Belmont Terrace
Inspection history, citations, penalties and survey trends for this long-term care facility in Bremerton, Washington.
- Location
- 560 Lebo Boulevard, Bremerton, Washington 98310
- CMS Provider Number
- 505290
- Inspections on file
- 30
- Latest survey
- March 2, 2026
- Citations (last 12 mo.)
- 22
Citation history
Health deficiencies cited at Belmont Terrace during CMS and state inspections, most recent first.
Surveyors found that the facility did not follow through on recommended gradual dose reductions for psychotropic medications for three residents. In each case, the consulting pharmacist's recommendations were accepted by providers, but either the medication was discontinued without proper communication, or no action was taken to adjust the medication orders, resulting in continued administration of the original doses. Staff interviews confirmed that these recommendations were not properly implemented.
Two residents with inconsistent documentation of urinary continence did not receive timely reassessment or updated interventions, despite changes in their bladder status and related care needs. Staff were unable to specify the type of incontinence or explain the lack of follow-up, and care plans were not updated to reflect current conditions.
A resident with chronic pain conditions was discharged with only a limited supply of prescribed oxycodone and no prescription for continued pain management, resulting in unmanaged pain until the resident could see a community provider. The DON confirmed that a prescription should have been provided, but this was missed during the discharge process.
A resident with respiratory failure and COPD was discharged with antibiotics, but the facility did not document end dates for the medications or communicate discontinuation instructions. The resident was sent home with a large quantity of antibiotics remaining and reported confusion about their use. The DON confirmed that end dates and communication were lacking.
A resident with respiratory failure and COPD, who had signed consent to receive the pneumococcal vaccine, was not administered the vaccine. The DON confirmed that, despite the completed consent, the vaccine was not given and there was no documentation of administration.
A resident with respiratory failure and COPD, who had signed consent to receive the COVID-19 vaccine, was not provided the vaccine. The DON confirmed that despite the resident's documented consent, the vaccine was not administered and there was no record of vaccination.
The facility failed to provide Advanced Directives (ADs) for four residents, compromising their right to have healthcare preferences honored. A resident signed an AD receipt but had no prior assistance in formulating one. Three other residents had no ADs or receipts documented in their EHRs, despite being cognitively intact or moderately impaired. Staff confirmed that ADs should have been completed upon admission but were not.
The facility failed to maintain a safe and homelike environment due to worn, stained, and poorly maintained carpets in the Olympic, Mountainview, and Medicare hallways. Observations showed issues like mismatched carpet patches and loose carpet squares, compromising the environment for residents. Staff acknowledged the problem and cited bureaucratic challenges in addressing it.
A facility failed to properly document and address grievances from a resident and the Resident Council. A resident's grievances about lack of services due to staff shortages were not logged or addressed promptly. The Resident Council also reported that their grievances were not consistently resolved, with several concerns not filed as grievances. Staff confirmed these issues should have been documented.
The facility failed to provide written transfer or discharge notices to four cognitively intact residents who were hospitalized, as required by policy. Staff interviews confirmed the absence of these notices, which placed residents and their representatives at risk of not making informed decisions about their transfers or discharges.
The facility failed to provide bed hold notices to three residents during hospital transfers, as required. Despite being cognitively intact, these residents were transferred without proper documentation in their EHRs, as confirmed by the DNS. This oversight risked the residents' ability to make informed decisions about their bed hold status.
The facility failed to ensure accurate MDS assessments for several residents, leading to potential risks for unmet care needs. Errors included incorrect documentation of weight loss programs, unrecorded significant weight loss, misclassification of medical devices, and missing active diagnoses despite medication use. These inaccuracies were acknowledged by facility staff.
The facility failed to ensure accurate and updated care plans for several residents, leading to discrepancies in bathing preferences, psychotropic drug use documentation, and intake/output monitoring. One resident's care plan did not reflect their current abilities or goals, and there was a discrepancy in their nutritional care plan regarding water intake. These issues highlight a lack of proper care plan management and documentation.
The facility failed to provide restorative services at the required frequency for six residents, leading to a deficiency in maintaining or improving their range of motion and mobility. Staffing issues were a significant factor, as the Restorative Aide was often pulled to work the floor, resulting in incomplete restorative programs. The Administrator acknowledged the staffing shortage, which affected the provision of necessary services, placing residents at risk for decreased ROM and other complications.
Expired medications and supplies were not removed from a medication storage room, including items like blood glucose lancets, ibuprofen, and a vaccine vial. Staff indicated that nursing staff were responsible for managing these items, but they were not removed by their expiration dates.
The facility did not seek Resident Council approval or provide bedtime snacks when extending the meal interval from 14 to 15 hours. Residents in various halls experienced a 15-hour gap between dinner and breakfast. The DON confirmed the lack of documentation for approval and stated that only diabetic residents were routinely given bedtime snacks, though snacks were available upon request.
The facility failed to follow infection control protocols, including improper use of PPE for a resident with a gastric tube, cross-contamination risks with PPE and food carts, and inadequate hand hygiene and equipment handling for residents with catheters and wound treatments. Staff acknowledged these practices did not meet expectations.
Three residents who consented to receive pneumococcal vaccines did not receive them due to the facility's failure to order and administer the vaccines. Staff acknowledged the oversight, which did not meet the facility's expectations.
The facility failed to maintain emergency fire doors in working order, with a loose metal piece in the floor causing significant difficulty in opening the doors. Staff and a resident using a walker struggled to open the door due to the resistance. Attempts to fix the issue included gluing the metal piece, but the problem persisted.
The facility failed to provide scheduled bathing and shaving assistance to several residents, leading to significant gaps in personal hygiene care. Residents reported dissatisfaction with the lack of services, and documentation confirmed extended periods without bathing or shaving, despite care plans indicating the importance of these activities. Staff acknowledged the oversight and the absence of specific documentation for these tasks.
The facility failed to administer the correct enteral formula volume to a resident, did not monitor fluid intake accurately for residents on fluid restrictions, and did not identify significant weight loss in a timely manner. These deficiencies involved residents with conditions such as malnutrition, kidney disease, and heart failure, leading to risks of inadequate nutrition and fluid imbalances.
The facility experienced significant staffing shortages, leading to unmet care needs and diminished quality of life for residents. Residents reported long wait times for assistance with ADLs, while staff confirmed being overworked and unable to complete daily tasks. The lack of sufficient staff affected the provision of restorative and bathing services, as aides were frequently reassigned to cover other duties. Facility leadership acknowledged the staffing issues and their impact on resident care.
The facility failed to provide meals that were appetizing and served at appropriate temperatures, as reported by several residents. Observations showed delays in meal delivery and improper handling of beverages, leading to meals being served cold. Residents expressed dissatisfaction with the taste, texture, and variety of the food, and their meal preferences were not always honored.
