consent or declination form. A QA leader stated residents were expected to be offered the vaccine on admission with education and a completed consent/declination form, but this was not done for the two residents.
Failure to inform and review advance directives for two residents. Two residents, one with pressure wounds, DM, and bipolar disorder and another with CKD, DM, and dementia, were able to make needs known and were their own responsible parties without POA or guardian. Record review showed both had ADs noted in care conference documentation, but the facility only addressed end-of-life care decisions in the admission packet and care conference process rather than reviewing the residents' AD decisions as required.
Unsafe and Non-Cleanable Resident Room Conditions: Two residents were found with room conditions that were not homelike. One resident with dementia and other cognitive/psychiatric diagnoses had a large unrepaired wall area above the bed exposing brown cardboard-colored material, and staff stated it was not homelike. Another resident had a foam pool noodle taped to the bed footboard by a family member; an LPN and the Administrator stated it was not a cleanable surface and did not create a homelike environment.
Failure to initiate and resolve a resident grievance. A resident with HTN, depression, anxiety, and wheelchair use reported that another resident was speeding up and down the hallway in a wheelchair and nearly contacted their wheelchair. Staff were aware of the concern, but no grievance was logged when the issue was reported to the DON/DNS, and the Administrator stated it should have been initiated.
Failure to report an injury of unknown source: A resident with Alzheimer's disease, CHF, and anxiety had a large bruise to the right breast documented as purple/maroon with yellowing at the edges. The resident could not explain the cause due to cognitive impairment and baseline confusion, yet the incident was logged as small bruises in vulnerable areas with no report made to the State Hotline. An RCM/LPN stated the bruise should have been reported because of its location.
Failure to investigate unexplained bruising: A resident with Alzheimer’s disease, CHF, and anxiety had a large bruise noted on the R breast, but the incident was logged only as small bruises in vulnerable areas with no further action and no State report. The RCM/LPN and Administrator both stated an incident report/investigation should have been completed, but no documentation could be located.
Failure to Provide Transfer/Discharge Notices and Bed-Hold Documentation: The facility did not ensure that two residents received proper transfer/discharge notices and/or bed-hold offers after hospital transfers. One resident’s transfer/discharge notice was left blank for the resident or representative, and another resident’s record showed no documentation of a bed-hold offer and no resident/representative signature on the notice, despite the resident being able to make needs known and having multiple chronic conditions.
Inaccurate comprehensive assessments for dental and skin conditions. A resident’s MDS listed the resident as edentulous even though observation showed damaged lower teeth and no upper teeth, and an RCM/LPN and the Regional Director of QA both stated the dental coding was inaccurate. Another resident had a documented right lower extremity ulcer and scrotal skin issues with ongoing TAR treatments, but the quarterly MDS recorded no skin issues; the MDSC/RN and QA director stated the skin coding was inaccurate.
Incomplete care plans and missed care conferences: The facility did not fully complete care plans for two residents. One resident with UTI/ESBL, DM, and a foot infection had no care plan focus, goals, or interventions for the ESBL infection or precautions, despite antibiotic orders. Another resident with HTN, depression, and anxiety reported not participating in a recent care conference, and the EHR showed the last conference was months earlier; the SSD and Administrator confirmed a quarterly care conference was missed.
Failure to address a resident’s hearing needs and hearing aid use. A resident with diagnoses including metabolic encephalopathy and repeated falls reported using hearing aids at home, but the aids were left there before admission. Staff observed the resident could hear only when spoken to in a raised voice, and a provider note documented significant hearing impairment with repeated requests for clarification. The care plan did not include hearing or hearing aid use, and an RCM/LPN and the QA director acknowledged the resident’s hearing needs were not addressed in the plan of care.
Incomplete Diabetic Nail Care: A resident with DM, polyneuropathy, and vascular dementia required extensive ADL assistance and had an order for weekly diabetic nail care. Observations showed the resident’s toenails were long, curved, and discolored, while an LPN signed off on nail care that was limited to fingernails only. The LPN stated the toenails were not included, and the RCM/LPN said nursing staff were expected to complete both fingernails and toenails with weekly diabetic nail care.
A resident with stroke, vascular dementia, and kidney failure was non-verbal and unable to make needs known, yet the facility did not develop or implement an individualized activity plan. The care plan had incomplete activity focus, goals, and interventions, and activity flow sheets showed the resident was not offered or participated in any individual or group activities. Observations showed the resident lying in bed awake looking at the ceiling or wall, with the TV in the room not on during the observations.
Fluid Restriction Not Followed for a Resident: A resident with CHF, ESRD, and respiratory failure was on an 1800 ml fluid restriction, but nursing, dietary, and nursing aide documentation showed the resident received more fluid than allowed on multiple days. The MAR documented nursing fluids, the tray card documented dietary fluids, and a fluid tracking form documented additional fluids, but the totals were not combined in the record review, and the resident consumed amounts above the ordered restriction.
A resident with dementia, diabetes, heart failure, and a right arm fracture was receiving Seroquel for vascular dementia without behaviors. Psychiatry recommended Keppra levels, consideration of a neurology consult, and discontinuation of Celexa due to possible mania, but the EHR showed the Keppra levels were not obtained and Celexa was not stopped. The resident later had a fall with injury and was sent to the hospital.
A resident with Alzheimer's Dementia, chronic pain, and diabetes was rarely or never understood, had short-term memory problems, made poor decisions, and needed extensive ADL assistance. The EHR showed no care plan for the dementia diagnosis and no behavior monitoring on the MAR, and an RCM/LPN stated they could not locate a dementia care plan for the resident.
Failure to address a resident’s denture needs. A resident with damaged lower teeth and no upper teeth stated their upper denture was at home, but the denture need was not included in the care plan. The MDS identified the resident as edentulous, and the nutritional assessment noted missing teeth, absent dentures, and risk for altered nutrition/hydration status related to missing teeth. An RCM/LPN and the Regional Director of QA both stated the resident’s dental needs should have been included in the plan of care and that the resident should have been referred for new dentures.
A resident with multiple serious conditions, including DVTs and a history of PE, was discharged from the hospital with a daily warfarin order that was later discontinued in the facility’s EHR without documented reason or replacement anticoagulant. No warfarin doses were given for several days, during which the resident developed increased swelling and worsened breathing, leading to hospital transfer where staff confirmed the missed doses and restarted warfarin and IV anticoagulation. The facility’s investigation found a communication and order-entry breakdown when the anticoagulant was discontinued and not resumed, and no follow-up occurred to clarify or reinstate anticoagulation despite the active DVT diagnosis.
A resident admitted with a lower leg wound did not receive a full wound assessment on admission, and weekly wound monitoring and documentation were inconsistent. Nursing staff failed to record wound measurements and changes as required, and concerns about wound progression, including exposed tendon and odor, were not promptly escalated. The resident's condition worsened, resulting in hospital transfer for surgical debridement due to necrotizing fasciitis.
A resident with sleep apnea who required a CPAP device and a shower chair was discharged without these essential items due to failures in discharge planning and coordination among staff. The discharge plan did not address the resident's equipment needs, and staff interviews confirmed that necessary orders and arrangements were not made prior to discharge.
The facility failed to accurately complete PASARR assessments for four residents, risking unidentified mental health needs. A resident with Alzheimer's and depression was not referred for a Level II evaluation despite SMI/ID conditions. Another resident with anxiety and depression also lacked a Level II referral. Two residents with dementia and depression had incomplete or missing PASARR forms, which did not meet facility expectations.
A resident with a therapeutic diet requiring easy to chew foods was served meals that did not meet these dietary needs, including fried chicken and country fried steak. The facility staff, including a Registered Dietician and the Administrator, confirmed that the meals provided did not align with the prescribed diet, placing the resident at risk of choking and diminishing their quality of life.
The facility failed to maintain sanitary conditions in the kitchen, with staff items improperly stored in the walk-in refrigerator and near the tray line. Observations also revealed inadequate hand hygiene practices, as staff turned off water with bare hands and failed to wash hands after retrieving items from the floor. These actions did not meet the facility's expectations, as confirmed by the Dietary Services Manager and the Administrator.
The facility failed to maintain a homelike environment by not addressing maintenance issues such as gouges and peeling paint in shared bathrooms and rooms, and by using plastic utensils due to a shortage of metal silverware. Staff acknowledged these issues were not reported or addressed in a timely manner, affecting the residents' quality of life.
