Caroline Kline Galland Home
Inspection history, citations, penalties and survey trends for this long-term care facility in Seattle, Washington.
- Location
- 7500 Seward Park Avenue South, Seattle, Washington 98118
- CMS Provider Number
- 505442
- Inspections on file
- 21
- Latest survey
- March 4, 2026
- Citations (last 12 mo.)
- 26
Citation history
Health deficiencies cited at Caroline Kline Galland Home during CMS and state inspections, most recent first.
Resident Council grievances were not timely addressed and verbal concerns were not consistently identified or documented. Residents reported repeated food concerns, including frequent cooked carrots and a resident’s preference to avoid tomato-based foods due to RA and nightshade sensitivity, but no resolution was communicated. Staff said concerns were only submitted as grievances after being repeated, and the resident’s no-tomato preference was not added to the food profile.
Inaccurate MDS Assessment of Wheelchair Seat Belt Restraints: The facility failed to accurately identify restraint use for four residents on the MDS. Although each resident’s MDS showed no restraints used, surveyors observed residents in wheelchairs with latched seat belts holding them in place; one resident stated the seat belt came with the wheelchair and staff had not discussed it, and another stated staff helped secure the belt without discussing it. The DON confirmed the seat belts were not accurately assessed on the MDS under restraints.
The facility failed to offer or document care conferences within the required quarterly timeframe for several residents, including residents with MS, neurogenic bladder, dementia, and no memory impairment. Staff said care conferences should occur upon admission, quarterly, after significant change, and as needed, but records showed long gaps or only limited conference documentation. The facility also failed to keep care plans current for residents whose isolation precautions had changed, including residents whose influenza-related precautions were discontinued or whose precaution status no longer matched the care plan.
The facility allowed MA-Cs to administer hazardous chemotherapy and hormone therapy drugs to several residents, failed to clarify and follow physician orders for tasks and PRN pain medication parameters, and did not administer insulin pens according to manufacturer instructions. Records and observations showed staff gave medications outside ordered parameters, documented tasks as completed when they were not, and used insulin pen techniques that did not match the IFU.
Failure to Provide Meaningful Resident Activities: Four residents with varied medical and cognitive needs were not provided consistent, person-centered activities despite care plans and assessments identifying interests such as music, news, TV, books, outdoor time, and family interaction. Observations and interviews showed residents were bored, had limited or no activity materials in their rooms, lacked access to TVs or devices, were not offered activities or escorted to them, and had little or no activity documentation in the record.
The facility failed to obtain provider orders, safety assessments, and resident or representative consents for wheelchair seatbelts used as physical restraints for four residents. Records showed no documentation for the seatbelts, while observations found the belts latched on residents with diagnoses including dementia, spinal stenosis, arthritis, amputation, depression, and autoimmune disorder; residents stated staff had not discussed the seatbelts with them.
Incorrect Portioning of Mechanically Altered Meals: Dietary staff did not provide the ordered portion size for several residents who required mechanically altered texture meals. Tray tickets showed a nine-ounce serving was required, but the meals were served using a scoop that the DSDM said was not the correct size. The Dietician stated it was important for residents to receive the portion size they were assessed to require.
Unsafe food handling and reheating practices were observed in the kitchen and on resident units. A cook changed gloves multiple times while preparing food without washing hands, unit kitchen staff did not have or use a thermometer as required to verify reheated food reached 165 F, and a CNA reheated a resident meal without checking the temperature. A resident receiving palliative care and needing feeding assistance had lunch left across the room for an extended period before staff returned to help, and staff described leaving trays in rooms and serving them later without rewarming.
The facility failed to honor resident choice for bathing and food preferences. Two cognitively intact residents who needed staff assistance for bathing said they were not given a choice about shower frequency and wanted showers twice weekly, but the facility generally provided only weekly showers. Another resident with arthritis repeatedly expressed a preference to avoid tomatoes, yet remained on a regular diet with no food preference accommodation, and staff acknowledged the preference was not accommodated.
A resident with dementia, TBI, and a history of falls had multiple unwitnessed falls that were not thoroughly investigated, and ordered neuro checks were not completed after the falls. The DON stated the assessments were missed and that contradictory documentation in one fall investigation was inaccurate.
PASRR assessments were not kept accurate for two residents with MH conditions. One resident with vascular dementia, TBI, and a new anxiety dx did not receive a PASRR review after the new SMI indicator was added. Another resident with schizophrenia, depression, anxiety, and behavioral issues had a Level I PASRR updated for Level II review, but the facility did not follow up with the PASRR evaluator for over 12 months, despite routine AP and AA use and ongoing behaviors.
Failure to provide ADL assistance affected two residents who were dependent on staff for care. One resident with cancer, HF, and urinary retention was observed with dirty teeth and no toothbrush despite needing help with oral care and hygiene. Another resident with TBI, a recent fracture, and weakness had long, jagged, broken fingernails, and records showed no nail care documentation or refusal. Staff stated morning care and nail care were expected, but the assistance was not provided.
The facility failed to monitor and carry out ordered care for two residents. One resident with ESRD on dialysis had low BP readings, but the provider was not notified after abnormal readings were documented. Another resident with lymphedema had swollen legs and feet, yet staff did not document the degree of edema, did not notify the provider about refusals to elevate the legs, and did not follow the ordered leg elevation and Coban wrap care. Staff interviews confirmed the missed monitoring and lack of documentation.
Leaking Catheter Not Reported or Addressed: A resident with MS, neurogenic bladder, and functional quadriplegia had an indwelling catheter that was documented as leaking over multiple months. The record showed no documented provider notification of the leak, the care plan had no interventions for the issue, and physician notes continued to reference the need for a urology referral that had not been scheduled. During catheter care, staff observed the catheter still leaking, and an RN stated the leak should have been reported to the provider.
A resident with vascular dementia, TBI, and an abnormal heart rhythm had daily refusals of care, including meals, supplements, oral care, and transfers, over multiple months. The care plan had no measurable goals or interventions for the refusals, and staff reported the refusals to the charge nurse, but the record lacked provider notification and documentation of IDT huddles or a care plan addressing the repeated refusals.
Failure to provide dental services for a resident with broken and missing teeth and oral pain. The resident’s MDS showed cavities or broken teeth and mouth/facial pain, and records documented no upper teeth, poor lower dentition, chewing and swallowing difficulty, and a pureed diet. The care plan called for coordination of dental care, but the chart had no dental referral, and staff stated no provider notification or dental exam/referral could be found.
Failure to follow infection control precautions during resident care. Staff did not consistently use PPE or perform hand hygiene for residents on EBP, including a resident with a stage 4 pressure ulcer and urinary catheter, and another resident receiving catheter care without PPE. Staff also failed to follow contact precautions on two units during an influenza A outbreak and droplet precautions, including wearing a mask below the chin and entering a room without eye protection. Contaminated PPE was also discarded outside a resident’s room instead of in-room.