The facility failed to provide prescribed therapeutic diets and correct portion sizes to residents, affecting their nutritional needs. Dietary staff placed tartar sauce on trays for residents with restricted diets and used incorrect spoodle sizes for portion control, leading to potential medical complications. The dietary manager confirmed these practices but did not take corrective action.
The facility failed to ensure effective communication and coordination with hospice providers for two residents, lacking current hospice care plans and documentation of visits and services in the EHR. Staff acknowledged communication issues and were in the process of improving documentation, but deficiencies persisted.
The facility failed to respect residents' privacy by not knocking or announcing themselves before entering rooms. Staff, including a CNA and housekeeping, entered rooms without notice, contrary to the facility's policy on resident rights. This repeated failure was acknowledged as unacceptable by the Resident Care Manager and the DON.
A resident with depression and dementia was prescribed risperidone, but the facility used incorrect consent forms with varying side effects listed. Additionally, venlafaxine was administered before obtaining consent. The Resident Care Manager and Director of Nursing Services acknowledged the expectation for correct classification and prior consent.
The facility failed to honor the bathing preferences of two residents, both of whom were cognitively intact and had identified their bathing choices as very important. One resident reported dissatisfaction with the quality of the shower received, while the other preferred more frequent showers than scheduled. The care plans did not reflect the residents' preferences, and there was no documentation in the EHR to show efforts to support resident choice. Staff indicated that residents were initially assigned one shower per week, with potential adjustments based on feedback.
The facility failed to ensure accurate PASRR documentation and timely Level II referrals for two residents, impacting their access to mental health services. One resident's PASRR inaccurately documented an anxiety disorder instead of depression, and another resident's PASRR was incorrectly updated to indicate a mood disorder. Staff confirmed these discrepancies, highlighting a lapse in the facility's processes.
The facility failed to develop comprehensive care plans for two residents, leading to potential risks for unmet care needs. One resident lacked care plans for activities and edema, and had an incorrect wound treatment site listed. Another resident had no care plan for their PICC line, despite receiving IV antibiotics. Staff interviews confirmed unmet care planning expectations.
A resident with moderate hearing difficulty did not receive complete earwax removal treatment, as the facility staff failed to flush the ears after administering Debrox ear drops. The care plan directed staff to administer ear drops and communicate effectively, but the medication records lacked instructions for ear flushing. The DON acknowledged the oversight, which left the resident with clogged ears and hearing issues.
A resident with sepsis and cellulitis was admitted with a PICC for IV antibiotics, but the facility failed to provide specific orders for the central line or a care plan. The EHR lacked administration rates for the antibiotics, and staff interviews revealed missing measurements and dressing change orders, leading to potential risks.
The facility failed to follow physician orders for two residents requiring dialysis care, specifically regarding post-dialysis fistula access care. A resident with End Stage Renal Disease was removing their own pressure dressing without documented training or authorization, leading to a hospital transfer due to bleeding. Staff interviews confirmed the absence of necessary documentation and adherence to care plans.
A facility failed to act on a pharmacist's Medication Regimen Review (MRR) recommendations for a resident with malnutrition and gastrostomy status. The MRR advised that Carafate, which could affect the absorption of other medications, be given on an empty stomach and separate from other medications. However, the resident's medication schedule showed Carafate and oxycodone were administered together, with no documentation of the MRR being reviewed or implemented.
Two residents experienced deficiencies in medication administration. One resident with ESRD did not have their port dressing removed as ordered, risking infection. Another resident with diabetes missed a dulaglutide dose due to pharmacy unavailability, with no makeup dose or provider notification. Staff interviews confirmed these actions did not meet facility expectations.
The facility failed to ensure residents were free from unnecessary psychotropic medications by not attempting Gradual Dose Reductions (GDR) for a resident with Major Depressive Disorder and bipolar disorder, and not following up on GDR recommendations for another resident with anxiety and depression. Despite recommendations, no GDR attempts were documented for the first resident, and laboratory tests were delayed for the second resident, highlighting a lack of adherence to required protocols.
The facility failed to administer COVID-19 vaccinations to two residents who had consented to receive them. The vaccines were not ordered from the supplier, as confirmed by the RCM and DNS, despite the residents' consent.
A resident admitted with a Stage II pressure ulcer experienced worsening conditions due to the facility's failure to consistently provide ordered treatments and timely interventions. Despite having a care plan, there were multiple missing entries in the EHR for treatment completion, and incorrect Braden Scale assessments identified the resident as low risk. The resident's condition deteriorated to a Stage 4 ulcer, with inconsistent documentation and lack of follow-up on care refusals.
A facility failed to conduct care plan conferences for a resident with heart failure and chronic kidney disease, who was cognitively intact and required substantial assistance. Despite the resident's wish to return home, no care conference was held, and staff acknowledged being behind on these meetings.
A facility failed to create and implement a discharge plan for a resident with heart failure and chronic kidney disease, who was ready to return home. Despite the resident's cognitive intactness and expressed desire to leave, no discharge discussions or evaluations were conducted. Staff turnover and lack of documentation contributed to this deficiency.
A resident with diabetes and peripheral vascular disease experienced chronic skin issues that were not consistently assessed or treated by the facility. Despite observations of ruddy, flaky skin and hemosiderin staining, staff lacked a clear treatment plan and documentation. Interviews revealed uncertainty about the cause and management of the condition, with no active treatment orders in place.
A resident with diabetes and peripheral vascular disease did not receive necessary nail care, resulting in long, thick, and jagged toenails. Despite the resident's willingness to see a podiatrist, there was no record of podiatry services being discussed or provided. Staff inconsistencies in documentation and provision of care were noted, with an LPN admitting to signing off on nail care that was not performed.
Failure to Implement Gradual Dose Reductions for Psychotropic Medications
Penalty
Summary
The facility failed to ensure that recommendations for gradual dose reductions (GDR) of psychotropic medications were followed for three residents. For one resident with vascular dementia and anxiety disorder, the consulting pharmacist recommended a GDR of escitalopram, which was accepted by the provider. The resident’s guardian was informed and objected to the reduction, but the medication was discontinued. Following the discontinuation, the resident exhibited increased behavioral symptoms, required additional medication for anxiety, and eventually had the escitalopram restarted after the guardian expressed distress over the discontinuation. Another resident with chronic obstructive pulmonary disease and Alzheimer's disease was due for a GDR of aripiprazole as recommended by the consulting pharmacist. The provider accepted the recommendation, but no new medication orders were written, and the resident continued to receive the original dose. Staff confirmed that the GDR was not implemented as recommended. A third resident with congestive heart failure and morbid obesity was also due for a GDR of bupropion, with the provider accepting the recommendation to discontinue the medication. However, no instructions were given to staff to discontinue the medication, and the resident continued to receive the same dose. Staff acknowledged that the order should have been clarified and acted upon. These failures were identified through observation, interview, and record review.