A facility failed to assist three residents with ADLs, including nail care and grooming. One resident with diabetes had long, yellowed nails despite a care plan for weekly nail care. Another resident with adult failure to thrive was observed with disheveled hair and dark sediment under fingernails, while a third resident dependent on staff for care was repeatedly seen with disheveled hair and a call light out of reach. Staff interviews confirmed the lack of adequate care.
The facility failed to implement pharmacist recommendations for two residents, leading to a deficiency in medication management. A resident's recommendations for diclofenac gel and rivaroxaban were not addressed, and another resident's medication decrease was delayed. Staff interviews confirmed delays in reviewing MRRs, placing residents at risk for adverse effects.
The facility failed to properly store and label medications, with missing temperature logs for a medication refrigerator and undated or expired medications found in two medication carts. Staff interviews revealed a lack of awareness regarding medication expiration and documentation requirements.
The facility failed to ensure proper PPE use for three staff members across three halls, with observations showing entry into rooms with posted precautions without necessary PPE. Additionally, there was a lack of documentation for N95 fit testing for several staff members. The facility also did not maintain ongoing infection control data collection and analysis for three months, with missing documentation for December 2024 and incomplete tracking for January and February 2025.
The facility failed to administer influenza and pneumococcal vaccines to three residents, despite their consent and the facility's policy. A resident with asthma was not documented as having received the influenza vaccine, another with hemiplegia was not offered the pneumococcal vaccine, and a third with respiratory failure consented to the pneumococcal vaccine but did not receive it. Staff interviews confirmed the lapse in following vaccination protocols.
The facility failed to offer and provide COVID-19 vaccines to two residents. One resident, admitted with diabetes, consented to the vaccine, but there was no record of administration. Another resident, with hemiplegia and a brain bleed, had no documentation of being offered the vaccine. Staff interviews confirmed the facility's protocol to offer vaccines on admission and annually was not followed.
The facility failed to ensure CNAs received the required 12 hours of in-service training, including dementia management, and did not maintain oversight of their performance evaluations. Interviews revealed a lack of access to training records, and staff reported not receiving recent evaluations. This deficiency placed residents at risk for unmet care needs.
A facility failed to obtain signed consent before administering Divalproex, a mood stabilizer, to a resident with major depression, altered mental status, and dementia. The resident, unable to communicate needs, received the medication for violent behavior without documented consent. Staff confirmed the lack of consent did not meet expectations.
A facility failed to obtain and periodically review an advanced directive (AD) for a resident with depression and anxiety disorder. Despite the resident's ability to communicate needs, there was no AD in place, and incorrect documentation indicated otherwise. Interviews with staff revealed a lack of awareness and documentation regarding the resident's AD status, which did not meet facility expectations.
A facility failed to assess and obtain consent for the use of physical restraints for a resident with dementia and high fall risk. The resident was observed in a tilt-in-space wheelchair and a low bed positioned against a wall, without documented assessment or consent. Staff confirmed these items could be used as restraints and should have been assessed and consented to prior to use.
A facility failed to transmit the MDS for a resident to CMS within the required timeframe. The resident was admitted and later discharged, with both the Medicare-5 Day MDS and discharge MDS completed but not submitted. Staff interviews revealed that MDS transmissions were conducted weekly, but the resident's assessments were missed due to an oversight. An audit was being conducted to address the issue.
A facility failed to accurately code the MDS for a resident who experienced an 11.72% weight loss over six months. Despite the resident's report of poor food taste and suspected weight loss, the MDS inaccurately documented no significant weight loss. Staff interviews confirmed the coding error.
The facility failed to develop comprehensive care plans for two residents, leading to deficiencies in addressing their specific needs. One resident experienced multiple falls without updated interventions in their care plan, while another resident with cerebral palsy and contractures lacked a plan for managing their condition. Staff interviews confirmed these omissions did not meet expectations.
A resident's care plan was not revised to reflect changes in diagnoses and medication orders. The care plan inaccurately included a dementia diagnosis and an intervention for a discontinued nutritional supplement. Additionally, it failed to document the use of an anticoagulant medication and monitoring for side effects, leading to unmet care needs and inaccurate documentation.
The facility failed to meet professional standards of care for several residents, including not notifying providers when medications were held, not following pain medication parameters, and not documenting necessary interventions. These actions placed residents at risk for unmet care needs and diminished quality of life.
A facility failed to provide an adequate activity program for two residents, one with schizophrenia and another with a history of stroke and dementia. Both residents were observed without engagement in their preferred activities, such as TV or music, despite care plans indicating these needs. Staff interviews revealed a lack of consistent implementation and documentation of activities, leading to a deficiency in meeting the residents' needs for engagement and stimulation.
The facility failed to provide care according to professional standards and care plans for several residents. A resident wore a brace without a provider order, another was not repositioned regularly to prevent skin issues, a third did not have a required knee immobilizer applied, and a fourth did not receive necessary bowel management interventions. Staff interviews confirmed these lapses in care.
A facility failed to provide necessary services to maintain or improve the range of motion for a resident with contractures. The resident, diagnosed with cerebral palsy and other conditions, was observed with rigid fingers and reported no care was provided for their hands. The care plan lacked instructions for range of motion exercises, and staff confirmed the management of the resident's contractures was inadequate.
The facility failed to maintain the required length for a bathroom emergency call light cord, which was positioned too high in a shared bathroom, potentially delaying emergency response. Observations and interviews revealed that the cord was not reported for correction in the TELS system, and both the Maintenance Director and Administrator were unaware of the issue. This placed residents, including one with multiple health conditions, at risk of being unable to reach the call light in an emergency.
A facility failed to monitor and document a resident's bi-weekly weights as ordered, despite the resident's diagnoses of malnutrition, anxiety disorder, and depression. The resident expressed concerns about food quality and potential weight loss. Staff interviews confirmed the failure to adhere to provider orders, placing the resident at risk for medical complications.
The facility failed to provide timely dental services for two residents. One resident, with malnutrition and diabetes, could not wear dentures due to discomfort and was not seen by the dentist as needed. Another resident, with hemiplegia and diabetes, had dental issues identified but lacked follow-up on recommended care. Staff acknowledged the mishandling of dental care for both residents.
A long-term care facility failed to properly manage enteral nutrition for four residents, leading to significant health risks. One resident suffered aspiration pneumonia due to improper bed positioning and overfeeding, while another received thin liquids against physician orders. Additionally, there were issues with syringe labeling and head elevation during feeding for other residents, increasing the risk of adverse outcomes.
Medication Refrigerator Temperature Logs Not Consistently Maintained
Penalty
Summary
The facility failed to consistently maintain medication refrigerator temperature logs in 2 of 2 medication rooms reviewed for medication storage, including the 100/200 hall medication room and the 300/400 hall medication room. The facility policy titled, Medication Storage, required refrigerated medications to be kept between 36 and 46 degrees Fahrenheit and required a temperature log or tracking mechanism to verify temperatures remained within accepted limits. It also required the temperature of any refrigerator storing vaccines to be monitored and recorded twice daily. In the 100/200 hall medication room, observation showed various liquid medications, including vaccines, stored in the refrigerator, and the thermometer read 28 degrees Fahrenheit, which was outside of parameters. Review of the April 2026 refrigerator temperature logs showed missing documentation and that temperatures were not consistently monitored and documented twice a day. In the 300/400 hall medication room, observation also showed various liquid medications, including vaccines, stored in the refrigerator, and review of the April 2026 logs showed missing documentation and inconsistent twice-daily monitoring. Staff E, Staff K, and the Administrator each acknowledged that the logs were not consistently documented twice daily and that this did not meet expectations.
Psychotropic Medication Monitoring and Documentation Deficiencies
Penalty
Summary
The facility failed to consistently monitor potential adverse side effects related to psychoactive medication use for four sampled residents. Resident 2, who was admitted with diagnoses including cerebral infarction, dementia, and COPD and was able to communicate needs, had an admission MDS showing antipsychotic use without behaviors. The provider order dated 02/13/2026 showed quetiapine 25 mg at bedtime without an indication or diagnosis. During interview, the RCM/LPN stated Resident 2 should have had an indication and diagnosis with the quetiapine order. Resident 11, who was admitted with diagnoses including a right arm fracture, dementia, diabetes, and heart failure and was not able to communicate needs, had a significant change MDS showing antipsychotic use. The provider order dated 03/10/2026 showed Seroquel 25 mg twice daily for vascular dementia without behaviors, and the EHR for March 2026 did not show orthostatic blood pressure results. Resident 14, who had schizoaffective disorder-depressive type, anxiety disorder, and PTSD and was able to make needs known, received routine antipsychotic medication, but the last AIMS assessment in the record was dated 09/09/2026. Resident 69, who had Alzheimer’s disease, CHF, and depression and was unable to make needs known, also received antipsychotic medication, and the record showed AIMS assessments on 04/01/2025 and 01/06/2026; staff stated the 01/06/2026 AIMS was conducted late. Staff interviews confirmed that antipsychotic use should have had appropriate diagnosis or indication, orthostatic blood pressure monitoring should have been completed for Resident 11, and AIMS assessments should have been completed every six months for residents receiving antipsychotic medications.