Failure to monitor and document appropriate ABO use: the facility did not fully implement its ABO stewardship program for two residents. One resident received an antibiotic for a UTI even though the infection preventionist stated McGeer and Loeb criteria were not met and the provider did not document why the ABO was ordered. Another resident had two wound-related ABO orders tied to a wound vac, but after the wound vac was discontinued, staff did not document contacting the provider about whether the ABOs should continue until two weeks later, when the wound was noted to have no signs of infection.
The facility failed to provide required written transfer/discharge notices to three residents during hospitalizations, as revealed through interviews and record reviews. A charge nurse admitted to not providing copies to residents or their representatives, only faxing them to the State LTC Ombudsman. The Director of Nursing confirmed the lack of documentation for these notifications, which placed residents at risk of not making informed decisions about their transfers.
The facility failed to conduct accurate PASRR evaluations for residents with mental health conditions, leading to deficiencies in care. A resident with anxiety and depression did not receive a necessary Level II evaluation after a significant change in condition. Another resident with dementia and a psychotic disorder was not referred for a Level II evaluation due to an oversight. Additional residents with mental health issues were not properly assessed due to staff's lack of awareness of regulations, placing them at risk of inappropriate placement and unmet needs.
The facility failed to ensure residents were free from unnecessary psychotropic medications and properly monitored for behaviors. A resident received an antianxiety medication beyond the 14-day limit, another lacked documentation for antipsychotic use, and a third had outdated target behaviors for medication monitoring. Staff acknowledged the deficiencies in monitoring and documentation.
The facility failed to implement an effective Infection Control Program, with staff not sanitizing glucometers, improperly handling uncovered food, and failing to use PPE and perform hand hygiene as required. These deficiencies were observed across multiple units, including the COVID unit, and involved improper storage of personal belongings in resident rooms.
The facility failed to provide dignified care to several residents, including inadequate toileting assistance, improper feeding practices, and lack of privacy during transport. Residents were instructed to use briefs instead of being assisted to the toilet, a CNA stood while feeding a resident, and another resident was exposed during transport. Additionally, a catheter bag was left uncovered, compromising privacy.
The facility failed to implement comprehensive care plans for several residents, leading to unmet needs and inappropriate care. A resident with memory impairment had an air mattress set incorrectly, risking skin integrity. Another resident's care plan lacked measurable goals for mood stability, while others had missing or incomplete plans for dental care, hearing aids, and communication needs.
The facility failed to update care plans for several residents, reflecting changes in their care needs, such as communication aids, dental status, and fall prevention measures. Additionally, two residents did not receive required care conferences, impacting their care coordination and preferences.
The facility failed to clarify physician's orders for two residents and did not administer medications timely for another. A resident with severe memory impairment had unclear antidepressant orders, while another with cancer experienced unmanaged pain due to lack of medication parameters. Additionally, a resident's morning medications were administered late, contrary to facility policy.
Two residents in an LTC facility did not receive adequate assistance with ADLs, including toileting and grooming. One resident, dependent on staff for toileting, was instructed to void in bed against their care plan, while another was observed in the same stained clothing over multiple days without being shaved. Staff interviews confirmed expectations for daily assistance, but these were not consistently met, leading to deficiencies in care.
Two residents in a LTC facility were not provided with meaningful activities, leading to a deficiency. One resident, who preferred religious activities, reported not being invited to any activities and spent days in bed. Another resident, who only spoke Bosnian, had no documented activities since admission, except for family visits. Staff confirmed the lack of an activities coordinator and documentation of activities offered or refused.
The facility failed to monitor and document signs of hypo/hyperglycemia and did not follow bowel management protocols for three residents. A resident with diabetes and constipation was not monitored for blood sugar symptoms, and the bowel protocol was not initiated despite no bowel movements for days. Another resident with constipation did not receive bowel management care as per the care plan. A third resident with diabetes had elevated blood sugar levels without proper monitoring instructions. Staff interviews confirmed these deficiencies.
The facility failed to provide prescribed restorative care and follow physician orders for residents with limited ROM and mobility. A resident was observed without a required palm protector, and two residents did not receive their prescribed restorative exercises as per their care plans. Staff interviews confirmed the inconsistencies and lack of documentation for refusals or missed sessions.
The facility failed to ensure two residents were up to date on pneumococcal vaccinations, placing them at risk for pneumonia. One resident's records lacked specific vaccine formulations, and the other had no documentation supporting vaccination status. Staff oversight in verifying and documenting vaccination status contributed to the deficiency.
Resident Council Grievances Not Timely Addressed
Penalty
Summary
The facility failed to ensure resident concerns were handled in a timely manner, verbal grievances were identified as grievances, resident rights were promoted periodically as required, and residents were given the opportunity to make grievances anonymously for 1 of 1 Resident Council groups reviewed. Review of the September 2025 through February 2026 Resident Council minutes showed no resident concerns documented, and the November 2025 through February 2026 grievance log showed no Resident Council concerns logged, despite Administrator attendance at each Resident Council meeting. During an interview, Residents 123, 186, and 59 stated food concerns were raised at every Resident Council meeting, including repeated concerns about the frequency of cooked carrots being served, but they reported no resolution was communicated. Resident 123 also stated they had expressed a preference not to be served tomato-based foods because of rheumatoid arthritis and avoiding nightshades, but the facility told them it could not accommodate the preference. Staff stated the food concerns led to a separate Food Committee meeting, that concerns were only submitted as grievances after being repeated, and that Resident 123’s preference for no tomatoes was not included in the food profile even though it should have been.
Inaccurate MDS Assessment of Wheelchair Seat Belt Restraints
Penalty
Summary
The facility failed to accurately assess restraint use on the MDS for 4 of 4 residents reviewed for restraints: Residents 59, 68, 123, and 186. Resident 59’s 11/20/2025 quarterly MDS indicated no memory impairment, diagnoses of autoimmune disorder and depression, and no restraints used, yet observations on 02/27/2026 and 03/03/2026 showed the resident in a wheelchair with a seat belt latched and holding them in the chair. Resident 68’s 02/02/2026 quarterly MDS showed no memory impairment, diagnoses of cervical spinal stenosis, anxiety, and depression, and no restraints used, but an observation on 03/03/2026 showed the resident in a wheelchair with a latched seat belt. Resident 123’s 02/03/2026 annual MDS showed no memory impairment, diagnoses of arthritis and below-the-knee amputation, and no restraints used, but during observation and interview on 03/02/2026 the resident was in a wheelchair with a seat belt latched and stated they received the wheelchair from the facility in April 2025 with the seat belt already on it and that staff had not discussed it with them. Resident 186’s 12/24/2025 quarterly MDS showed severe memory impairment, diagnoses of dementia, below-the-knee amputation, diabetes with unstable blood sugar, and pressure sores, and no restraints used, but on 03/03/2026 the resident was observed in a wheelchair with a latched seat belt and stated staff assisted with securing the seat belt and getting them into the wheelchair without discussing it. The DON stated staff were expected to accurately complete assessments for seat belt use and that these residents’ seat belts were not accurately assessed on the MDS under restraints.