Failure to Assess and Address Changes in Urinary Incontinence
Penalty
Summary
The facility failed to accurately assess and identify changes in urinary incontinence for two residents, resulting in a lack of appropriate treatment planning and interventions. For one resident admitted with a history of arm fracture and no cognitive impairment, initial assessments and progress notes showed inconsistencies in bladder continence status. Despite documentation of frequent urination, use of diuretics, and initiation and discontinuation of medication for bladder spasms, there was no evidence of reassessment or updated interventions to address the resident's changing continence needs. Staff were unable to specify the type of incontinence or explain the lack of follow-up. Another resident, admitted with a cognitive communication deficit and no cognitive impairment, also had conflicting documentation regarding bladder continence. The care plan did not address bladder status, and progress notes indicated the resident experienced both small and large amounts of urinary incontinence, as well as a urinary tract infection requiring treatment. Staff interviews confirmed the absence of reassessment and care plan updates to address these inconsistencies. The facility did not implement further assessments or interventions for either resident, as required.
Failure to Provide Adequate Pain Management at Discharge
Penalty
Summary
A resident with a history of respiratory failure, COPD, and osteoporosis was admitted to the facility and experienced ongoing pain, for which oxycodone was prescribed and administered as needed. The care plan required staff to assess and monitor the resident's pain each shift and document medication side effects. During the resident's stay, pain levels ranged from 4 to 7 out of 10, and oxycodone was given two to three times daily. Upon discharge, the resident was sent home with only three oxycodone tablets and no prescription to ensure continued pain management until follow-up with a community provider. The resident reported feeling overwhelmed by the number of medications provided at discharge and did not initially notice the insufficient supply of pain medication. It was later discovered that no prescription for additional oxycodone was provided, resulting in the resident experiencing pain until they could see their provider. The Director of Nursing confirmed that a prescription should have been sent but was not, possibly due to an oversight by a new staff member handling the discharge process.
Failure to Implement Antibiotic Protocols and Communicate Medication End Dates
Penalty
Summary
The facility failed to consistently implement antibiotic protocols to ensure antibiotics were appropriately prescribed and managed for one of three sampled residents reviewed for antibiotic use. A resident with respiratory failure and chronic obstructive pulmonary disease was discharged from the hospital with orders to take cefuroxime and metronidazole, each for 14 doses. However, the facility's order summary did not specify end dates for these antibiotics, and the resident was later sent home with a large quantity of both medications remaining. The resident reported confusion about the medications and was not informed about discontinuing them. The Director of Nursing confirmed that end dates should have been documented and communicated at discharge, but this was not done.
Failure to Administer Pneumococcal Vaccine After Consent
Penalty
Summary
The facility failed to provide a pneumococcal vaccination to a resident who had been admitted with respiratory failure and chronic obstructive pulmonary disease. Documentation showed that the resident had signed a consent form indicating their wish to receive the pneumococcal vaccine, and the form was signed by a nurse on the same day. However, review of the resident's electronic health record revealed no documentation that the vaccine was administered. The Director of Nursing confirmed that, despite the signed consent, the vaccine was not given.
Failure to Administer COVID-19 Vaccine After Consent
Penalty
Summary
The facility failed to provide the COVID-19 vaccine to a resident who had expressed consent to receive it. The resident, admitted with respiratory failure and chronic obstructive pulmonary disease, had a signed consent form dated 01/15/2025 indicating their wish to receive the COVID-19 vaccine, with the form also signed by a nurse on the same day. However, review of the resident's electronic health record showed no documentation that the vaccine was administered. The Director of Nursing confirmed that although consent was obtained, the vaccine was not given as it should have been.
Failure to Provide Advanced Directives for Residents
Penalty
Summary
The facility failed to provide Advanced Directives (ADs) for four out of five sampled residents, which compromised their right to have their healthcare preferences and decisions honored. Resident 59, who was cognitively intact, signed an AD receipt indicating a choice not to formulate an AD, but there were no documented attempts to offer or assist in formulating an AD prior to this. Staff I, the Patient Advocacy Resource, confirmed the absence of other ADs for Resident 59, and the Director of Nursing Services acknowledged the issue. For Residents 28, 43, and 60, there were no ADs or AD receipts found in their Electronic Health Records (EHRs). Resident 28's EHR lacked documentation of any inquiry about an AD or informing them of their right to formulate one. Resident 43, who was moderately cognitively impaired, and Resident 60, who was cognitively intact, also had no ADs or AD receipts documented. Staff I confirmed that ADs or AD receipts should have been completed upon admission for these residents but were not.
Facility Fails to Maintain Safe and Homelike Environment Due to Carpet Issues
Penalty
Summary
The facility failed to maintain a safe, clean, and comfortable environment, as evidenced by the poor condition of the carpets in several areas, including the Olympic, Mountainview, and Medicare hallways. Observations revealed worn areas, stains, and the use of tape to prevent carpet peeling, which compromised the homelike environment for residents. Specific issues included worn and heavily soiled carpets with multiple stains in the Olympic Hallway's activity room, mismatched carpet patches secured with duct tape in the Mountainview Hallway, and large stains and loose carpet squares in the Medicare Hallways. Interviews with staff members confirmed awareness of the carpet issues. The Administrator acknowledged the need for carpet replacement and mentioned plans to start the work soon. The Maintenance Supervisor also recognized the poor condition of the carpets and expressed challenges in addressing the issue due to bureaucratic obstacles. These observations and staff admissions highlight the facility's failure to uphold the residents' right to a safe and homelike environment, as required by regulations.
Failure to Properly Address and Document Grievances
Penalty
Summary
The facility failed to ensure that grievances were properly initiated, logged, investigated, and resolved in a timely manner for a resident and the Resident Council. Resident 40, who was cognitively intact, filed two grievances regarding the lack of restorative services and showers due to staff shortages. These grievances were not documented on the grievance log and were not addressed until 14 days later, contrary to the facility's policy which required a response within three working days. The Director of Nursing Services acknowledged that the grievances should have been documented and discussed in meetings. Additionally, the Resident Council expressed concerns about the grievance process, indicating that their grievances were not consistently addressed or resolved. Multiple concerns raised during Resident Council meetings were not filed as grievances, including issues related to staffing, appointment notifications, and pharmacy services. A grievance filed by the Resident Council regarding appointment notifications did not include any notification of resolution. Staff members confirmed that these concerns should have been documented as grievances and acknowledged the failure to meet expectations in handling these issues.