Sharps Containers Not Kept Closed and Accessible
Penalty
Summary
The facility failed to ensure sharps containers were regularly emptied and that used sharps were inaccessible to residents for 2 of 4 sampled sharps containers on the 200 hall and 300 hall. On 04/24/2026 at 10:18 AM, observation of the 200 hall medication cart showed a sharps container affixed to the side with used needles visible and accessible, stacked flush to the rim, and the spinning part that would allow needles to fall to the bottom was not visible because of the amount of needles stacked on top. On 04/24/2026 at 10:20 AM, observation of the 300 hall medication cart showed a sharps container with a few visible needles, and the spinning part did not turn when needles were inserted, with needles beginning to stack on top. During interviews, the Administrator stated that sharps containers with visible or accessible needles did not meet expectations, and the Regional Director of Quality Assurance stated that used sharps were to be regularly emptied and fully enclosed at the bottom of the container.
Failure to Document Non-Pharmacological Interventions Before PRN Pain Medication
Penalty
Summary
The facility failed to consistently provide non-pharmacological interventions before administering as-needed acetaminophen for 2 of 5 sampled residents, Residents 11 and 14. Resident 11 was admitted with diagnoses including a right arm fracture, dementia, diabetes, and heart failure and was not able to communicate needs. The April 2026 MAR showed acetaminophen was given as needed seven times, and the order required nonpharmacological interventions to be offered before the pain medicine was administered; however, the interventions were documented as not applicable. Resident 14 was readmitted with diagnoses including high blood pressure, anxiety disorder, and osteoporosis and was able to make needs known. The April 2026 MAR showed an order for as-needed acetaminophen with documentation of NPI attempted prior to giving the medication and listed NPIs including a code for refusal. On 04/07/2026, acetaminophen was given for pain, but not applicable was documented instead of an NPI code, and no NPIs were documented. The TAR also showed an order to document pain scale rating each shift and record intervention and effectiveness every day and night shift, with pain level documented as 0 each shift.
Failure to Offer and Educate on Flu and Pneumonia Vaccinations
Penalty
Summary
The facility failed to offer and provide education on influenza and pneumococcal vaccinations for 2 of 5 sampled residents, Residents 21 and 10, as documented by interview and record review. Resident 21 was admitted on 07/02/2022, and the electronic health record contained no documentation that the facility provided education on the risks and benefits of the influenza vaccine for the 2025/2026 season. Resident 10 was admitted on 01/10/2026, and the electronic health record contained no documentation that the facility provided education on the risks and benefits of the influenza vaccine or the pneumovax vaccine in 2026. During interview, Staff C, Regional Director of Quality Assurance, stated the expectation was that all residents be offered pneumococcal vaccines on admission and influenza vaccine annually, with education on risks and benefits and a consent or declination form completed, and stated this was not done for Residents 21 and 10.
Failure to Document COVID-19 Vaccine Education and Consent
Penalty
Summary
The facility failed to ensure COVID-19 vaccination education was documented in the medical record for 2 of 5 sampled residents, Residents 10 and 7, who were reviewed for COVID-19 vaccinations. Review of Resident 10's electronic health record showed an admission date of 01/10/2026, but there was no documentation that the facility provided education on the risks and benefits of the COVID-19 vaccine. Review of Resident 7's electronic health record showed an admission date of 02/11/2026, and there was also no documentation that the resident was provided education on the risks and benefits of the COVID-19 vaccine. During an interview on 04/24/2026 at 11:39 AM, Staff C, Regional Director of Quality Assurance, stated it was the facility's expectation that all residents be offered the COVID-19 vaccine on admission with education on risks and benefits and a consent/declination form completed, and stated this was not done for Residents 7 and 10.
Failure to Inform and Review Advance Directives
Penalty
Summary
The facility failed to inform residents of their right to formulate an advance directive and failed to periodically review residents' decisions regarding advance directives for 2 of 3 sampled residents, Residents 57 and 63. Resident 57 was admitted with diagnoses including a pressure wound of the lower back, diabetes, and bipolar disorder, was able to make needs known, and was listed as their own responsible party without a power of attorney or guardian. Resident 63 was admitted with chronic kidney disease, diabetes, and dementia, was also able to make needs known, and was listed as their own responsible party without a power of attorney or guardian. Record review showed both residents had an advance directive noted in Care Conference Information evaluations, but the facility did not review the residents' advance directive decisions as required. Staff J, the Social Services Director, stated the advance directive referenced in the evaluations related to end-of-life care decisions and said the facility was unsure how advance directives were being reviewed. Staff J later stated advance directives should be reviewed on admission, quarterly, and as needed, but the facility was only reviewing end-of-life care decisions in the admission packet and Care Conference Information evaluation, not the residents' advance directives. Staff A, the Administrator, stated the facility reviewed advance directives through the admission packet and they should be reviewed at the quarterly care conference.
Unsafe and Non-Cleanable Resident Room Conditions
Penalty
Summary
The facility failed to maintain a safe, clean, comfortable, and homelike environment for 2 of 17 sampled residents. Resident 10 was admitted with diagnoses including Wernicke's encephalopathy, dementia, and delusional disorder, and was unable to make needs known. Observation showed a large damaged circular area about one foot in diameter above Resident 10's bed, exposing brown cardboard-colored material beneath. The damage was observed on 04/20/2026 and was still unrepaired on 04/24/2026. The Maintenance Director stated the wall damage should have been reported through the electronic maintenance system so repairs could be completed and said the damaged wall was not homelike. The Administrator also stated that one-foot diameter wall damage was not homelike. Resident 48 was readmitted with diagnoses including heart failure and depression and was able to make needs known. Observation showed the footboard of Resident 48's bed had a foam noodle/pool noodle taped to the top, which the resident said had been placed there by a family member. The Resident Care Manager/LPN stated the taped pool noodle did not create a homelike environment and was not a cleanable surface, and that the issue needed follow-up to determine whether a cleanable device could be used instead. The Administrator also stated the pool noodle on the footboard was not a cleanable surface and that a medical-grade device would need to be considered to create a homelike environment and provide a cleanable surface.
Failure to Initiate and Resolve a Resident Grievance
Penalty
Summary
The facility failed to initiate, investigate, and resolve a grievance for Resident 50, who was readmitted with diagnoses including high blood pressure, depression, and anxiety disorder and used a wheelchair for mobility. Resident 50 was able to make needs known and reported that Resident 27 sped up and down the hallway in a wheelchair very fast all day, and that on one occasion Resident 27's wheelchair wheel got caught in Resident 50's wheelchair before moving around it. Resident 50 stated staff were aware of the concern. Review of the grievance log from November 2025 through April 15, 2026 showed no grievance was logged for this safety concern. The Administrator stated Resident 50 had been evaluated by physical therapy for wheelchair safety after reporting the concern to the DNS, but a grievance was not initiated when the concern was reported to the DNS.
Failure to Report Injury of Unknown Source
Penalty
Summary
The facility failed to ensure an injury of unknown source was reported to the State Hotline for Resident 42. Resident 42 was admitted with diagnoses including Alzheimer's disease, congestive heart failure, and anxiety, and was able to make needs known. The February 2026 accident and incident log documented an entry for 02/28/2026 describing small bruises in areas generally vulnerable to trauma, with no further action taken and no report made to the State Agency. However, a 02/28/2026 progress note documented a large bruise to the right breast, described as purple/maroon with yellowing at the edges, and noted that Resident 42 was unable to recall or explain the cause of the bruising due to cognitive impairment and baseline confusion. During interview, the RCM/LPN stated the resident could not explain the injury because of cognitive impairment and that the location of the bruise meant it should have been reported to the State Hotline.