Missed Care Conferences and Outdated Care Plans
Penalty
Summary
The facility failed to conduct resident and/or resident representative care conferences within seven days of each quarterly assessment for 4 of 7 residents reviewed. Facility policy stated residents and/or their representatives would be offered a care conference at the time of care plan review or as needed, and staff stated care conferences were expected upon admission, quarterly, after a significant change, and when requested. For Resident 54, who had multiple sclerosis, neurogenic bladder, functional quadriplegia, and an indwelling catheter, staff could only identify a care conference on 09/12/2025 and could not find any others in the prior year. Resident 68’s record showed a care conference on 08/15/2025 with no documentation of additional conferences offered within seven days of quarterly assessments, and the resident stated they had not had a care conference for about ten months. Resident 36’s record showed a social services note that the POA declined attending a care conference on 03/14/2025, but the resident was able to participate in decisions for their own care and there was no documentation of a care conference offered within seven days of quarterly assessments. Resident 123’s record showed a social services note that the resident was offered a care conference for alternate placement and declined, but there was no documentation of care conferences offered within seven days of each quarterly assessment. Both residents stated they could not remember being offered care conferences, and Resident 36 stated they would want one. The facility also failed to update care plans as resident conditions changed for 3 of 7 residents reviewed. Resident 190’s care plan for isolation precautions had not been resolved and updated after the resident was removed from isolation precautions for influenza. Resident 123’s revised influenza care plan continued to direct strict aerosol/contact precautions and private-room services even though a progress note discontinued droplet precautions and staff stated the resident was no longer on those precautions and could leave the room. Resident 4 had physician orders for aerosol/contact precautions and private-room care during active infection, but the orders did not specify a diagnosis or symptoms; later observations showed the precaution sign was removed, the resident said they were happy not to be on isolation anymore, and the care plan still had not been updated to reflect the resident’s current status.
Medication Administration and Order-Following Failures
Penalty
Summary
The facility failed to ensure appropriate delegation of nursing tasks to non-licensed staff by allowing Medication Assistants-Certified (MA-Cs) to administer chemotherapy and other hazardous drugs to multiple residents. Resident 225 had a physician order to start a chemotherapy drug once daily on Monday through Thursday each week, and the MAR showed MA-Cs administered the drug on multiple dates in June and July 2025. Resident 218 had a physician order to start a chemotherapy drug once daily, and the MAR showed the drug was administered by an MA-C on multiple dates in October 2025. Resident 226 had a physician order to start a chemotherapy drug twice daily, and the MAR showed MA-Cs administered the drug repeatedly in December 2025 and January 2026. Resident 171 had a physician order for a hormone therapy drug to treat prostate cancer, and the February 2026 MAR showed an MA-C administered the drug each day for 22 doses. The facility also failed to clarify and follow physician orders for several residents. Resident 7 had orders to elevate the legs while in bed, keep quarter side rails up for self-bed mobility, and ensure shoes were worn when in the wheelchair. However, observations showed the resident sitting in a recliner with no bed in the room, and the resident stated they could not wear shoes because their feet were very swollen. Staff stated the bed was not in the room per the resident’s preference, and that the orders should have been clarified with the provider and not documented as completed when they were not. Resident 8 had an order for an antidepressant twice daily for anxiety disorder and major depressive disorder, but the record also showed the medication was being used for pain, with prior consent forms and a provider note reflecting pain use; staff stated the order should have been clarified and the diagnosis corrected. Resident 205 had PRN pain medication orders with specific pain-score parameters, but the MAR showed an opioid pain medication was given for pain scores outside the ordered range, and staff acknowledged the medication was administered outside the physician’s parameters. The facility further failed to ensure insulin was prepared and administered according to manufacturer instructions. For Resident 206, the manufacturer’s instructions required priming the insulin pen before each use and holding the dose knob during injection for a slow count of five. During observation, one RN did not prime the pen before administration and pressed and immediately released the dose knob, while another RN primed the pen with 0.5 units horizontally and no insulin ejection was observed before administering the ordered dose. Staff stated nurses were expected to prime insulin pens with two units before each administration and hold the dose knob down for five to ten seconds during injection.
Failure to Provide Meaningful Resident Activities
Penalty
Summary
The facility failed to ensure residents were provided meaningful, life-enriching activities for 4 of 4 residents reviewed for activities. The report states that this failure placed residents at risk for boredom and a diminished quality of life. The facility policy required staff to ask residents about activity interests on admission, complete activity assessments when residents moved to LTC, and document participation, goals, interventions, quarterly preference reviews, and refusals in the record. Resident 213 had fractures and heart failure, and the MDS identified music, books/newspapers, and keeping up with the news as important. The activity care plan directed staff to monitor the resident’s ability to continue self-directed activities. During interview and observation, the resident stated they needed help reaching the remote control to turn on the TV and that no one came to assist. The resident also stated they did not have any activities to do, and the room did not have the TV on or any books or magazines available. The Activities Director stated staff should assess activity needs, incorporate interests into the care plan, and could deliver books to bedbound residents. Resident 215 had fractures, ESRD, and a neurological condition, and the MDS showed an interest in keeping up with the news. The activity care plan focused on satisfaction with activities and monitoring verbal and nonverbal cues. Assessments showed the resident enjoyed watching football and said they would be depressed unless they could watch something with comedy. During observations, the resident used a phone to keep busy and stated they needed help using the cellphone when they wanted to listen to something; there was no TV in the room, no books or magazines, and the room was dimly lit with the blinds closed. The resident later stated they wanted to watch TV. Staff stated bedbound residents should receive one-on-one activities and music, that a TV was important for independence and ownership of activities, and that all residents should have a TV, but staff were not aware this resident did not have one. Resident 217 had hearing that was minimally impaired, clear speech, cognitive impairment, and substantial/maximal assistance needs for bed mobility and transfers. The MDS identified music and keeping up with the news as favorite activities and stated it was very important for the resident to participate in favorite activities. The care plan directed staff to invite the resident to live music and take them outside for fresh air, and the initial activity assessment showed the resident preferred family time and music and needed invitations, reminders, and escorting. The resident stated they were unaware of the activities offered, felt they only stayed in bed, and wanted to go to activities. The resident later stated they were bored, and the activity calendar was observed out of reach. Records showed no activity documentation, and staff stated group activities did not occur on the unit and that documenting participation was not their practice. Resident 212 had clear speech, adequate vision with glasses, mild cognitive impairment, and was unable to transfer out of bed during the assessment look-back period due to medical conditions; the resident also required tube feeding. The MDS identified keeping up with the news, favorite activities, and going outside for fresh air as very important. The resident’s assessments identified a preference for independent activities, spending time outdoors in nature, classical and instrumental music, and a need for prompts and assistance to participate. The resident stated they had limited interaction except during care and exercise, got bored, were given a weekly activity calendar, but were never offered activities, outdoor time, or items to keep occupied in the room. Observation showed no reading materials in the room, and the CD player was out of reach with a cord too short to use from bed. Staff stated the Activity Director provided group activities on another unit, social services oversaw activities for the TCU, refusals should be documented, and activity participation might be documented in progress notes, but the record contained no notes describing participation, interest, requests, or refusals beyond the initial assessments.