Failure to Provide Transfer/Discharge Notices
Penalty
Summary
The facility failed to provide written transfer or discharge notices to residents and their representatives for four residents who were hospitalized. This deficiency was identified during a review of the facility's records and interviews with staff. The facility's policy, revised in November 2016, mandates that information regarding transfers should be provided to residents and their representatives in a language they understand. However, for Residents 18, 40, 16, and 60, there was no documentation in the electronic health records (EHR) indicating that they were offered or provided with a transfer or discharge notice when they were hospitalized. Resident 18, who was cognitively intact, was transferred to the hospital and returned without any record of a transfer notice. Similarly, Resident 40, also cognitively intact, was transferred to the hospital without a completed transfer notice. Staff interviews confirmed the absence of these notices, with the Director of Nursing Services acknowledging that the notices should have been completed. Residents 16 and 60, both cognitively intact, were also hospitalized and returned without documented transfer notices. The lack of these notices placed residents and their representatives at risk of not being able to make informed decisions about their transfers or discharges.
Failure to Provide Bed Hold Notices During Hospital Transfers
Penalty
Summary
The facility failed to provide a bed hold notice to residents or their representatives during hospital transfers, affecting three out of four sampled residents. Resident 40, who was cognitively intact, was transferred to the hospital on July 1, 2024, and returned to the facility without any documentation of a bed hold notice in their Electronic Health Record (EHR). Staff E, a Resident Care Manager/Registered Nurse, confirmed that Social Services was responsible for completing bed hold notifications but could not find any record of it. Staff B, the Director of Nursing Services, acknowledged that the bed hold notification for Resident 40 was not completed as required. Similarly, Resident 16, also cognitively intact, was hospitalized from March 16 to March 20, 2024, without any bed hold notice documented in their EHR. Resident 60, who was hospitalized from September 13 to September 19, 2024, also lacked documentation of a bed hold notice. Staff B confirmed the absence of bed hold notices for both Resident 16 and Resident 60, stating that these notifications should have been completed. This oversight placed the residents and their representatives at risk of not being able to make informed decisions regarding bed hold policies, potentially affecting their quality of life.
Inaccurate MDS Assessments for Multiple Residents
Penalty
Summary
The facility failed to ensure the Minimum Data Set (MDS) assessments accurately reflected the status of six residents, leading to potential risks for unmet care needs and diminished quality of life. Resident 53 was incorrectly documented as being on a prescribed weight loss program due to diuretic use, while Resident 10's significant weight loss was not recorded on the MDS. Resident 21 was mistakenly coded as having an ostomy when they only had a suprapubic catheter. Resident 56 was inaccurately documented as having a diagnosis of depression, which was not present in their records. Additionally, Resident 176's MDS incorrectly indicated that the pneumococcal vaccination was not offered, despite documentation showing consent and offer. Resident 23's MDS failed to include active diagnoses of psychosis, anxiety, or depressive disorders, despite receiving antipsychotic medication and having a PASRR evaluation indicating serious mental illness. These inaccuracies in the MDS assessments were acknowledged by the facility staff during interviews.
Care Plan Deficiencies in LTC Facility
Penalty
Summary
The facility failed to ensure that resident care plans were reviewed, revised, and accurately reflected the residents' care needs for several residents. For Resident 62, the care plan directed staff to provide assistance with bathing according to the resident's chosen schedule, but it did not specify what that schedule was. Similarly, Residents 176 and 376 expressed a desire for more frequent showers than what was scheduled, but their care plans did not reflect their preferences for the type or frequency of bathing. Resident 67's care plan also lacked details about their preferred bathing type and frequency. Resident 23's care plan for psychotropic drug use required documentation of hallucinations and delusions but did not specify the nature or effect of these experiences or any actions staff should take. Resident 28's care plan included monitoring intake and output (I&O) as per facility policy, but there was no order for I&O, and staff were not monitoring it. Similar issues were noted for Resident 176, whose care plan also included I&O monitoring without an order or actual monitoring taking place. Resident 21's care plan was outdated and did not reflect their current abilities or goals. The care plan included interventions for physical therapy and daily activities that were not being provided or were beyond the resident's current capabilities. Additionally, there was a discrepancy in the nutritional status care plan regarding the amount of water to be given, which had not been updated to match the current order. These deficiencies indicate a lack of proper care plan management and documentation, potentially affecting the quality of care provided to the residents.
Deficiency in Restorative Services Due to Staffing Issues
Penalty
Summary
The facility failed to provide restorative services at the frequency required for six residents, leading to a deficiency in maintaining or improving their range of motion (ROM) and mobility. Residents 48, 22, 55, 46, 25, and 61 were assessed to need specific restorative nursing programs (RNPs) to prevent decline in ROM and contracture formation. However, the facility did not consistently offer these programs as required. For instance, Resident 48 was supposed to receive an active ROM program five times a week but only received it on 10 of 25 days in September and 7 of 26 days in October. Similarly, Resident 22 was to participate in an active ROM program five times a week but only received it on 14 of 21 days in October. The deficiency was further highlighted by the facility's staffing issues, which were acknowledged by both the Restorative Aide and the Administrator. The Restorative Aide, Staff FF, reported being frequently pulled from their duties to work the floor, which resulted in most restorative programs not being completed. This staffing shortage was confirmed by the Administrator, who admitted that the lack of restorative staff detracted from the provision of services at the required frequency. Resident 61 also reported receiving physical therapy less frequently than prescribed due to these staffing issues. The report indicates that the facility's failure to provide the necessary restorative services placed residents at risk for decreased ROM, development of contractures, increased dependence on staff, and diminished quality of life. The deficiency was documented under WAC 388-97-1060, highlighting the facility's non-compliance with the required standards for restorative care.
Expired Medications and Supplies Not Removed
Penalty
Summary
The facility failed to ensure the removal and disposal of expired medications and supplies in one of the two medication storage rooms reviewed. During an observation on November 4, 2024, several outdated items were found, including blood glucose lancets, blood glucose strips, ibuprofen, vitamin B-6, a daily vitamin formula with iron, an Arexvy vaccine vial, a tuberculin purified protein derivative vial, and urine reagent strips. These items had expiration dates ranging from June to October 2024, and some were opened but not dated. Staff C, the Resident Care Manager, indicated that nursing staff were responsible for managing expired medications and supplies. On November 12, 2024, Staff B, the Director of Nursing, expressed that expired medications should be destroyed or removed by their expiration date.
Failure to Obtain Resident Council Approval and Provide Bedtime Snacks
Penalty
Summary
The facility failed to obtain approval from the Resident Council and did not ensure that residents were provided a nourishing snack at bedtime when the interval between dinner and breakfast was extended from 14 hours to 15 hours. This deficiency was identified through interviews and record reviews. Specifically, residents in the Garden Room, Medicare A hall, Medicare B, [NAME] Mountain, and Mountain View Halls were served dinner between 5:00 PM and 5:20 PM and breakfast between 8:00 AM and 8:20 AM, resulting in a 15-hour gap between meals. The Director of Nursing Services confirmed the lack of documentation for Resident Council approval and stated that only diabetic residents were routinely served snacks at bedtime, although snacks were available upon request for other residents.