Failure to Investigate Unexplained Bruising
Penalty
Summary
The facility failed to thoroughly investigate a potential abuse and/or neglect incident involving a resident with Alzheimer's disease, congestive heart failure, and anxiety who was able to make needs known. The February 2026 incident log documented small bruises in areas generally vulnerable to trauma and indicated no further action was taken, with the incident not reported to the State Agency. However, a progress note from the same date documented a large bruise to the right breast, described as purple/maroon with yellowing at the edges, and stated the resident was unable to recall or explain the cause of the bruising due to cognitive impairment and baseline confusion. During interviews, the RCM/LPN stated an incident report should have been completed but could not locate an investigation, and the Administrator stated they could not locate any documentation related to the incident and that an investigation should have been completed.
Failure to Provide Transfer/Discharge Notices and Bed-Hold Documentation
Penalty
Summary
The facility failed to ensure that residents received a transfer/discharge notice and/or were offered a bed hold for 2 of 3 sampled residents reviewed for hospitalization and discharge. Resident 6 was admitted to the facility and later discharged to the hospital, but the nursing home transfer or discharge notice was not given to the resident or the resident’s representative, and the form was left blank in that area. Staff M stated the admission department would follow up after hospital discharge, offer a bed hold, complete the transfer or discharge notice, and send it to the ombudsman, while Staff C stated Resident 6’s transfer or discharge notice to the hospital did not meet expectations. Resident 12 was readmitted to the facility with diagnoses including diabetes, heart failure, and an anxiety disorder, and was able to make needs known. The resident stated they had gone to the hospital but did not recall whether the facility offered or provided a bed hold. The nursing home transfer or discharge notice showed the resident was notified of transfer to the hospital, but the form was signed by a staff member and not by Resident 12 or the resident’s representative. The record also showed no documentation that Resident 12 was offered or provided a bed hold. Staff A stated it was the facility’s expectation that transfer/discharge forms and bed holds be provided to the resident and/or representative, and stated they were not aware that Resident 12 had not been offered/provided a bed hold or had a signed transfer or discharge notice.
Inaccurate comprehensive assessments for dental and skin conditions
Penalty
Summary
The facility failed to ensure the comprehensive assessment was accurate for Resident 35’s dental condition. Resident 35 was admitted with diagnoses including spondylosis with myelopathy, metabolic encephalopathy, and repeated falls, and was able to make needs known. On observation, Resident 35 had damaged lower teeth and no upper teeth, but the 5-day MDS described the resident as edentulous. During interview, the RCM/LPN stated Resident 35 had lower teeth and that the 5-day MDS was inaccurate and needed correction; the Regional Director of QA also stated the MDS was inaccurate for dental status and did not meet expectations. The facility also failed to accurately assess Resident 3’s skin condition on the quarterly MDS. Resident 3 was readmitted with diagnoses including heart failure, peripheral vascular disease, a non-pressure chronic ulcer of the right calf, and inflammatory disorders of the scrotum, and was able to make needs known. Resident 3 stated they had a wound along the right leg that was wrapped and treated by staff. The care plan included a non-pressure chronic ulcer of the right calf/ankle and lymphedema to the scrotum, and the March and April 2026 TARs showed treatment for wounds/impaired skin on the right lower extremity and scrotum. However, the quarterly MDS documented no skin issues. The MDSC/RN stated the MDS was not coded for impaired skin integrity and should have been, and the Regional Director of QA stated it was not coded accurately and needed to be modified to reflect the resident’s skin status.
Incomplete care plans and missed care conferences
Penalty
Summary
The facility failed to complete care plans within 7 days of the comprehensive assessment and to have them prepared, reviewed, and revised by a team of health professionals for 2 of 17 sampled residents. Resident 12 was re-admitted with diagnoses of UTI with ESBL, diabetes, and a foot infection. Provider orders dated 04/19/2026 showed antibiotics were ordered for the ESBL and foot infection, but the care plan reviewed on 04/23/2025 did not include a focus, goal, or interventions for the ESBL infection or the precautions that should be used. During interview, the Resident Care Manager/LPN stated Resident 12 should have the ESBL/UTI infection and precautions on the care plan, and the Regional Director of QA stated the care plan did not meet expectations about ESBL. Resident 50 was re-admitted with diagnoses including HTN, depression, and anxiety disorder and was able to make needs known. The resident stated it had been a while since participating in a care conference and did not remember attending one recently. The EHR showed the last care conference was held on 11/26/2025. The SSD stated care conferences were to be conducted initially within the first 7 to 10 days after admission and then quarterly and/or as needed, and that Resident 50 should have had another quarterly care conference in February 2026 that did not occur. The Administrator also stated another care conference should have been conducted and that they were unable to locate an invite for it in the resident's EHR.
Failure to Address Hearing Needs and Hearing Aid Use
Penalty
Summary
The facility failed to ensure Resident 35 was assessed for hearing needs, obtained needed hearing devices, and had hearing device use included in the plan of care. Resident 35 was admitted with diagnoses including spondylosis with myelopathy, metabolic encephalopathy, and repeated falls, and was able to make needs known. During an interview and observation, Resident 35 stated they used hearing aids at home and had left them there before coming to the facility. Observation showed the resident could hear questions only when the speaker raised their voice to a soft yell. The plan of care initiated on 02/12/2026 did not include a focus area related to hearing or hearing aid use. A provider encounter note dated 02/20/2026 documented significant hearing impairment, with repeated questions and clarification needed during the interview and frequent requests for repetition due to hearing difficulties. During interviews, the RCM/LPN stated the resident was hard of hearing, required a raised voice to communicate, and would benefit from a device to increase hearing; the staff member also stated they were unaware the resident had hearing aids at home and that the facility should have reached out to obtain them. The RCM/LPN later stated the resident's hearing difficulties and hearing aid use should have been included in the plan of care. The Regional Director of QA stated the facility should have attempted to obtain the hearing aids and, if unsuccessful, referred the resident to a hearing specialist to obtain new hearing aids.
Incomplete Diabetic Nail Care
Penalty
Summary
The facility failed to provide complete nail care for one resident who required extensive staff assistance with ADLs. The resident was admitted with diabetes, polyneuropathy, and vascular dementia. On observation, the resident was lying in bed with feet in pressure-relieving boots, and the toenails on both feet were long, curved, and discolored. The provider had ordered diabetic nail care weekly on Wednesdays, but the resident’s toenails remained long, curved, and discolored on subsequent observations. The April MAR showed that an LPN signed off on diabetic nail care on 04/22/2026. During interview, the LPN stated diabetic nail care included both toenails and fingernails, but said the care completed for the resident was filing of the fingernails only and the toenails were not included. The LPN stated thick toenails would be referred to podiatry, but did not explain why the resident’s toenails were not completed and said they would be done when there was time. The RCM/LPN stated the expectation was for nursing staff to complete both fingernails and toenails with weekly diabetic nail care, and that referral was only needed if there was a provider order or if the resident had thick toenails.
Incomplete individualized activity plan and no documented activity participation
Penalty
Summary
Provide activities to meet all resident's needs. Based on observation, interview, and record review, the facility failed to develop and implement an individualized activity plan for Resident 61, who was admitted with diagnoses of stroke, vascular dementia, and kidney failure and was non-verbal and unable to make needs known. The resident's care plan had incomplete activity focus, goals, and intervention areas. Observations on 04/20/2026, 04/21/2026, and 04/22/2026 showed the resident lying in bed awake looking at the ceiling or wall, with a television present in the room but not observed on during any of the observations. Review of the March and April 2026 activity flow sheets showed the resident was not offered and did not participate in any individual or group activities. During interview, the Activity Director reviewed the record and stated staff should have contacted the resident's representative to assist with the activity care plan and that the resident had not been offered any independent or group activities, which did not meet expectations.
Fluid Restriction Not Followed for a Resident
Penalty
Summary
The facility failed to ensure a resident on a fluid restriction was not provided too much fluid. Resident 78 was admitted with acute hypoxemic respiratory failure, chronic systolic congestive heart failure, and end-stage renal disease, and was able to make needs known. The care plan initiated on 01/12/2026 showed a fluid restriction of 1800 ml, with nursing providing 480 ml twice a day for 965 ml total and dietary providing 835 ml total per tray card. A provider order dated 04/18/2026 later showed the fluid restriction remained 1800 ml, with nursing providing 540 ml twice a day for 1080 ml total and dietary providing 240 ml per meal tray for 720 ml total. Review of the January through April 2026 MAR showed nursing documented the amount of fluid provided, but it did not include fluids provided by dietary or the total amount consumed. For 04/19/2026 through 04/21/2026, the MAR showed nursing provided 1080 ml each day, while the tray card dated 04/23/2026 showed dietary provided 827 ml total per day. A fluid tracking form printed 04/23/2026 showed nursing aides provided 958 ml, 840 ml, and 640 ml on those same days. The combined records showed Resident 78 consumed 2,865 ml, 2,747 ml, and 2,547 ml on those dates, which was 1,065 ml, 947 ml, and 747 ml over the fluid restriction. Staff stated the facility expected nursing, nursing aides, and dietary to record and total fluids to ensure residents on fluid restriction were not provided too much fluid, and that Resident 78 was provided fluids over the restriction on some days.