Failure to Obtain Orders, Assessments, and Consents for Wheelchair Seatbelts
Penalty
Summary
The facility failed to obtain provider orders, complete safety assessments, and obtain resident or representative consents for the use of seatbelts on wheelchairs for 4 residents reviewed for physical restraint use. The facility policy titled "Restraint Free Environment" stated that a seat belt in a chair that prevented a resident from rising was a physical restraint and required a determination of a specific medical symptom, documentation of how the restraint would treat that symptom, anticipated length of use, who may apply it, release frequency, direct monitoring and supervision, a provider order, less restrictive alternatives, ongoing safety assessments, care plan updates, and resident or representative consent before use. Resident 59 had no memory impairment and diagnoses of autoimmune disorder and depression; records showed no documentation for a wheelchair seatbelt, including no safety assessments, consent, or physician order, yet observations showed the resident seated with the belt latched. Resident 68 had no memory impairment and diagnoses of cervical spinal stenosis, anxiety, and depression; the resident stated they could not use their left arm and depended on staff for transfers and positioning, and records again showed no seatbelt documentation while observation showed the belt latched. Resident 123 had no memory impairment and diagnoses of arthritis and below-the-knee amputation; records showed no seatbelt documentation, and the resident stated the wheelchair arrived from the facility with the seatbelt already attached and staff had not discussed it. Resident 186 had severe memory impairment and diagnoses of dementia, below-the-knee amputation, diabetes with unstable blood sugar, and pressure sores; records showed no seatbelt documentation, and observation showed the resident in a wheelchair with the belt latched while the resident stated staff assisted with securing it but had not discussed it.
Incorrect Portioning of Mechanically Altered Meals
Penalty
Summary
The facility failed to ensure residents were provided the portion size they were assessed to require for two sampled residents and four supplementary residents. The report states that, under the facility’s revised Nutrition Assessment Policy, a nutritional assessment and nutritional interventions were to be completed within 14 days of admission. On 03/02/2026, the scheduled lunch menu listed penne pasta with [NAME] sauce as the regular entree, and residents requiring a mechanically soft altered texture entree were to receive a mechanically softened version of the same meal. During tray line observation, the regular entree and the mechanically soft entree were prepared on the steam table with different scoops for portioning, but the menu did not identify the portion size to be served. At lunch tray assembly, the tray tickets for Resident 7, Resident 17, Resident 224, Resident 22, Resident 202, and Resident 223 each indicated a nine-ounce serving of the mechanically softened texture preparation. Observation showed these residents, along with other residents requiring mechanically altered texture meals, were served using the green scoop. The Dietary Services Manager stated dietary staff should follow the orders on residents’ tray tickets to ensure they received the nutrition they were assessed to require, and stated the scoop used for the mechanically altered texture meals was not the correct size for a nine-ounce portion. The Dietician stated they were not sure which colored scoops represented what portion sizes, but that it was important for residents to be given the size portion they were assessed to require.
Unsafe Food Handling and Improper Reheating
Penalty
Summary
Meals were not prepared in sanitary conditions in the main kitchen when a cook handled food and kitchen items while repeatedly changing gloves without washing hands. During lunch preparation, the cook stirred ground meat, handled containers and pots, changed gloves several times, moved a cart, placed cooked pasta in a pan, ladled sauce into the pan, covered it, and later removed gloves, touched a garbage can lid, wiped hands with paper towels, and put on new gloves without washing hands. Staff T, the Director of Culinary Services, stated washing hands was an important step in food preparation and that cooks were expected to wash their hands whenever they were soiled and with glove changes. Food was also not reheated as required in the unit kitchens. In the 100 East unit kitchen, a sign above the microwave directed staff and visitors to ensure all food reheated for residents reached 165 F and to sanitize the thermometer, but no thermometer or sanitizer was available on multiple observations. Staff Q looked for a thermometer and could not find it, and Staff S stated there should be a thermometer by the microwave at all times. In the 200 East unit kitchen, a CNA reheated a resident’s meal in the microwave but did not use the thermometer stored on the side of the microwave to verify the food reached 165 F, despite the posted directions. The facility also failed to reheat lunch for a resident who required feeding assistance. Resident 213 had palliative care, a debilitating fracture, malnutrition, and heart failure, and could sometimes be understood or understood by others. The resident stated they were hungry and could not reach their tray, which had been left across the room and covered with a napkin. Staff later returned to assist, but the tray had been left in the room for an extended period before feeding began. Staff stated bed-bound residents were fed after residents in the dining room, that trays were sometimes left in rooms, and that food could be left out for up to one hour before it needed to be served; the DON stated staff should not leave the meal tray in the room and then serve it without rewarming the food first.
Failure to Honor Resident Bathing and Food Preferences
Penalty
Summary
The facility failed to honor resident choice regarding bathing routines for three residents who were reviewed for preferences. Resident 8 was cognitively intact, able to make self-understood, and dependent on staff for showering; the resident stated staff did not give a choice about shower frequency and said they wanted to shower twice a week, but staff told residents they could receive only one shower each week. Resident 8's February 2026 bathing record showed one shower and no bed bath documented in 28 days. Resident 186 was also cognitively intact, had impaired functional range of motion in both legs, and was dependent on staff for bathing; the resident stated they were not given a choice about shower frequency and wanted showers twice a week, while the facility provided once-weekly showers. Their February 2026 bathing record showed three showers in 28 days. The facility also failed to accommodate a food preference for Resident 123. Resident 123 had no memory impairment, a diagnosis of arthritis, and no therapeutic diet. Multiple nutritional/dietary notes documented that the resident did not want nightshades, specifically tomatoes, related to arthritis, but the resident remained on a regular diet with no food preferences identified or accommodated. The resident stated they had told the Director of Culinary Services they did not want tomato-based foods and were told the facility could not accommodate the preference. Staff later stated the resident's preference for no tomatoes was not accommodated and should have been, and the dietician stated it was a preference rather than an allergy and should have been added to the resident's food profile.
Incomplete Fall Investigations and Missing Neurological Assessments
Penalty
Summary
The facility failed to thoroughly investigate Resident 190’s falls and did not complete the required neurological assessments after unwitnessed falls. Resident 190 was admitted with diagnoses including vascular dementia, traumatic brain injury, and an abnormal heart rhythm, and the MDS indicated short- and long-term memory problems and two or more falls since admission. The care plan identified the resident as high risk for falls and injury due to a history of falls, with interventions to report signs of acute changes to the provider as needed. Review of the fall investigations showed an unwitnessed fall in the resident’s room due to a wheelchair malfunction, an unwitnessed non-injury fall when the resident attempted to self-transfer to the bathroom without assistance, and another unwitnessed non-injury fall when attempting to self-transfer from the wheelchair to the bed. Each investigation listed neurological assessments per protocol as an intervention, but Staff B stated these assessments were not completed for the resident’s falls. Staff B also stated the contradictory root cause statement in the 04/17/2025 fall investigation was inaccurate, and the report noted conflicting documentation describing that fall as witnessed, assisted, and with injury despite staff statements that it was unwitnessed and non-injury.