Infection Control Deficiencies in PPE and Equipment Handling
Penalty
Summary
The facility failed to adhere to infection prevention and control protocols, particularly in the use of Enhanced Barrier Precautions (EBP) for Resident 7, who had a gastric feeding tube. Staff W, an LPN, admitted to not wearing the required PPE while administering medication to Resident 7, despite the EBP order. This oversight was acknowledged by both the Infection Preventionist and the Director of Nursing, who confirmed that the expectation was for staff to follow the EBP orders. Additionally, the facility did not maintain proper hygiene practices with PPE and food carts. Observations revealed that staff placed personal items and food on PPE carts, which were then used to store and transport PPE items into resident rooms. Similarly, food carts were improperly used, with coffee stored on the bottom shelf while used trays were placed above, risking cross-contamination. Staff interviews confirmed that these practices did not meet the facility's expectations for infection control. The facility also failed to follow standard precautions in handling medical equipment and performing hand hygiene. Resident 21's catheter tubing was observed to be improperly positioned, with urine pooling in the tubing and the bag touching the floor. Staff did not perform hand hygiene when handling the catheter. Similarly, Resident 56's negative pressure wound treatment tubing was found on the floor, contrary to infection control expectations. These observations were confirmed by staff interviews, indicating a lack of adherence to infection control protocols.
Failure to Administer Pneumococcal Vaccines
Penalty
Summary
The facility failed to provide pneumococcal vaccines to three residents who had consented to receive them, placing them at a higher risk for pneumococcal infections. Resident 176 was admitted to the facility and had consented to the pneumococcal vaccination, as documented in the Admission Minimum Data Set and a consent form. Despite this, the resident was not administered the vaccine during their stay and was discharged without receiving it. The Infection Preventionist, Staff X, acknowledged that they were not notified of the consent and confirmed the vaccine was not given. Similarly, Resident 10 and Resident 21 both consented to receive the pneumococcal vaccine, but it was not ordered from the supplier. Staff C, the Resident Care Manager, and Staff B, the Director of Nursing Services, both acknowledged that the vaccines were not ordered and that this did not meet the facility's expectations. These oversights were identified during interviews and record reviews, highlighting a lapse in the facility's vaccination administration process.
Emergency Fire Door Malfunction
Penalty
Summary
The facility failed to maintain the emergency fire doors in working order in one of the three main halls, specifically outside a room. During an observation, a square metal piece in the floor of the Medicare A and B hallway was found to be loose and protruding. This metal piece affected the functionality of the fire door, requiring significant force to open it. Staff members, including a Licensed Practical Nurse and a Certified Nursing Assistant, encountered difficulties in opening the door, with the CNA needing both hands to do so. A resident using a walker was also unable to open the door due to the resistance. The Maintenance Supervisor attempted to fix the issue by gluing the metal piece, but the glue had not cured, and further attempts to secure it were planned. The Administrator later stated that the metal piece had been repaired to eliminate the tripping hazard.
Failure to Provide Scheduled ADL Assistance
Penalty
Summary
The facility failed to provide scheduled bathing and showering opportunities for six residents who required assistance with activities of daily living (ADLs). Resident 43, who was moderately cognitively impaired, did not receive a shower for 14 days despite being scheduled for weekly showers. Staff acknowledged the oversight, confirming that the resident should have been showered and documented on the scheduled day. Similarly, Resident 176, who was cognitively intact and expressed a preference for more frequent showers, was only offered a bath once in a 21-day period, contrary to their care plan. Resident 19, who required extensive assistance with ADLs, expressed dissatisfaction with the lack of shaving services, stating that they had to repeatedly request a shave without success. The resident's care plan and electronic health record lacked documentation regarding shaving activities. Resident 64, also moderately cognitively impaired, reported similar issues with shaving and haircuts, with documentation showing infrequent offers of shaving despite a physician's order for regular offers. Staff confirmed the lack of specific documentation for shaving tasks in the electronic health record. Residents 67 and 62, both cognitively intact, experienced significant gaps in bathing services due to staffing issues. Resident 67 went without bathing for extended periods, including a 25-day gap, while Resident 62 experienced a 42-day gap without being offered a bath. Both residents' care plans indicated the importance of bathing preferences, yet these were not consistently honored. Staff confirmed the documentation gaps and acknowledged the failure to provide the necessary care as per the residents' preferences and care plans.
Deficiencies in Nutritional and Fluid Management
Penalty
Summary
The facility failed to ensure that residents receiving enteral feedings were administered the correct formula at the physician-ordered rate and volume. Specifically, Resident 21, who had diagnoses including malnutrition and hyponatremia, was ordered to receive 1400 milliliters of formula but was only given 406 ml on one occasion and 938 ml on another, with no documentation explaining the discrepancies. Additionally, Resident 21's weight was not monitored as required, with no weights recorded since August, despite recommendations for updated weights in September and October. The facility also failed to monitor and document fluid intake accurately for residents on fluid restrictions. Resident 58, who had kidney disease and heart failure, was on a 1500 ml/day fluid restriction, but there was no system in place to reconcile fluid intake from meals and nursing records to calculate a 24-hour total. Similarly, Resident 10, with heart failure and end-stage renal disease, was on a 1000 ml/day fluid restriction, but fluid intake records were incomplete, lacking documentation of fluids given by nursing staff. Furthermore, the facility did not identify and address significant weight loss in residents. Resident 64, who had end-stage renal disease, experienced a significant weight loss of more than 7.5% over three months, which was not identified until a quarterly review. The facility's failure to obtain routine weights and identify weight loss trends in a timely manner contributed to this oversight. These deficiencies placed residents at risk for inadequate nutrition, fluid imbalances, and other medical complications.
Staffing Shortages Impact Resident Care
Penalty
Summary
The facility failed to provide sufficient staffing to meet the needs of its residents, as evidenced by multiple resident and staff interviews, grievances, and observations. Residents reported long wait times for assistance with activities of daily living (ADLs), such as grooming, showers, and bathroom use. Some residents expressed frustration with the inconsistency of staff response times, which varied depending on who was on duty. The lack of available staff also affected the provision of restorative services and infection control, as aides were frequently pulled from their assignments to cover other duties. Staff interviews corroborated the residents' concerns, with several staff members indicating that they were unable to complete their daily tasks due to staffing shortages. Certified Nursing Assistants (CNAs) and Licensed Practical Nurses (LPNs) reported being overworked, often having to work overtime or longer shifts to manage their responsibilities. The facility's Director of Nursing Services and Administrator acknowledged the staffing issues and their impact on resident care, including the inability to provide scheduled bathing and restorative services. The report highlighted specific instances where residents filed grievances due to missed showers and lack of restorative services. Resident Council minutes further documented ongoing concerns about insufficient staffing and the impact on residents' quality of life. The facility's failure to maintain adequate staffing levels resulted in unmet care needs and diminished quality of life for the residents, as they were unable to receive timely assistance and services as required by their care plans.
