Garden Terrace Healthcare Center Of Federal Way
Inspection history, citations, penalties and survey trends for this long-term care facility in Federal Way, Washington.
- Location
- 491 South 338th Street, Federal Way, Washington 98003
- CMS Provider Number
- 505512
- Inspections on file
- 23
- Latest survey
- September 12, 2025
- Citations (last 12 mo.)
- 1
Citation history
Health deficiencies cited at Garden Terrace Healthcare Center Of Federal Way during CMS and state inspections, most recent first.
A resident with multiple complex medical conditions experienced several days of diarrhea, resulting in distress and fatigue. Despite care plan requirements, nursing staff did not assess the condition, intervene, or notify the physician, and the DON confirmed there was no documentation or policy for managing diarrhea.
The facility did not provide required skin care for a resident with a documented skin impairment, failing to assess and treat the condition as per policy. Additionally, two residents with GI diagnoses did not receive bowel management interventions according to physician orders and the facility's bowel protocol, resulting in prolonged periods without a bowel movement and lack of appropriate documentation or follow-up.
The facility did not ensure proper kitchen sanitation, as surface sanitizer was unavailable at an effective concentration and exhaust fans above the meal assembly area were visibly dirty, with one fan directly over the steam table showing accumulated dust and debris. The Food Service Manager confirmed the lack of sanitizer and the presence of debris, attributing the issues to communication lapses and maintenance responsibilities.
Staff failed to consistently follow infection control protocols, including not wearing required PPE when entering rooms of residents on Contact Precautions or EBP, incorrect signage for precautions, improper handling of soiled linens, and allowing visitors to use shared equipment like ice scoops without hand hygiene. These lapses were observed among multiple residents with infection risks and confirmed by staff interviews.
A resident was discharged home after completing treatment and meeting care goals, but the facility did not provide the required Notification of Medicare Non-Coverage (NOMNC) letter. Although other discharge paperwork and notifications were completed, staff confirmed that the NOMNC letter was not issued as required.
Several resident rooms were found with unblended paint patches, scratches, chipped and soiled baseboards, and a privacy curtain stained with dark spots and liquid. A resident reported dissatisfaction with the room's cleanliness, and maintenance staff acknowledged incomplete repairs and cleaning, contrary to facility policy requiring a clean, homelike environment.
The facility did not properly address grievances for three residents, including missing personal items and concerns about medication administration. In each case, required grievance forms were not completed or logged, and follow-up was inadequate. Staff interviews confirmed that the facility's grievance policy was not followed, resulting in unresolved issues for the affected residents.
A resident reported that a nurse exchanged their pain medication for a different pill, suspecting drug diversion. The facility's investigation was limited to reviewing the MAR, narcotic sheet, and progress notes, without interviewing the resident about medication effectiveness, identifying or interviewing the alleged nurse, or speaking with other staff or residents. The investigation did not meet facility policy requirements for thoroughness and documentation.
The facility did not develop or implement individualized care plans for three residents with specific needs, including respiratory care, monitoring of swelling, and assessment of bruising. Staff confirmed the absence of care plans and physician orders to guide care for these conditions, despite facility policy requiring comprehensive care planning.
Multiple dependent residents did not receive required assistance with ADLs such as personal hygiene, grooming, and bathing, despite being assessed as needing this care and not refusing it. Observations and interviews confirmed that staff did not consistently provide morning care, nail care, or shaving as outlined in care plans and facility policy.
Three residents did not receive individualized or meaningful activities, with limited and repetitive options such as nail painting and bingo offered regardless of personal interests. Residents reported boredom and a lack of engagement, and staff failed to document or consistently provide one-on-one activities, resulting in unmet needs for those with specific preferences or younger age.
A resident with anxiety and depression repeatedly requested a psychological evaluation, but the referral remained pending with no documented follow-up. The resident continued to display emotional distress, and staff confirmed that no referral was made, resulting in the resident not receiving necessary behavioral health services.
Surveyors found that medications and biologicals were not properly labeled or stored, including an opened sterile swab package without a date and inhalers lacking resident identification or open/discard dates. Additionally, narcotic logbooks were missing required nurse signatures during shift changes, indicating failures in medication documentation and accountability.