PASRR assessments were not kept accurate for residents with mental health diagnoses
Penalty
Summary
The facility failed to ensure PASRR assessments were accurate for 2 residents with mental health conditions. For Resident 190, the record showed diagnoses including vascular dementia, traumatic brain injury, anxiety, and dementia with psychotic disturbances. The resident received a new diagnosis of anxiety on 05/22/2025, and the Director of Social Services stated PASRR reviews were done when a new mental health diagnosis was added to the care plan. Staff K also stated a PASRR review did not occur for Resident 190 after the new anxiety diagnosis and that the resident should have been referred for a Level II PASRR. For Resident 52, the record showed diagnoses including schizophrenia, depression, anxiety disorder, and moderate memory impairment, with routine antipsychotic and antianxiety medications during the assessment period. Social services notes showed the resident was referred to behavioral health services due to increased behaviors, and the PASRR Level I was updated to reflect SMI indicators and emailed for a Level II evaluation. The updated Level I identified schizophrenia, depression, and anxiety disorder and indicated a Level II referral was required, but the facility did not follow up with the PASRR evaluator for over 12 months. Staff Y stated the PASRRs should be accurate and sent timely for Level II evaluations so residents would receive timely and necessary services.
Failure to Provide ADL Assistance
Penalty
Summary
The facility failed to assist dependent residents with ADLs, including oral care, bathing, personal hygiene, and nail care, for 2 of 5 residents reviewed. The facility policy stated it would provide the necessary services to maintain good nutrition, grooming, personal, and oral hygiene for residents unable to carry out ADLs independently. Resident 6 had diagnoses of cancer, heart failure, and urinary retention, and the MDS showed the resident required one-person assistance with personal hygiene, oral care, eating, and toileting with no rejection of care during the assessment period. The care plan also directed staff to assist with oral care, bathing, personal hygiene, and toileting. Observations on multiple dates showed Resident 6 lying in bed with dirty teeth and a slight odor, and the resident stated they had not brushed their teeth for a few days because they did not have a toothbrush. Staff later confirmed there was no toothbrush in the resident’s oral care washbasin, and a charge nurse stated staff were expected to provide morning care including oral care, shaving, and dressing as residents allowed, but they did not. Resident 217 had diagnoses including traumatic brain dysfunction, recent fracture, and weakness, and the MDS showed cognitive impairment with no rejection of care. The care plan did not include instructions for nail care, and observations showed the resident’s fingernails were long, jagged, and broken. The resident stated staff did not offer to assist with nail trimming, task documentation showed no nail care provided, and staff interviews indicated nail care was typically offered on bathing days and refusals should be documented, but no refusal was documented.
Failure to monitor edema and blood pressure as ordered
Penalty
Summary
The facility failed to ensure that two residents were monitored and received treatment as ordered for edema management and blood pressure monitoring. The report states that Resident 3 had hypertension, end stage renal disease, and low blood pressure and was receiving dialysis. The dialysis care plan directed staff to contact providers immediately for problems and to take vital signs before and after dialysis. On 03/02/2026, Resident 3 had blood pressure readings of 107/36 mmHg and 116/46 mmHg, which were outside normal parameters, but the progress notes did not show that the provider was notified of the low readings. Staff later stated that vital signs should be rechecked and the provider notified when blood pressure is low, and the DON stated staff should have stopped the outing the next morning because of the low blood pressure and notified the provider. Resident 7 was admitted with cancer, kidney failure, lymphedema, and functional limitation in both legs. The physician orders directed staff to apply Coban wraps to both legs daily and elevate the legs while in bed. Observations showed Resident 7 sitting in a recliner with both legs and feet swollen and both feet on the floor, and the resident stated they liked to sleep in the recliner and could not elevate their feet because it hurt. The record showed no indication that staff assessed or monitored the severity of the edema, documented the degree of edema, or notified the provider. The revised ADL decrease in function care plan did not include interventions or instructions related to lymphedema. During interview, an LPN stated the resident did not like to elevate their feet and staff did not notify the provider about refusals or document them in the record. The charge nurse reviewed the record and could not provide documentation of refusals to elevate the legs, and stated there was no physician order to assess, monitor, document the degree of edema, or identify when to notify the provider. The DON stated staff did not follow the physician order, did not notify the provider of refusals, and did not document assessment or monitoring of edema in the resident's record.
Leaking Catheter Not Reported or Addressed
Penalty
Summary
The facility failed to provide appropriate catheter care and services for Resident 54, who was admitted with diagnoses of Multiple Sclerosis, Neurogenic Bladder, and Functional Quadriplegia and had an indwelling urinary catheter. The resident’s records showed the catheter was leaking, including a progress note on 09/25/2025 documenting the leak. There was no documented provider notification of the catheter leak, and the resident’s alteration in elimination care plan did not include interventions to address the leaking catheter. Subsequent physician progress notes continued to document that the catheter was still leaking and that a urology referral was needed. One note stated the resident should be referred to a urology specialist, and later notes showed the provider re-approached the nursing team to schedule the appointment, but the urology appointment had not yet been scheduled. During an interview, the resident stated the catheter had been leaking for multiple months without resolution. During observation of catheter care, staff observed the catheter leaking, and an RN stated the leak had been known for approximately two weeks and should have been reported to the provider. The DON stated staff were expected to notify the provider any time a catheter leaked and to timely schedule and document provider referrals, but the record did not show the urology referral had been addressed or the appointment scheduled.
Failure to Address Repeated Refusals of Care and Social Service Needs
Penalty
Summary
The facility failed to provide medically related social services to help Resident 190 achieve the highest practicable physical, mental, and psychosocial well-being, and failed to assist with resolution of refusals of treatment and care. Resident 190 was admitted with diagnoses including vascular dementia, traumatic brain injury, and an abnormal heart rhythm. The MDS showed daily rejections of care and worsening behaviors during the assessment period. Review of the care plan on 02/27/2026 showed no care plan with measurable goals or interventions to address refusals of care. Record review showed repeated refusals across December 2025 through February 2026, including refusals of meals, nutritional supplements, oral care, and attempts to get out of bed. December documentation showed 59 of 93 meals refused, 45 of 93 supplements refused, 15 of 93 oral care refusals, and 16 of 93 transfer refusals. January documentation showed 66 of 93 meals refused, 43 of 93 supplements refused, 24 of 93 oral care refusals, and 22 of 93 transfer refusals. February documentation showed 67 of 84 meals refused, 46 of 84 supplements refused, 18 of 84 oral care refusals, and 24 of 84 transfer refusals. Staff stated refusals were reported to the charge nurse and discussed in weekly rounds, but there was no documentation of provider notification for the refusals, and the Director of Social Services stated there was no documentation of the IDT huddle or care plan for the refusals during that period.