Failure to Follow Psychiatry Recommendations for Resident on Antipsychotic Medication
Penalty
Summary
The facility failed to ensure recommendations from mental health consultations were followed for Resident 11, who was admitted with diagnoses including a right arm fracture, dementia, diabetes, and heart failure and was unable to communicate needs. Review of the significant change MDS showed the resident was receiving an antipsychotic medication and had experienced a fall with injury. A provider order dated 03/10/2026 showed Seroquel 25 mg twice daily for vascular dementia without behaviors. Psychiatry evaluated Resident 11 on 03/06/2026 and recommended Keppra levels and consideration of a neurology consultation. Psychiatry evaluated the resident again on 03/11/2026 and recommended discontinuing Celexa due to potential side effects of mania. The EHR showed Keppra blood levels were not obtained and the recommendation to discontinue Celexa was not followed. Resident 11 later had a fall with injury on 03/19/2026 and was sent to the hospital. During interview, the RCM/LPN stated the process was to read specialist recommendations such as psychiatry and follow up on them, and stated Resident 11's psychiatric recommendations should have been completed.
Missing Dementia Care Plan and Behavior Monitoring
Penalty
Summary
Failure to provide appropriate treatment and services for a resident with dementia was identified for Resident 9, who was admitted with diagnoses of Alzheimer's Dementia, chronic pain, and diabetes. The resident was rarely or never understood, had short-term memory problems, made poor decisions, and required extensive assistance with activities of daily living. Review of the electronic health record showed there was no care plan specifically addressing Alzheimer's Dementia, and the April 2026 MAR showed no behavior monitoring in place related to the dementia diagnosis. During interview, the RCM/LPN stated they were unable to locate a care plan for Resident 9 related to dementia care and stated the expectation was that residents have an individualized care plan addressing all areas of care.
Failure to Address Resident Denture Needs
Penalty
Summary
The facility failed to ensure that Resident 35 had dental devices available to improve the ability to eat. Resident 35 was admitted with diagnoses including spondylosis with myelopathy, metabolic encephalopathy, and repeated falls, and was able to make needs known. During observation, Resident 35 had damaged lower teeth and no upper teeth, and stated they used an upper denture that was at home. The MDS identified the resident as edentulous, and the nutritional assessment noted missing teeth, dentures that were not present, and risk for altered nutrition/hydration status related to missing teeth. The care plan initiated on 02/12/2026 did not include a focus area or interventions for dental or denture use. During interview, the RCM/LPN stated the resident used upper dentures but this was not included in the plan of care, and the facility should have reached out to obtain the denture or referred the resident for a new one if it could not be obtained. The Regional Director of QA stated residents were assessed for dental needs on admission, quarterly, and as needed, and that residents with dental needs should have a dental plan of care; the director also stated Resident 35's dental needs should have been included in the plan of care and the resident should have been referred for new dentures.
Failure to Administer Ordered Anticoagulant Resulting in Interruption of Therapy
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident was free from significant medication errors when an ordered anticoagulant was not administered as prescribed. A resident with multiple serious diagnoses, including heart disease, CHF, end-stage renal disease, COPD, acute respiratory failure with hypoxia, and documented DVTs in a lower leg and an upper arm, was discharged from the hospital to the facility with a daily warfarin (Coumadin) order for treatment of these blood clots. The facility’s electronic health record showed that the warfarin was discontinued on 03/26/2026 without any documented reason, and there was no documentation of a substitute anticoagulant or revised order to continue anticoagulation therapy despite the resident’s active DVT diagnosis. Record review and provider documentation showed that the resident did not receive warfarin for five days, during which nursing reported increased right foot swelling and the provider noted worsened breathing and leg swelling, with concern for recurrent clot formation and complications given the missed doses and the resident’s history of large DVT/PE. The resident was sent to the hospital for evaluation and treatment, where hospital staff confirmed that no warfarin doses had been administered since the resident’s discharge back to the facility, and the resident was admitted for treatment of the blood clot and restarted on warfarin and IV anticoagulation. The facility’s internal investigation identified a system breakdown when the anticoagulant was discontinued and not resumed, with no replacement or revised anticoagulation order entered and no documented follow-up or clarification to ensure ongoing anticoagulation therapy, despite the resident’s need for continued treatment.
Failure to Assess and Monitor Wound Leading to Deterioration
Penalty
Summary
The facility failed to ensure that a wound was fully assessed on admission and monitored weekly as ordered for a resident admitted with a lower leg wound. Upon admission, the nursing documentation noted the presence of a skin tear and an open wound, but did not include specific details such as the location, measurements, appearance, drainage, odor, dressing type, or pain assessment. The facility's policy required a comprehensive skin evaluation and weekly wound documentation, including measurements and progress, but these were not completed as required. There was a gap of ten days after admission before the first wound measurement was documented, and subsequent weekly wound evaluations were inconsistent, with missing daily skilled notes and measurements. The resident, who was cognitively impaired and required assistance with activities of daily living, was admitted for skilled nursing care and wound healing. Over the course of their stay, wound documentation indicated the presence of necrosis, slough, and eventually exposed tendon, with purulent drainage and odor developing over time. Despite these changes, documentation of wound progression and communication with providers was inconsistent. Staff interviews revealed that wound care training was informal, and the wound nurse learned procedures from the previous nurse and external wound clinic staff. The DON acknowledged that wound measurements and daily skilled notes were not consistently completed, and that wound assessments were not always accurate or thorough. Concerns about the resident's wound were raised by the care team, the resident's representative, and staff, particularly when the wound developed an odor and exposed tendon. Despite these concerns, there was a delay in escalating care and obtaining appropriate provider evaluation. Eventually, the resident was sent to the hospital, where they were diagnosed with necrotizing fasciitis and required emergent surgical debridement. The lack of timely and thorough wound assessment, documentation, and monitoring contributed to the deterioration of the resident's condition.
Failure to Provide Required Medical Equipment at Discharge
Penalty
Summary
The facility failed to develop and implement a comprehensive discharge plan that addressed all of a resident's needs prior to discharge. Specifically, a resident with a diagnosis of sleep apnea, who required nightly use of a CPAP device and a shower chair, was discharged to an Adult Family Home without these essential items. The resident's records documented consistent use of the CPAP device during their stay, and orders were in place for both the CPAP and a shower chair. However, the discharge summary and plan did not include arrangements for these items, and no orders were made to ensure their availability upon discharge. Interviews with facility staff revealed a lack of coordination and communication regarding the ordering of necessary durable medical equipment. The social services director acknowledged that the order for the shower chair was missed and believed nursing was responsible for ordering the CPAP, but neither item was provided at discharge. The resident care manager was aware that the equipment did not accompany the resident but was unclear about the reasons. The facility's policy required interdisciplinary collaboration to identify and arrange for discharge needs, but this process was not followed, resulting in the resident being discharged without critical equipment.
Inaccurate PASARR Assessments for Residents
Penalty
Summary
The facility failed to ensure accurate completion of Pre-Admission Screening and Resident Review (PASARR) assessments for four out of five sampled residents, which placed them at risk for unidentified mental health care needs. Resident 5, who was readmitted with Alzheimer's, depression, and a psychotic disorder, had a Level I PASARR completed that did not indicate the need for a Level II evaluation, despite having serious mental illness/intellectual disability (SMI/ID) conditions. Staff G, the Social Service Director, was unaware of the need to forward the Level I PASARR to the Level II evaluator. Similarly, Resident 28, with anxiety disorder, depression, and a psychotic disorder, had a Level I PASARR that showed serious mental illness indicators but was not referred for a Level II evaluation. Resident 38, admitted with dementia, major depression, and bipolar disorder, was using antipsychotics and antidepressants but was not identified as needing a Level II PASARR referral. Resident 66, with major depression, altered mental status, and dementia, had no Level I PASARR form in the record. Staff G stated that PASARRs were to be completed prior to admission and reviewed for accuracy, but this was not done for Residents 38 and 66. Staff A, the Administrator, acknowledged that the lack of accurate PASARR forms did not meet expectations.