Deficiency in Meal Preparation and Delivery
Penalty
Summary
The facility failed to ensure that meals were appetizing, palatable, and served at appropriate temperatures for several residents. Multiple residents reported dissatisfaction with the food, describing it as having poor taste, inappropriate texture, and being served at incorrect temperatures. Specific complaints included meals being consistently cold, food tasting bland or freezer burnt, and a lack of variety in the menu. Observations confirmed that meal carts were delayed in delivery, leading to meals being served cold. Additionally, residents noted that their meal preferences were not always honored, contributing to their dissatisfaction. Further investigation into meal preparation revealed that beverages were removed from refrigeration and placed on meal trays well in advance of meal service, resulting in them being served at unsafe temperatures. A test tray confirmed that beverages and food items were not at appropriate temperatures when served. Staff indicated that this practice was intended to streamline the tray line process, but no measures were taken to ensure beverages remained cold, such as placing them on ice. This oversight in meal preparation and delivery placed residents at risk for decreased nutritional intake and dissatisfaction with their meals.
Failure to Provide Prescribed Therapeutic Diets and Portion Sizes
Penalty
Summary
The facility failed to ensure that residents received therapeutic diets as prescribed by their physicians and assessed by the interdisciplinary team. During an observation, it was noted that dietary staff placed tartar sauce on all resident trays, including those for residents on specific diets that should not have included tartar sauce. This affected five residents who were on various restricted diets, such as renal, no added salt (NAS), and low sodium diets. The dietary manager confirmed the error but did not take corrective action to remove the tartar sauce from the trays of affected residents. Additionally, the facility did not provide the correct portion sizes for residents with specific dietary orders. Six residents with orders for small or large portions received incorrect serving sizes. Staff used a standard 1/2 cup spoodle and visually adjusted the amount, rather than using the appropriate size spoodle for the ordered portion sizes. This practice was confirmed by the dietary manager and staff, who acknowledged that the method used was not acceptable. The failure to adhere to prescribed diets and portion sizes placed residents at risk for medical complications and unmet nutritional needs.
Deficient Communication and Coordination with Hospice Services
Penalty
Summary
The facility failed to ensure effective communication, collaboration, and coordination of care between the facility and the hospice provider for two residents receiving hospice services. For Resident 64, the facility did not maintain a current hospice coordinated plan of care or document hospice visits and care provided in the Electronic Health Records (EHR). The hospice care plan indicated limited hospice involvement, with the facility responsible for most Activities of Daily Living (ADL) assistance. However, the facility's hospice service binder lacked comprehensive documentation, and there was no designated person for hospice communication, leading to inadequate record-keeping and coordination. Similarly, for Resident 28, the facility did not have a current coordinated hospice plan of care, and the EHR lacked documentation of hospice visits and services provided. The hospice care plan required weekly nurse and aide visits, but the facility could not verify these visits or their details. Staff acknowledged issues with communication and documentation between hospice and the facility, and efforts to improve this were in progress, but the deficiencies remained unaddressed at the time of the survey.
Failure to Respect Resident Privacy and Dignity
Penalty
Summary
The facility failed to respect and value the residents' private space by not knocking and/or announcing themselves before entering the rooms of three out of four sampled residents. This deficiency was observed during a survey where staff members, including a Certified Nursing Assistant (CNA), housekeeping staff, and a CNA/Shower Aid, entered residents' rooms without prior notice. Specifically, Staff F, a CNA, entered a room without knocking or announcing themselves and later acknowledged that this was not acceptable behavior. Similarly, Staff G from housekeeping entered rooms without knocking or announcing themselves on multiple occasions, admitting to forgetting the protocol. The facility's policy on Residents Rights, revised in 2016, clearly states that residents have the right to a dignified existence, which includes staff knocking and announcing themselves before entering a room. Interviews with the Resident Care Manager and the Director of Nursing Services confirmed that the expectation is for staff to knock and announce themselves, and the repeated failure to do so was deemed unacceptable. This lack of adherence to policy placed residents at risk of being treated with a lack of dignity and a diminished quality of life.
Failure to Obtain Proper Consent for Psychotropic Medications
Penalty
Summary
The facility failed to ensure that residents were fully informed and had signed consent prior to the administration of psychotropic medications. Specifically, Resident 21, who had diagnoses of depression and dementia with psychosis, was prescribed risperidone, an antipsychotic medication. However, the consent forms signed for this medication were inconsistent and incorrect, as they were classified under different drug categories such as anticonvulsant and antianxiety, each listing different side effects. This inconsistency in classification and information provided to the resident was acknowledged by the Resident Care Manager and the Director of Nursing Services, who both stated that the expectation was for risperidone to be classified correctly as an antipsychotic. Additionally, the facility administered venlafaxine, an antidepressant, to Resident 21 before obtaining the necessary consent. The administration of venlafaxine began on May 3, 2024, while the consent was only signed on May 17, 2024. Both the Resident Care Manager and the Director of Nursing Services confirmed that their expectation was for consent to be obtained prior to the administration of the medication. These actions placed the resident at risk of receiving medication without proper knowledge of the medication or its side effects, potentially impacting their quality of life.
Failure to Honor Resident Bathing Preferences
Penalty
Summary
The facility failed to honor the bathing preferences of two residents, both of whom were cognitively intact and had identified their bathing choices as very important. Resident 376, who was admitted to the facility, reported not being asked about their bathing preferences and was informed they would receive one shower a week. The resident expressed dissatisfaction with the quality of the shower received, noting it did not meet their standards of cleanliness. The resident's care plan indicated assistance with bathing once a week, but there was no documentation in the electronic health record (EHR) to show that the facility attempted to support the resident's choice. Similarly, Resident 176 was not consulted about their preferred bathing frequency or type and was also scheduled for one shower per week. The resident preferred daily showers but was willing to accept a shower every three days while at the facility. The care plan for Resident 176 required substantial assistance with bathing but did not specify the frequency. The EHR lacked documentation of efforts to facilitate the resident's self-determination regarding bathing preferences. Staff interviews revealed that residents were initially assigned one shower per week upon admission, with the possibility of changes based on resident requests or feedback during care conferences.