Failure to Provide Dental Services for Resident with Broken and Missing Teeth
Penalty
Summary
The facility failed to ensure dental services were provided for Resident 190, who had a significant change MDS showing obvious or likely cavities or broken teeth, mouth or facial pain, and a diagnosis of malnutrition. The resident’s nutrition and dietary notes documented no upper teeth, poor lower dentition, difficulty chewing and swallowing, and a pureed food texture. The oral health problems care plan identified missing upper natural teeth, possible cavities, difficulty chewing, and poor mouth hygiene due to refusals of oral care, and it directed staff to coordinate arrangements for dental care. The resident’s record did not contain documentation of a dental referral. During observation, Resident 190 was lying in bed and had no upper teeth and broken and missing natural lower teeth. Staff reviewing the record stated there were no provider notifications of the resident’s dental status and no dental referrals were made, although they should have been. The MDS coordinator stated dental needs were assessed quarterly and that charge nurses were expected to coordinate dental care, but could not find documentation that the resident had been referred to or offered dental services since admission. The DON also reviewed the record and was unable to find documentation of a dental exam or referral.
Failure to Follow Infection Control Precautions During Resident Care
Penalty
Summary
The facility failed to provide and implement an infection prevention and control program when staff did not consistently follow contact precautions, Enhanced Barrier Precautions (EBP), and hand hygiene practices during resident care. The report states that these failures placed residents and staff at risk for exposure to and development of contagious, communicable infectious diseases. For Resident 68, who had a stage 4 pressure ulcer, a urinary catheter, and an order for EBP, staff did not follow the resident’s EBP care plan during wound care and catheter-related care. A registered nurse assisting with wound care wore a mask below the nose, and later two CNAs provided incontinence care without gowns while one CNA also wore a mask below the nose. During catheter care, a CNA washed the resident’s skin and catheter, then dressed the resident and covered them with blankets without changing gloves or performing hand hygiene between the dirty and clean tasks. For Resident 142, an EBP sign outside the room directed staff to wear PPE for urinary catheter care, but a charge nurse entered and performed catheter care without PPE. For Resident 4, an aerosol contact precautions sign directed staff to wear gown, gloves, face mask, and eye wear, but staff discarded contaminated PPE in a trash bin across the hall rather than in the resident’s room, and the infection preventionist stated there should have been a trash bin in the room for contaminated PPE. The report also documented failures to follow contact precautions on two units. On the East 2B Transitional Care Unit, an influenza A outbreak sign directed staff to wear a mask covering the nose and mouth for resident care, but the administrator was observed in the dining area with the mask pulled below the chin while residents were present. On the 1 East unit, a droplet contact precautions sign directed staff to wear eye protection before entering a resident’s room, but a CNA entered and provided care without eye protection and later stated they only provided care for a short while. The infection preventionist stated staff were expected to follow the signs posted on resident doors for EBP, contact, and aerosol precautions, but they did not.
Failure to Monitor and Document Appropriate Antibiotic Use
Penalty
Summary
The facility failed to establish and carry out an infection prevention and control program that included an antibiotic stewardship program to promote appropriate antibiotic use and reduce unnecessary antibiotic use for two residents reviewed for antibiotic use. The facility policy stated the infection preventionist would monitor infections through observation, chart review, laboratory reports, interviews, and other means, and that antibiotic medications would be monitored for appropriate use, with staff communicating with the attending provider when needed to document the reason for antibiotic use, whether the infection was improving, and whether the antibiotic should continue. For one resident, the record showed a physician order on 02/06/2026 for an antibiotic twice daily for five days for a urinary tract infection. The resident’s quarterly MDS showed a stage four pressure ulcer and a urinary catheter. During an interview on 03/02/2026, the infection preventionist stated the resident did not meet the facility’s McGeer or Loeb criteria for a urinary tract infection and that the antibiotic should not have been given. The infection preventionist also stated the provider prescribed and staff administered the antibiotic, but the provider did not document why it was prescribed without meeting criteria. For the second resident, the admission MDS showed moderate cognitive impairment, a serious wound infection, three pressure ulcers, and antibiotic use during the assessment period. The resident had two antibiotic orders dated 12/05/2025 related to a wound infection, both directing discontinuation when the wound vacuum was discontinued. The wound vacuum was discontinued on 02/12/2026, but progress notes from 02/12/2026 through 02/25/2026 did not document that the physician was notified or contacted about whether the antibiotics should continue after the wound vacuum stopped. A 02/26/2026 note showed staff finally contacted the physician to clarify the antibiotics after the wound dressing order changed, and staff documented the wound had no signs of infection.
Failure to Provide Written Transfer/Discharge Notices
Penalty
Summary
The facility failed to ensure that residents received the required written notices at the time of transfer or discharge, or as soon as practicable, for three residents reviewed for hospitalizations. This deficiency was identified through interviews and record reviews, which revealed that the facility did not provide written transfer/discharge notifications to the residents or their representatives. Specifically, Resident 133 was transferred to an acute care hospital on two occasions, but there was no documentation of a transfer/discharge notice for the first transfer, and the notice for the second transfer was not provided to the resident or their representative. Staff E, the charge nurse, confirmed that they did not provide a copy of the notice to the resident or their representatives, only faxing it to the State Long-Term Care Ombudsman. Similarly, Resident 17 and Resident 142 were transferred to acute care hospitals, but their records showed no documentation of written transfer notifications being provided to them or their representatives. Staff B, the Director of Nursing, acknowledged the lack of documentation for these residents and stated that they would investigate further, but no additional documentation was provided. This failure to provide written notifications in a language and manner understood by the residents or their representatives placed them at risk of not having the opportunity to make informed decisions about their transfers or discharges.
Deficiency in PASRR Evaluations for Residents with Mental Health Conditions
Penalty
Summary
The facility failed to ensure accurate Pre-Admission Screening and Resident Review (PASRR) assessments for residents with mental health conditions, leading to a deficiency in the care provided. Resident 159, who had significant mental health diagnoses including anxiety and depression, did not have an updated PASRR Level II evaluation following a significant change in their condition. Despite the presence of Serious Mental Illness (SMI) indicators, the facility did not conduct the necessary reassessment, as confirmed by the Director of Nursing and the Assistant Social Services Director. Resident 27, diagnosed with non-Alzheimer's dementia, a psychotic disorder, and depression, was observed to be in distress and received antidepressant medication. However, the Level I PASRR inaccurately omitted the psychotic disorder, and no Level II evaluation was conducted. Staff acknowledged the oversight and the need for a Level II referral. Similarly, Resident 48, with anxiety, depression, and PTSD, was not referred for a Level II evaluation despite the presence of mental health issues, due to staff's unawareness of new regulations. Resident 169 and Resident 115 also experienced deficiencies in their PASRR evaluations. Resident 169, with mood and anxiety disorders, was not referred for a Level II evaluation as required. Resident 115, who exhibited cognitive changes and mood decline, was not considered for a Level II evaluation due to staff's lack of knowledge about the process. These failures in the PASRR process placed residents at risk of inappropriate placement and unmet mental health needs.