Failure to Provide Individualized Therapeutic Diet
Penalty
Summary
The facility failed to provide food in an individualized manner for Resident 23, who was on a therapeutic diet requiring easy to chew foods. Resident 23, diagnosed with schizophrenia, epilepsy, and psychosis, was at risk of aspiration and had a provider's order for a regular easy to chew texture diet. However, during observations, Resident 23 was served meals that did not meet these dietary requirements. On one occasion, Resident 23 received a large piece of unaltered fried chicken, and on another, a country fried steak, both of which were not easy to chew as required by the resident's diet order. Interviews with facility staff, including a Registered Dietician and the Administrator, confirmed that the meals provided to Resident 23 did not align with the prescribed diet. The Registered Dietician acknowledged that the fried chicken and country fried steak were regular textures and not suitable for an easy to chew diet. The Administrator stated that diet orders were supposed to be followed as per the provider's instructions, and the failure to do so did not meet the facility's expectations. This deficiency placed Resident 23 at risk of choking and diminished their quality of life.
Sanitation and Hand Hygiene Deficiencies in Kitchen
Penalty
Summary
The facility failed to maintain sanitary conditions in the kitchen, which placed residents at risk of foodborne illness. Observations revealed that the kitchen walk-in refrigerator contained personal staff items, such as energy water drinks and a coffee canned drink, which were not supposed to be stored with facility food items. Additionally, an extra-large fountain drink with a straw was found in a different area of the refrigerator. Staff Y, a Registered Dietician, confirmed that these items were likely staff belongings and should not have been stored in the facility's refrigerator. Furthermore, a preparation table behind the tray line contained a disposable coffee cup, and a shelf underneath the tray line had a disposable cup with a lid and a fork, which were identified as staff items by Staff X, the Dietary Services Manager. The report also highlighted improper hand hygiene practices among the dietary staff. Staff X and Staff V were observed turning off the water with bare hands after performing hand hygiene, which is against the expected protocol. Additionally, Staff W, a Dietary Aide, did not perform hand hygiene after retrieving a milk glass that had dropped on the ground. Staff X acknowledged that staff should use a paper towel to turn off the water and perform hand hygiene after picking up items from the floor. The facility's Administrator, Staff A, confirmed that the storage of staff items with facility food and the observed hand hygiene practices did not meet the facility's expectations.
Facility Fails to Maintain Homelike Environment and Dining Experience
Penalty
Summary
The facility failed to maintain a homelike environment in several areas, as observed on multiple occasions. In the shared bathroom for certain rooms, the doorway frame and walls had gouges and peeling paint, which were not reported in the TELS system for maintenance. Staff J, the Maintenance Director, acknowledged the oversight and stated that the issues should have been reported. Additionally, room observations revealed wall gouges, peeling paint, and makeshift solutions like a plastic bag used as a light cord, indicating a lack of timely maintenance. Staff A, the Administrator, was unaware of these unreported issues, which did not meet the facility's expectations. Furthermore, the facility failed to provide a homelike dining experience by using plastic utensils instead of metal silverware on one of the halls. Resident 46 noted the occasional use of plastic silverware, and Staff W, a Dietary Aide, confirmed the use of plastic utensils due to a shortage of metal ones. Staff X, the Dietary Services Manager, admitted that the facility did not maintain enough metal silverware for all residents, which could affect the homelike environment. Staff A, the Administrator, acknowledged that using plastic silverware did not meet the facility's expectations for a homelike dining experience.
Failure to Assist Residents with ADLs
Penalty
Summary
The facility failed to assist three residents with activities of daily living (ADL), specifically in the areas of nail care and grooming. Resident 10, who has hemiplegia, diabetes, and deafness, was observed with long, yellowed nails despite having a care plan and provider's order for weekly diabetic nail care. Interviews with staff confirmed that Resident 10's ADL services did not meet expectations, as the resident's nails remained untrimmed. Resident 421, diagnosed with adult failure to thrive and requiring assistance with personal care, was observed in a state of neglect. The resident was seen with disheveled hair, improperly worn sneakers, and dark sediment under their fingernails. Despite being able to make needs known, staff did not offer assistance, and the resident's care plan indicated a need for partial physical assistance with various ADLs. Resident 425, who is dependent on staff for all care due to cerebral infarction, hemiplegia, and vascular dementia, was repeatedly observed with disheveled hair, dark sediment under fingernails, and a call light out of reach. The resident's care plan required one- or two-person assistance for all ADLs, yet observations showed a lack of timely and adequate care. Staff interviews confirmed the resident's dependency and the failure to provide necessary assistance as per the care plan.
Failure to Implement Pharmacist Recommendations for Medication Management
Penalty
Summary
The facility failed to act on the consultant pharmacist's medication regimen review (MRR) recommendations for two residents, leading to a deficiency in medication management. For Resident 24, the pharmacist recommended clarifying the administration parameters for diclofenac gel and discontinuing rivaroxaban in favor of apixaban due to a higher risk of side effects. These recommendations were not implemented, and the physician/prescriber response section on the MRR form was left blank. Staff interviews revealed that the pharmacy recommendations for March 2025 were received late and had not been addressed in a timely manner. For Resident 4, the facility did not review the pharmacist's recommendation to decrease certain medications until over a month later, which did not meet the expected timeline for review. The January 2025 recommendation was also not addressed. Staff interviews confirmed that the facility struggled to review MRRs within the expected 72-hour timeframe, leading to delays in addressing the pharmacist's recommendations. These inactions placed the residents at risk for adverse side effects and medical complications.
Medication Storage and Labeling Deficiency
Penalty
Summary
The facility failed to ensure proper storage and labeling of medications, which was observed in two of four medication carts and one of two medication rooms. Specifically, the temperature log for the medication refrigerator in the 100/200 medication room was missing documentation for 22 out of 26 opportunities in March 2025. This refrigerator stored vaccinations, medications, and emergency medication supplies. Staff E, an LPN, confirmed that licensed nurses were responsible for checking and documenting the refrigerator temperature twice daily. Additionally, the 100 hall medication cart contained several medications that were not dated when opened, including eye drops, artificial tears, and nasal spray. There were also expired containers of Fluconazole. The 300 hall medication cart had an insulin pen that was past its expiration date. Staff interviews revealed a lack of awareness regarding the expiration of medications and the requirement to date multi-use medications when opened. The Corporate Registered Nurse acknowledged that the expired and undated medications, as well as the lack of temperature documentation, did not meet the facility's expectations.
Inadequate PPE Use and Infection Control Data Tracking
Penalty
Summary
The facility failed to ensure proper fit and use of personal protective equipment (PPE) as required for transmission-based precautions (TBP) for three nursing staff members across three different halls. Observations revealed that Staff N, O, and P entered rooms with posted contact or droplet/contact precautions without donning the necessary PPE, such as gloves, gowns, masks, and eye protection. Additionally, an aerosol precautions sign indicated that the door should remain closed and that a fit-tested N95 respirator should be worn, but there was no documentation of fit testing for several staff members, including Staff R, S, T, and U. Interviews with staff confirmed the expectation that PPE should be used according to posted signs, but documentation of fit testing was missing. The facility also failed to complete the ongoing collection and analysis of infection control data, including the identification of organisms present in the facility for three consecutive months. The infection preventionist, Staff Q, had only recently started in the position and had to create line listings and maps for January and February 2025, but none were created for December 2024. The facility's policy required daily updates to the infection control line listing, including the type and site of infection and identified organisms, but this was not adhered to. Interviews with staff confirmed the expectation for daily tracking of infections, but the necessary documentation was not maintained.
Failure to Administer Vaccines to Residents
Penalty
Summary
The facility failed to offer and provide influenza and/or pneumococcal vaccines to three residents, which was identified during a review of their electronic health records (EHR). Resident 56, who had a history of skin infection and asthma, was offered the influenza vaccine and accepted it, but there was no documentation that the vaccine was administered. Resident 37, diagnosed with hemiplegia and a brain bleed, had no documentation in their EHR indicating that they were offered, educated about, or provided the pneumococcal vaccine. Resident 48, with respiratory failure and diabetes, consented to receive the pneumococcal vaccine, but there was no record of the vaccine being administered. Interviews with facility staff revealed that the expected protocol was to offer and administer these vaccines upon admission and annually. However, this protocol was not followed for the three residents in question. Staff Q, a Registered Nurse/Infection Preventionist, acknowledged that the vaccines should have been offered and administered, but this did not occur. Staff C, a Corporate Registered Nurse, confirmed the expectation that staff should educate, offer, and administer the vaccines as part of the facility's procedures.