Inaccurate PASRR Documentation and Delayed Referrals
Penalty
Summary
The facility failed to ensure the accuracy and timely referral for Level II PASRR evaluations for two residents, which could impact their access to specialized mental health services. Resident 60 was admitted with a diagnosis of depression, but the Level I PASRR inaccurately documented an anxiety disorder. Despite the exemption for a hospital discharge with an anticipated stay of less than 30 days, a Level II PASRR referral was delayed beyond the required timeframe. Staff interviews confirmed the discrepancy between the PASRR documentation and the resident's actual diagnosis, highlighting a failure to identify and correct the error in a timely manner. Similarly, Resident 56's Level I PASRR was updated to indicate a serious mental illness with a mood disorder, despite the absence of such a diagnosis in the resident's health records. Staff acknowledged the incorrect coding of the PASRR, which did not reflect the resident's actual mental health status. These inaccuracies in PASRR documentation for both residents demonstrate a lapse in the facility's processes for ensuring accurate mental health assessments and timely referrals, as required by regulations.
Failure to Develop Comprehensive Care Plans for Residents
Penalty
Summary
The facility failed to develop and implement comprehensive person-centered care plans for two residents, leading to potential risks for unmet care and safety needs. Resident 56, who was admitted with diagnoses including surgical amputation, muscle weakness, and hypertension, did not have a care plan addressing their interest in activities or their documented edema. Additionally, there was an error in the care plan regarding the site of negative pressure wound treatment, which was incorrectly listed as the left side instead of the right side where the amputation wound was located. Resident 126, admitted with sepsis and cellulitis, was receiving intravenous antibiotics through a PICC line. However, there was no care plan addressing the management of the PICC line. Interviews with staff, including the Resident Care Manager and the Director of Nursing Services, revealed that the expectations for care planning were not met for both residents, as essential aspects of their care were not documented or addressed in their care plans.
Failure to Complete Earwax Removal Treatment
Penalty
Summary
The facility failed to ensure that a resident, identified as Resident 176, received appropriate treatment and services to maintain their hearing. Resident 176, who was cognitively intact and had moderate difficulty hearing, reported experiencing ear pain and hearing difficulties due to earwax build-up. The resident had requested staff assistance to address the issue. Although the nursing staff administered Debrox ear drops as part of the treatment plan, they did not complete the treatment by flushing the resident's ears with warm water, as required by the medication's instructions. The care plan for Resident 176, which was revised to address hearing loss, directed staff to administer ear drops as ordered and to communicate with the resident by moderately elevating their tone. However, the medication administration records did not include instructions to flush the ears after the treatment, leading to incomplete care. The Director of Nursing Services acknowledged that the treatment should have included ear flushing and that the nursing staff should have identified and clarified the incomplete order. This oversight resulted in the resident continuing to experience clogged ears and difficulty hearing.
Deficiency in IV Medication Administration and Central Line Management
Penalty
Summary
The facility failed to administer parenteral medication in accordance with professional standards for a resident who was receiving intravenous antibiotics. The resident, who had been diagnosed with sepsis and cellulitis, was admitted with a peripherally inserted central catheter (PICC) for medication administration. However, the electronic health record (EHR) lacked specific orders for the central line, and there was no care plan in place for the PICC. Additionally, the orders for the IV antibiotics did not specify the rate of administration, which is a critical component of safe medication delivery. Interviews with staff revealed further deficiencies in the management of the resident's care. The Resident Care Manager/Registered Nurse (RCM/RN) was unable to find a previous measurement of the external catheter length, which is necessary for monitoring the PICC. The Director of Nursing Services confirmed that the facility's expectations were not met, as the measurement should have been taken upon admission and with dressing changes. Furthermore, there were no orders for the frequency of dressing changes, and the staff were expected to confirm the rate of administration with each medication order, which was not done. These oversights placed the resident at risk for complications and infections.
Failure to Follow Dialysis Care Orders
Penalty
Summary
The facility failed to ensure that physician orders were followed for two residents requiring dialysis care, specifically regarding the post-dialysis fistula access care. Resident 72, who was cognitively intact and diagnosed with End Stage Renal Disease, was dependent on renal dialysis and had a dialysis fistula in their left arm. The physician's order and the care plan both instructed that the pressure dressing should be removed two hours after dialysis. However, Resident 72 reported that they often removed the pressure dressing themselves, sometimes waiting until much later in the day, and had previously experienced bleeding from the fistula site due to early removal, which resulted in a hospital transfer. Interviews with facility staff revealed that there was no documented training or teaching for Resident 72 to self-manage their pressure dressing removal. Staff C, the Resident Care Manager, could not locate any documentation of such training in the Electronic Health Record (EHR). Additionally, Staff B, the Director of Nursing Services, stated that there should have been a self-administration form, care plan address, and physician order for Resident 72 to remove their own dressing, none of which were documented. This lack of documentation and adherence to the care plan and physician orders led to the deficiency.
Failure to Implement Pharmacist's Medication Regimen Review Recommendations
Penalty
Summary
The facility failed to ensure that the pharmacist's Medication Regimen Review (MRR) recommendations were acted upon for a resident reviewed for unnecessary medications. The facility's policy required that MRR recommendations be provided to the responsible physician, Medical Director, and Director of Nursing within a week of the review, with documentation in the resident's medical record regarding any actions taken. However, for Resident 21, who had diagnoses of malnutrition and gastrostomy status and experienced constant pain, there was no documentation that the MRR recommendations were implemented. Specifically, the recommendation noted that Carafate, which could alter the absorption of other medications, should be given on an empty stomach and two hours before or after other medications. Despite this recommendation, the medication administration record for August and September showed that Resident 21 was scheduled to receive both oxycodone and Carafate at the same times. Interviews with facility staff revealed that there was no documentation of the MRR recommendations being implemented or reviewed, nor was there evidence that the provider was aware of the recommendation. The Director of Nursing Services confirmed the expectation that the doctor would have confirmed a conversation about the medication, but they were unable to provide documentation that this occurred.
Medication Administration Deficiencies for Two Residents
Penalty
Summary
The facility failed to ensure quality care for two residents by not adhering to medication orders, which led to deficiencies in their drug regimens. Resident 10, who was cognitively intact and had a diagnosis of end-stage renal disease requiring dialysis, had an order for the removal of the dressing on their port two hours after dialysis on specific days. However, the November 2024 administration record and progress notes indicated that the dressing was not being removed, increasing the risk of infection. Staff interviews revealed that the order was not correctly written, and there was a lack of communication to address the issue, which did not meet the facility's expectations. Resident 56, who had a moderately impaired mental status and a diagnosis of type two diabetes, missed a scheduled dose of dulaglutide upon returning from a hospital stay because the medication was not available from the pharmacy. The progress notes lacked documentation of notifying the provider about the missed dose, and no additional orders were found. The next dose was administered a week later, and staff interviews confirmed that there was no makeup dose or communication with the provider, which did not meet the facility's expectations.