Failure to Monitor and Discontinue Unnecessary Psychotropic Medications
Penalty
Summary
The facility failed to ensure that three residents were free from unnecessary psychotropic medications and were properly monitored for behaviors. Resident 159 was prescribed an as-needed antianxiety medication that exceeded the 14-day requirement for discontinuation, as per the facility's policy. The Director of Nursing acknowledged that staff should have obtained a physician order to monitor target behaviors every shift and included a stop date for the medication. Resident 142 was receiving a routine antipsychotic medication without proper documentation of target behaviors or individualized behavioral interventions. Despite recommendations from the pharmacist to update the resident's health records with specific behavior monitoring and nonpharmacological interventions, these were not implemented by the nursing staff. The Assistant Director of Nursing admitted that the necessary documentation was missing and should have been included in the resident's records. Resident 45 was administered antipsychotic and antidepressant medications for anxiety/agitation and mood disorder, respectively, with identified target behaviors that were not observed for over six months. The Charge Nurse confirmed that the resident's target behaviors needed to be updated and revised, as the resident was not ambulating or self-propelling their wheelchair. This lack of updated documentation and monitoring placed the residents at risk of receiving unnecessary medications and experiencing adverse side effects.
Infection Control Deficiencies in LTC Facility
Penalty
Summary
The facility failed to implement an effective Infection Control Program across multiple units, leading to several deficiencies. Staff did not consistently sanitize glucometers between uses, as observed with a medication tech who used the same glucometer for multiple residents without sanitizing it or performing hand hygiene. This lapse in protocol was acknowledged by the staff involved, as well as by the primary RN and the Assistant Director of Nursing, who confirmed the importance of these practices in preventing the spread of infections. Additionally, the facility did not adhere to infection control standards in food handling. Staff were observed distributing uncovered food items, such as desserts and fruits, through hallways, which is against the facility's expectations. The Director of Culinary Services stated that meal trays should not be carried uncovered past more than two rooms, yet multiple instances of this practice were documented. The report also highlighted failures in PPE usage and hand hygiene. Staff on the COVID unit were observed not wearing the required fit-tested respirators, and some staff did not perform hand hygiene between glove changes during wound and incontinence care. These actions were contrary to the facility's infection prevention expectations, as stated by the Director of Nursing and the Infection Preventionist. Personal belongings were also improperly stored in resident rooms, which was against the facility's policy and posed an infection risk.
Failure to Provide Dignified Care and Privacy
Penalty
Summary
The facility failed to provide dignified care and services to several residents, as observed through various incidents. Resident 106, who is blind and dependent on staff for toileting hygiene, was not provided with appropriate toileting assistance. Despite the care plan indicating the need for two-person assistance for toileting, staff directed Resident 106 to urinate in bed, which was against the resident's wishes and care plan. Similarly, Resident 12, who requires assistance for toilet transfers, reported being instructed to go in their brief instead of being assisted to the toilet, contrary to their care plan. Resident 144, who requires substantial assistance for toilet transfers, was also not provided with the necessary support. The resident reported that staff instructed them to use their brief instead of offering a urinal, which was not in line with their care plan. Additionally, Resident 45 was observed being fed by a CNA who was standing, which was against the facility's expectation that staff should sit while feeding residents to avoid intimidation. Further observations revealed that Resident 123 was transported in a shower chair with inadequate coverage, exposing their backside to others, which compromised their privacy and dignity. Resident 156 was observed with an uncovered catheter bag while being transported, exposing its contents to others, which was against the facility's policy to cover catheter bags for privacy. These incidents collectively demonstrate a failure to uphold residents' rights to dignified care and privacy.
Deficiencies in Comprehensive Care Planning
Penalty
Summary
The facility failed to develop and implement comprehensive care plans for several residents, leading to unmet care needs and inappropriate care. Resident 88, who had severe memory impairment and was at risk for pressure ulcers, had a care plan that required the air mattress to be set at a medium firmness. However, observations showed the mattress was consistently set at the firmest setting, contrary to the care plan instructions. Staff interviews confirmed the incorrect setting, which could affect the resident's skin integrity. Resident 83, with complex medical diagnoses including depression, was observed lying in bed multiple times. The care plan for mood and behavior lacked measurable goals, making it difficult for staff to evaluate the resident's mental status and mood stability. The Director of Nursing acknowledged the importance of having measurable goals to assess the adequacy of interventions and the resident's progress. Other residents, such as Resident 81, lacked care plans for essential needs like dental care, while Resident 119 was not repositioned as required to prevent pressure wounds. Resident 115's care plan did not address the use of hearing aids, and the resident reported missing aids, affecting their ability to communicate. Additionally, Resident 429's care plan did not address communication needs despite having a brain disorder and mild aphasia, leading to inadequate support for their communication difficulties.
Deficiencies in Care Plan Updates and Care Conferences
Penalty
Summary
The facility failed to ensure that care plans (CPs) were updated to reflect changes in residents' care needs, affecting five residents. For instance, Resident 45's CP was not revised to reflect that they no longer used a pocket talker or amplifier and had no elopement or wandering behaviors. Additionally, Resident 45 was on end-of-life services and no longer participated in the restorative program, yet these changes were not updated in the CP. Similarly, Resident 83's CP was not updated to reflect the change from a partial upper denture to a full upper denture, and the CP still included outdated instructions for antibiotic therapy that had concluded. Resident 156's CP lacked specific details about their bathing preferences, despite the resident expressing a desire for more frequent bathing. Resident 106's CP did not include the use of fall mats, even though they had experienced multiple falls and fall mats were observed in use. Resident 169's CP did not specify their bathing preferences, and the resident had communicated a preference for bed baths due to childhood trauma, which was not documented. The facility also failed to conduct care conferences as required for two residents. Resident 134, who was cognitively intact, had not had a care conference since admission, despite being at the facility for about four weeks. Similarly, Resident 17, who had been at the facility for six months, had not been offered a care conference, even though they expressed a desire to discuss discharge plans with each comprehensive assessment. These deficiencies in updating CPs and conducting care conferences placed residents at risk for unmet care needs and unnecessary frustration.