Failure to Administer COVID-19 Vaccines to Residents
Penalty
Summary
The facility failed to offer and provide COVID-19 vaccines to two residents, identified as Residents 28 and 37, which was identified during a review of their electronic health records (EHR). Resident 28, who was admitted with a diagnosis of diabetes, had consented to receive the COVID-19 vaccine on 10/31/2024, but there was no documentation in the EHR indicating that the vaccine was administered. Resident 37, admitted with diagnoses including hemiplegia and a brain bleed, had no documentation in the EHR showing that the COVID-19 vaccine was offered, provided, or declined. Interviews with staff revealed that the facility's protocol required offering the COVID-19 vaccine upon admission and annually, obtaining an order, and administering it if consented. However, this protocol was not followed for Residents 28 and 37, as confirmed by Staff Q, a Registered Nurse/Infection Preventionist, and Staff C, a Corporate Registered Nurse.
Deficiency in CNA Training and Performance Evaluation
Penalty
Summary
The facility failed to ensure that certified nurse assistants (CNAs) received the required 12 hours of in-service training per year, including mandatory dementia management training. This deficiency was identified through interviews and record reviews, which revealed that the facility did not maintain oversight of the CNAs' training and performance evaluations. Staff CC, a CNA, reported not remembering any recent performance evaluations or specific training requirements. Additionally, Staff Q, a Registered Nurse and Staff Development Coordinator, confirmed the lack of access to computer training records, making it impossible to verify if the required training hours were met. Further interviews highlighted the facility's inability to provide documentation of the CNAs' training and performance reviews. Staff C, a Corporate Registered Nurse, expressed the expectation that staff competencies and performance reviews should be readily available. Staff DD, a Pay Benefit Coordinator, also noted their lack of access to the training records. The facility's Administrator, Staff A, acknowledged that the records should be accessible and that necessary training should be completed to ensure staff competency in resident care. The absence of documentation and oversight placed residents at risk for potential negative outcomes and unmet care needs.
Failure to Obtain Consent for Mood-Altering Medication
Penalty
Summary
The facility failed to obtain signed consent prior to administering mood-altering medication to a resident, identified as Resident 66, who was part of a sample of five residents reviewed for unnecessary medication use. This deficiency was identified through interviews and record reviews. Resident 66, who was admitted with diagnoses including major depression, altered mental status, and dementia, was unable to communicate needs. The electronic health record (EHR) showed an order for Divalproex, a mood stabilizer, to be administered twice daily starting from February 28, 2025, and the medication was given from March 1 to March 26, 2025, for violent behavior. However, there was no consent documented in the EHR for the use of Divalproex. During interviews, both a Registered Nurse/Resident Care Manager and a Corporate Registered Nurse confirmed the absence of consent and acknowledged that this did not meet expectations.
Failure to Obtain and Review Advanced Directive for a Resident
Penalty
Summary
The facility failed to obtain and periodically review an advanced directive (AD) for Resident 24, who was admitted with diagnoses including depression and anxiety disorder. Despite being able to make their needs known, Resident 24 did not have an AD in place and declined assistance in formulating one. The Comprehensive Plan of Care Review form indicated that Resident 24 did not wish to establish an AD, and the care plan intervention required quarterly reviews of the AD status. However, documentation from care conferences on two occasions incorrectly marked that an AD was in place, and there was no documented discussion or review of the AD. Interviews with facility staff revealed that the Social Services Director acknowledged the lack of documentation regarding AD discussions during care conferences, which did not meet the facility's expectations. The Administrator confirmed that new residents or their responsible parties were asked to provide or establish an AD upon admission and that ADs were to be reviewed quarterly and as needed. However, the Administrator was unaware that Resident 24 did not have an AD or that there was no documented quarterly review, which also did not meet the facility's expectations.
Failure to Assess and Obtain Consent for Use of Physical Restraints
Penalty
Summary
The facility failed to conduct an assessment and obtain signed consent for the use of physical restraints for a resident, identified as Resident 38. This resident was admitted with diagnoses including dementia, dislocation of an internal left hip prosthesis, and depression. The resident was assessed as a high fall risk and required staff assistance for mobility, with an inability to communicate needs. Observations revealed that the resident was placed in a tilt-in-space wheelchair with the upper body reclined and in a low bed positioned next to a wall, which restricted access and movement. The care plan for Resident 38 included interventions for fall risk, such as placing the bed against the wall and keeping it in the lowest position. However, there was no documented assessment or consent for the use of the low bed, bed by the wall, and tilt-in-space wheelchair. Interviews with facility staff, including a Licensed Practical Nurse and a Corporate Registered Nurse, confirmed that these items could be used as restraints and should have been assessed and consented to prior to use. The lack of assessment and consent did not meet the facility's expectations, as per the staff interviews.
Failure to Transmit MDS Timely for a Resident
Penalty
Summary
The facility failed to transmit the Minimum Data Set (MDS) for one resident, identified as Resident 53, to the Centers for Medicare & Medicaid Services (CMS) within the required timeframe. Resident 53 was admitted to the facility and later discharged, with both the Medicare-5 Day MDS and the discharge MDS completed but not submitted to CMS. Interviews with facility staff revealed that MDS transmissions were conducted weekly, but Resident 53's assessments were not submitted due to an oversight. Staff members, including a Registered Nurse/MDS Nurse, a Regional Reimbursement Analyst, and a Corporate Registered Nurse, acknowledged the lapse and indicated that an audit was being conducted to address the issue. This failure to ensure timely submission of MDS assessments placed the resident at risk for unmet care needs and diminished quality of life.
Inaccurate MDS Coding for Resident's Weight Loss
Penalty
Summary
The facility failed to ensure the Minimum Data Set (MDS) accurately reflected a significant weight loss for Resident 24, who experienced a weight loss of 11.72% over six months. Resident 24, who was readmitted to the facility with diagnoses including malnutrition, anxiety disorder, and depression, reported that the food did not taste good and suspected weight loss due to insufficient eating. The electronic health record (EHR) documented the resident's weight as 124.6 pounds on August 7, 2024, and 110.0 pounds on February 11, 2025. However, the quarterly MDS inaccurately documented no or unknown weight loss of 10% or more in the last six months. Staff interviews confirmed the MDS was inaccurately coded, failing to capture the significant weight loss.
Failure to Develop Comprehensive Care Plans for Residents
Penalty
Summary
The facility failed to develop comprehensive care plans for two residents, leading to deficiencies in addressing their specific needs. Resident 10, who was admitted with hemiplegia, diabetes, and deafness, experienced multiple falls between October and December 2024. Although new fall interventions were developed after each incident, these were not incorporated into the resident's care plan. Interviews with facility staff confirmed that the absence of a fall prevention care plan did not meet expectations, as staff relied on care plans to guide interventions. Resident 7, admitted with cerebral palsy, anxiety, depression, and muscle contractures, did not have a care plan that included interventions for managing contractures or a range of motion plan. Observations revealed that the resident's fingers were rigid and curled, and the resident reported that staff did not address their hand condition. Despite having worked with occupational therapy and having hand splints, the resident's refusal to use them was not documented in the care plan. Staff interviews confirmed that the lack of a comprehensive care plan for maintaining the resident's functions did not meet expectations.
Care Plan Revision Deficiency for a Resident
Penalty
Summary
The facility failed to ensure that a resident's care plan was revised and accurately reflected the resident's care needs. Resident 24, who was readmitted with diagnoses including anxiety disorder, depression, psychotic disorder, and malnutrition, had care plans that inaccurately included a diagnosis of dementia. Despite the removal of the dementia diagnosis by a mental health professional, the care plans for antipsychotic medication and nutritional problems continued to reference dementia. Additionally, the care plan included an intervention for an oral nutritional supplement that was discontinued, yet the care plan was not updated to reflect this change. Furthermore, the care plan did not document the use of an anticoagulant medication prescribed for atrial fibrillation, nor did it include interventions to monitor for side effects. Interviews with staff revealed that the care plans were not revised as needed with changes in the resident's condition or medication orders, which did not meet the facility's expectations. This oversight placed the resident at risk for unmet care needs and inaccurate care documentation.