Failure to Implement Gradual Dose Reductions and Follow-Up on Laboratory Tests
Penalty
Summary
The facility failed to ensure that residents were free from unnecessary psychotropic medications by not attempting Gradual Dose Reductions (GDR) for certain residents. Resident 27, who was readmitted with diagnoses of Major Depressive Disorder and bipolar disorder, was prescribed duloxetine. Despite the requirement for GDRs, there was no evidence of any attempts to reduce the dosage from January 2024 through October 2024. The interdisciplinary team reviews conducted in February, June, and September 2024 also did not document any GDR attempts. The Director of Nursing Services acknowledged the lack of documentation and attempted to contact the physician for further information, but no additional documentation was provided. Additionally, the facility did not follow up on GDR recommendations that included laboratory tests for Resident 21, who had diagnoses of anxiety and depression. A psychiatry note recommended reducing the antianxiety medication dose and conducting laboratory tests to exclude delirium. Although the medication dose was reduced, the laboratory tests were not performed until a change in the resident's condition in November 2024. The Resident Care Manager could not find evidence of the recommendation being followed, and the Director of Nursing Services admitted that they should have followed up on the laboratory tests after the psychiatry visit.
Failure to Administer Consented COVID-19 Vaccinations
Penalty
Summary
The facility failed to ensure that residents who consented to receive COVID-19 vaccinations were administered the vaccines. Resident 10, who was admitted to the facility and consented to receive the COVID-19 vaccination on two separate occasions, did not receive the vaccine because it was not ordered from the supplier. This oversight was acknowledged by the Resident Care Manager and the Director of Nursing, who both confirmed that the vaccine had not been ordered as expected. Similarly, Resident 21 consented to receive the COVID-19 vaccination but did not receive it due to the same issue of the vaccine not being ordered. The Director of Nursing confirmed that the expectation was for the vaccine to be administered once consent was given, which did not occur in these cases.
Failure to Provide Consistent Pressure Ulcer Care
Penalty
Summary
The facility failed to consistently provide treatments as ordered and implement timely and appropriate interventions to prevent the worsening of pressure ulcers for a resident. The resident, identified as Resident 64, was admitted with a Stage II pressure ulcer on the sacrum. Despite having a care plan and physician's orders for treatment, there were multiple instances where the treatment was not documented as completed in the Electronic Health Record (EHR). These missing entries spanned several dates, indicating a lack of adherence to the prescribed care regimen. The facility's policy required regular assessments and documentation of pressure ulcers, but there were lapses in this process. The initial assessment and subsequent Braden Scale evaluations incorrectly identified the resident as being at low risk for pressure ulcers, despite the presence of existing ulcers. The resident's condition worsened over time, with the development of additional pressure ulcers and a progression to a Stage 4 ulcer. The facility's documentation was inconsistent, with missing entries for weekly skin checks and treatment orders, and there was a lack of follow-up on the resident's refusals of care. Interviews with the Director of Nursing Services revealed that the facility was aware of the resident's worsening condition but failed to provide specific details about the events leading to the deterioration. The facility's contracted wound care provider was involved, but their notes were not integrated into the EHR. The Director acknowledged the incorrect Braden Scale assessments and the lack of documentation for treatment refusals, indicating a failure to adhere to the facility's skin care policy and procedures.
Failure to Conduct Care Plan Conferences
Penalty
Summary
The facility failed to ensure that care plan conferences were held with a resident, identified as Resident 2, who was cognitively intact and required substantial assistance with activities of daily living. Resident 2 was admitted with diagnoses including heart failure and chronic kidney disease. Despite the care plan being revised to reflect the resident's wish to return to their apartment, no care conference was conducted or offered from May to October 2024. Resident 2 expressed a desire to discharge home but reported that staff had not discussed discharge plans or care conferences with them. Staff members, including the Social Services staff, Administrator, and Director of Nursing, acknowledged that the facility was behind on care conferences and had not been completing them consistently.
Failure to Develop and Implement Discharge Plan
Penalty
Summary
The facility failed to develop and implement a personalized discharge plan for Resident 2, who was admitted with diagnoses including heart failure and chronic kidney disease. Despite being cognitively intact and expressing a desire to return to their apartment, the resident reported that no discharge plans had been discussed with them. The resident felt they had improved sufficiently to manage in their prior living situation but was unaware of any evaluations regarding their readiness or safety for discharge. Staff C, a new social services staff member, and Staff A, the Administrator, both confirmed the absence of discharge planning documentation for Resident 2. Staff B, the Director of Nursing, acknowledged turnover in social services staff and suggested that documentation might be in a different format, but no further information was provided. This lack of discharge planning documentation and communication placed the resident at risk for delayed discharge and unmet care needs.
Failure to Assess and Treat Chronic Skin Condition
Penalty
Summary
The facility failed to accurately assess and determine appropriate treatments for a chronic skin condition in a resident with diabetes mellitus, peripheral vascular disease, and peripheral angiopathy. The resident was admitted with a risk for skin breakdown, and the care plan included monitoring skin hydration and applying treatments as ordered. However, multiple skin evaluations and interdisciplinary team reviews failed to document the condition of the resident's legs, despite the presence of hemosiderin staining and chronic skin issues noted in the Wound Clinic notes. Observations revealed the resident's legs were ruddy with dried, flaky skin, and there was no evidence of consistent treatment or documentation of the skin condition. Staff interviews revealed a lack of clarity and consistency in managing the resident's chronic skin condition. Nursing staff acknowledged the resident's skin impairment was chronic, with periods of healing and flare-ups, but were unsure of the cause and lacked a current treatment plan. The resident was sensitive to creams and lotions, and there was no active order for treatment. The Director of Nursing confirmed the absence of a current treatment plan and indicated that skin monitoring was conducted weekly, but no further information was provided to address the deficiency.
Failure to Provide Diabetic Nail Care
Penalty
Summary
The facility failed to provide necessary diabetic nail care and treatment for a resident with diabetes mellitus, peripheral vascular disease, and peripheral angiopathy. The resident's care plan required daily inspection of feet for sores, blisters, and redness, and the Treatment Administration Record indicated weekly diabetic nail care. However, observations revealed the resident's toenails were long, thick, and jagged, causing discomfort. The resident expressed a desire for nail care and willingness to see a podiatrist, but there was no record of podiatry services being discussed or provided. Staff interviews revealed inconsistencies in nail care documentation and provision. A nursing assistant and an LPN acknowledged the resident's long and jagged toenails, with the LPN admitting to signing off on nail care even when it was not performed due to the resident's refusal. The LPN also mentioned not reporting the refusal to a supervisor. The Director of Nursing was unaware of the false documentation and stated that mobile podiatry services were available, but no evidence of nail care was provided upon further review.
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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Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release June 24, 2026) and official state health department websites — never guesswork.
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