Medication Administration and Order Clarification Deficiencies
Penalty
Summary
The facility failed to ensure physician's orders were clarified for two residents and did not administer medications timely for another resident. Resident 88, who has severe memory impairment and diagnoses of anxiety and depression, had a physician's order for an antidepressant medication that was not clearly specified for a single condition, as required. The Director of Nursing acknowledged the need for clarification, stating that psychotropic medications should be prescribed for one specific diagnosis. Resident 144, diagnosed with cancer, experienced constant pain in their left shoulder but did not receive a change in pain medication despite discussing it with their doctor. The resident's medication administration records showed a lack of documentation for pain assessments and non-medication interventions, and there were no parameters for administering different pain medications based on pain levels. Additionally, the facility did not adhere to its medication administration policy for Resident 432. During a medication pass, it was observed that the resident's morning medications, scheduled for 8:00 AM, were administered late. The facility's policy allows for medications to be given within one hour before or after the scheduled time, but this was not followed. Staff acknowledged the error and stated that if medications could not be administered within the designated timeframe, the provider should be notified and the order updated.
Deficiencies in ADL Assistance for Residents
Penalty
Summary
The facility failed to provide adequate assistance with Activities of Daily Living (ADL) for two residents, specifically in the areas of toileting, cleanliness, and grooming. Resident 106, who was dependent on staff for toileting hygiene and frequently incontinent of urine, did not receive the necessary assistance as outlined in their care plan. Despite the care plan specifying two-person assistance for toileting, staff instructed Resident 106 to void in their bed, which was against the resident's dignity and care plan directives. This incident was observed when Resident 106 used their call light for assistance, and staff failed to provide the required support, citing safety concerns from therapy without verifying the care plan. Resident 119, who was cognitively impaired and required total assistance with personal hygiene and dressing, was observed wearing the same stained clothing over multiple days and was not shaved. The care plan for Resident 119 indicated a need for staff assistance with dressing and shaving, yet staff did not adhere to these requirements. Staff interviews revealed an expectation for daily assistance with ADLs, including changing clothes and shaving, but these actions were not documented or performed consistently, leading to neglect in personal hygiene care for Resident 119. The facility's failure to adhere to the care plans and provide necessary ADL assistance for Residents 106 and 119 resulted in deficiencies related to toileting, dressing, and grooming. These deficiencies placed the residents at risk for poor hygiene and diminished quality of life, as the facility did not follow its policy to ensure residents' ADL abilities did not diminish unless unavoidable. The Director of Nursing and other staff acknowledged the importance of following care plans and providing appropriate assistance, yet the observed practices did not align with these expectations.
Deficiency in Meeting Residents' Activity Needs
Penalty
Summary
The facility failed to ensure that activity programs met the needs of two residents, leading to a deficiency in providing meaningful activities. Resident 106, who was admitted to the facility and had preferences for favorite and religious activities, reported that they were not provided with any activities or invitations to participate, resulting in them spending their days in bed. Despite the care plan indicating that Resident 106 should receive visits from a Rabbi and be invited to live music opportunities, no activities were documented as offered or refused since their admission. Interviews with staff revealed that there was no current activities coordinator for the long-term care and hospice units, and the Assistant Director of Life Enrichment, who was overseeing activities, confirmed the lack of documentation for activities provided to Resident 106. Similarly, Resident 142, who only spoke and understood Bosnian, was found to have no documented activities since their admission, except for family visits. The resident's care plan included interventions such as providing a weekly activity calendar and escorting them to activities, but observations showed the resident mostly stayed in their room with the lights off. Interviews with staff indicated that the activities staff member for the hospice and long-term care unit had left, and the responsibility for overseeing activities had shifted to other staff members. The lack of documented activities for Resident 142 was confirmed by the Assistant Director of Life Enrichment, highlighting a deficiency in meeting the resident's activity needs.
Failure in Monitoring and Protocol Adherence for Diabetic and Constipated Residents
Penalty
Summary
The facility failed to provide necessary care and services to three residents, as per professional standards of practice, specifically in monitoring hypo/hyperglycemia and following bowel management protocols. Resident 142, diagnosed with diabetes and constipation, did not have documented monitoring for signs and symptoms of hypo/hyperglycemia. Additionally, the facility's bowel protocol was not initiated despite the resident not having a bowel movement for several days, contrary to the care plan directives. Resident 169, who was dependent on staff for toileting hygiene and had a diagnosis of constipation, also did not receive the necessary bowel management care. The facility's bowel protocol was not followed when the resident did not have a bowel movement for multiple consecutive days, as outlined in the care plan. This oversight was acknowledged by the Assistant Director RN, who confirmed the importance of adhering to the bowel protocol to prevent potential complications. Resident 429, with diagnoses of dementia and diabetes, had a care plan that lacked specific interventions for monitoring signs and symptoms of hyperglycemia. Despite having multiple instances of elevated blood sugar levels, the facility did not provide clear instructions on the symptoms to watch for or actions to take in case of hyperglycemia. The Medication Administration Record and other documentation did not include necessary guidance, which was confirmed by staff interviews.
Failure to Provide Prescribed Restorative Care and Follow Physician Orders
Penalty
Summary
The facility failed to provide appropriate care for residents with limited range of motion (ROM) and mobility, as evidenced by the lack of adherence to physician orders and restorative nursing programs (RNP). Resident 27, who had limited ROM in both arms and legs, was observed without the required palm protector on multiple occasions, despite physician orders and care plan instructions to keep it on at all times. Staff interviews confirmed that the palm protector was not applied as directed, and there was no documentation of refusal or notification to the charge nurse. Additionally, Residents 134 and 144 did not receive their prescribed restorative exercises as per their care plans. Resident 134 was supposed to receive RNP 15 minutes, 3-5 times a week, but was only offered the program twice in a week. Similarly, Resident 144 was to receive upper and lower body exercises 2-3 times a week but was only offered the program once in a week. Interviews with the residents and staff confirmed the inconsistency in providing the restorative programs, and there was a lack of documentation for refusals or explanations for missed sessions.
Failure to Ensure Residents Are Up to Date on Pneumococcal Vaccinations
Penalty
Summary
The facility failed to ensure that two residents were up to date on pneumococcal vaccinations as per the CDC recommendations, which placed them at risk for contracting pneumonia and its associated complications. Resident 45's records showed historical entries of receiving two doses of Pneumovax prior to admission, but the specific formulations were not documented, making it unclear if the resident was up to date. The facility's electronic records software update removed the details of the actual doses received, and the state immunization registry confirmed the resident received an unspecified pneumococcal vaccine in 1999 and a PPSV23 in 2016. Staff O, who was covering for the infection control nurse, acknowledged the importance of keeping residents up to date with vaccinations to prevent respiratory diseases. Resident 169 was admitted to the facility with an MDS indicating they were not up to date on their pneumococcal vaccine. Although a consent form in the resident's health records stated they had already received the vaccine, there was no documentation to support this claim either within or outside the facility. Staff O had not checked the Washington State Immunization Information System (WAIIS) to confirm the resident's vaccination status until the survey, which revealed the resident was not up to date. This oversight in verifying and documenting vaccination status contributed to the deficiency.
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.
Trusted data from CMS and state health departments
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.
Trusted by long-term care providers and associations.