Deficiencies in Professional Standards of Care
Penalty
Summary
The facility failed to meet professional standards of care for several residents, leading to deficiencies in care and services. For Resident 5, the facility did not notify the provider when Lantus insulin was held due to low blood glucose levels on multiple occasions. Despite the expectation that the provider should be contacted and documentation should be made in the electronic health record (EHR), this was not done, placing the resident at risk for unmanaged diabetes. Resident 10 was prescribed two PRN pain medications but did not have parameters for acetaminophen administration or orders for nonpharmacological interventions (NPI) before administering pain medications. The resident received oxycodone outside the prescribed pain parameters and without being offered NPI, which did not meet the facility's expectations. Similarly, Resident 24 received oxycodone without documented respiratory rate checks or NPI, and there was no monitoring for side effects of anticoagulant medication, which was also not documented as expected. Resident 59 was placed on one-on-one monitoring due to new behaviors and suicidal statements, but alert charting was not completed every shift, and the care plan was not updated. Resident 19's medications were not held as directed when the pulse was below 60, and the provider was not notified, contrary to the provider's orders. These failures in following provider parameters and documenting care placed residents at risk for unmet care needs and diminished quality of life.
Failure to Provide Adequate Activity Program for Residents
Penalty
Summary
The facility failed to provide an adequate activity program for two residents, leading to a deficiency in meeting their needs for engagement and stimulation. Resident 3, who has schizophrenia, diabetes, and epilepsy, was observed multiple times without any activities such as TV or music, despite their care plan indicating a preference for these activities. The resident's care plan also included one-on-one activities like listening to music and manicures, but records showed only one group and one one-on-one activity in a 30-day period. Interviews with staff revealed that both activity and nursing staff were responsible for ensuring the resident's TV was on, but this was not consistently done. Similarly, Resident 425, who has a history of stroke, hemiplegia, and vascular dementia, was observed repeatedly in bed without any TV or music playing, and no activity staff present. The resident's care plan required staff to provide social and one-on-one visits, but there were no progress notes documenting any activities for February and March 2025. The Activity Director confirmed that activities should be documented if there was any participation or attempts, indicating a lack of adherence to the care plan and documentation requirements.
Deficiencies in Resident Care and Treatment
Penalty
Summary
The facility failed to ensure that residents received treatment and care in accordance with professional standards of practice and person-centered care plans. For Resident 37, there was no provider order or care plan documentation for the application of a brace/splint on the right lower leg/foot, despite observations of the resident wearing the device. Staff interviews revealed that the brace was applied without a current order, indicating a lapse in documentation and adherence to care protocols. Resident 425, who was dependent on staff for all care, was not repositioned every two hours as required to prevent skin integrity issues. Observations showed the resident remained in the same position for extended periods, contrary to the care plan and staff expectations. Interviews with staff confirmed the expectation for regular repositioning, highlighting a failure to implement necessary care interventions. Resident 38 did not have a knee immobilizer applied as per the provider's order, despite being at high fall risk and requiring the device to minimize knee movement. Observations confirmed the absence of the immobilizer, and staff interviews acknowledged the oversight. Additionally, Resident 66 did not receive necessary bowel management interventions despite a lack of documented bowel movements for six days. The facility failed to administer prescribed medications for constipation, as confirmed by staff interviews, indicating a neglect in following bowel protocols.
Failure to Provide Range of Motion Services for Resident with Contractures
Penalty
Summary
The facility failed to provide appropriate services to maintain or improve the range of motion for a resident with contractures. Resident 7, who was admitted with cerebral palsy, anxiety, depression, and muscle contractures, was observed with rigid fingers curled inward, indicating a lack of intervention for their condition. The resident communicated that staff did not provide any care for their hands. A review of the care plan revealed no instructions for performing range of motion exercises for the resident's hands. Interviews with the Director of Rehabilitation and a Corporate Registered Nurse confirmed that the resident's contracture management did not meet expectations, as services to maintain their functions were not adequately set up.
Emergency Call Light Cord Length Deficiency
Penalty
Summary
The facility failed to ensure that the bathroom emergency call light cord in one of the hallways was within the required length of no higher than six inches from the floor. Observations on multiple occasions revealed that the emergency call cord in the shared bathroom for certain rooms was positioned at the handlebar attached to the wall, which was greater than six inches from the floor. This deficiency was identified during interviews and observations with residents and staff. Resident 28, who had multiple diagnoses including high blood pressure, chronic kidney disease, dementia, and osteoarthritis, did not use the bathroom at the time of the interview. Resident 17, who was independent with transfers, walking, and toileting, used the bathroom but did not notice the short emergency call cord. Staff interviews revealed that the Maintenance Director, Staff J, acknowledged the emergency call light cords should hang approximately two inches from the floor to ensure accessibility in case of a fall. However, the short cord in the shared bathroom was not reported in the TELS system, which is used for work orders. The Administrator, Staff A, was also unaware of the issue and confirmed that the situation did not meet the facility's expectations. The failure to report and address the short emergency call cord placed residents at risk of being unable to reach the call light in an emergency, potentially delaying response and affecting their quality of life.
Failure to Monitor and Document Resident Weights
Penalty
Summary
The facility failed to monitor and consistently document the weights of a resident, identified as Resident 24, as per the provider's orders. Resident 24, who was readmitted to the facility with diagnoses including malnutrition, anxiety disorder, and depression, was ordered to have bi-weekly weights taken due to concerns about weight loss. However, a review of the electronic health record (EHR) revealed inconsistencies and omissions in the documentation of these weights. Specifically, the treatment administration records (TAR) for January, February, and March 2025 showed either missing initials or weights not documented in the weights tab, despite being marked as completed. Interviews with facility staff confirmed these documentation failures. Resident 24 expressed concerns about the taste of the food and suspected weight loss due to inadequate food intake. Staff H, a Licensed Practical Nurse/Resident Care Manager, acknowledged that the bi-weekly weights were not documented as required, and Staff C, a Corporate Registered Nurse, confirmed that the nurses did not follow the provider's orders. This lack of adherence to the prescribed monitoring placed the resident at risk for medical complications and unmet needs.
Failure to Provide Prompt Dental Services for Residents
Penalty
Summary
The facility failed to provide prompt dental services for two residents, leading to a deficiency in care. Resident 28, who was readmitted with diagnoses including malnutrition and diabetes, was unable to wear dentures due to poor fit and discomfort. Despite a referral for denture adjustment on 01/23/2025, Resident 28 was not seen by the dentist during their visit on 03/25/2025. Staff interviews revealed that the resident's need for dental care was known, but they were not included on the list for the dentist's visit, and the administrator acknowledged the mishandling of the resident's dental care. Resident 10, admitted with hemiplegia, diabetes, and deafness, also experienced a lapse in dental care. A dental examination on 05/22/2024 recommended x-rays, evaluation, and tooth extraction, but there was no follow-up documented. The care plan noted missing and decayed teeth, but the recommendations from the examination were not addressed. Staff interviews confirmed that the family should have been contacted for follow-up, but this did not occur, and the corporate RN acknowledged the failure to meet expectations in following up on dental recommendations.
Improper Enteral Nutrition Management in LTC Facility
Penalty
Summary
The facility failed to ensure proper administration of enteral nutrition for four residents, leading to significant health risks and harm. Resident 1, who was dependent on staff for bed mobility and received more than 51% of their nutrition via a feeding tube, was found in respiratory distress due to improper positioning and overfeeding. The resident was positioned at a 10-degree angle while receiving tube feeding, contrary to the facility's policy of maintaining a 30-45 degree angle. This resulted in aspiration pneumonia, requiring hospitalization and subsequent discharge to hospice care. Resident 2, who was alert and oriented, also experienced issues with tube feeding management. The resident was observed sliding down in bed, which compromised the intended head elevation during feeding. Additionally, there were discrepancies in the labeling and dating of feeding syringes, and the resident was given thin liquids despite being on a thickened liquid diet, contrary to physician orders. Staff failed to follow proper procedures for syringe replacement and fluid administration, increasing the risk of aspiration. Residents 3 and 4 also faced deficiencies in tube feeding management. Resident 3's care plan required head elevation during feeding, but there was no signage to remind staff of this requirement. Similarly, Resident 4's care plan included head elevation during feeding, but no signs were posted to ensure compliance. These oversights in care planning and execution put residents at risk for inadequate nutrition, dehydration, and other adverse outcomes.
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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