A resident with moderate memory impairment was placed on a mechanically altered diet without timely assessment by an SLP, despite expressing dissatisfaction and having no documented swallowing issues at admission. Due to delayed communication and referral processes, the resident did not receive an SLP evaluation or appropriate diet upgrade until eight days after admission.
The facility did not consistently follow physician orders for medication administration, failed to clarify unclear medication and monitoring orders, and did not properly monitor or document resident weights and edema. These deficiencies affected multiple residents with complex medical needs, resulting in unmet care requirements and unaddressed changes in condition.
Two residents with complex pain needs did not receive effective pain management, as staff failed to follow physician orders for pain medication dosages and did not implement required non-pharmacological interventions. One resident experienced ongoing pain after brain surgery and blood clots, while another with a bone infection received lower medication doses than ordered and was not provided alternative pain relief methods. Staff interviews confirmed that pain management protocols and facility policy were not consistently followed.
A resident with multiple medical conditions and a deep tissue injury on their buttocks did not receive the recommended honey-based dressing treatment due to a delay in processing the order. The treatment was not scheduled or carried out by the nursing staff, as it was not entered into the Treatment Administration Record, leading to a failure in providing necessary care.
A resident experienced a dislocated hip prosthesis during a rough brief change, highlighting the facility's failure to implement abuse and neglect policies. The staff did not follow care plan interventions, and the incident was not thoroughly investigated. The resident's care plan lacked necessary non-weight bearing instructions, indicating oversight in ensuring safety and adherence to protocols.
The facility failed to provide written transfer or discharge notices for three residents who were hospitalized. A resident was transferred to the hospital without a written notice being provided to them or their representative, who only learned of the transfer from the hospital. The facility's Executive Director confirmed that the notice was not completed due to an oversight. Similarly, two other residents were discharged to the hospital without receiving the required written notices, which was attributed to a transition of staff in social services.
A resident with a history of falls and multiple medical conditions, including COVID-19, fell in their room due to inadequate supervision and lack of specific interventions in their care plan. The facility's guidelines for fall prevention were not followed, as the resident's care plan did not include necessary measures such as frequent visual checks or a safety assessment for the bed's low position. Staff confirmed the absence of orders for monitoring, and the resident's fall was attributed to discomfort from COVID-19 and loose bowel movements.
The facility failed to maintain sanitary conditions in the kitchen and resident refrigerators, leading to unsanitary food storage and preparation. Observations revealed unlabeled and undated food, spoiled items, and dirty kitchen and refrigerator environments. Staff interviews confirmed lapses in following facility policies on food safety and cleanliness.
The facility failed to provide written notice of the bed hold policy to three residents or their representatives during hospitalizations, as required. Staff responsible for offering bed holds confirmed the oversight, and the Executive Director acknowledged the importance of this policy for residents' well-being.
The facility failed to develop comprehensive care plans for seven residents, leading to unmet care needs such as malnutrition, unmanaged psychiatric conditions, and unaddressed fall risks. Staff interviews and record reviews confirmed these deficiencies.
The facility failed to provide appropriate pain management for residents, including the lack of nonpharmacological interventions, failure to identify pain parameters for PRN medications, and failure to document the location of pain. Residents experienced untreated pain due to these deficiencies.
The facility failed to maintain an infection prevention and control program, did not implement or follow isolation precautions for five residents, and did not consistently perform hand hygiene during meal service on two resident units. These failures placed residents at risk for facility-acquired infections.
The facility failed to transmit a resident's assessment data to CMS within the required timeframe. The discharge assessment for a resident, completed on December 5, 2023, was not transmitted until April 10, 2024, exceeding the 14-day requirement. The delay was identified during a record review and confirmed by the Executive Director and DON.
The facility failed to ensure accurate MDS assessments for two residents. One resident's poor dental status was not identified, and another resident's active dementia diagnosis was missed. These inaccuracies were confirmed by staff and led to incomplete care plans.
The facility failed to provide necessary assistance with ADLs for two residents. One resident with severe memory impairment and swallowing difficulties was left to eat alone, while another resident dependent on staff for personal hygiene did not receive a bath for 24 days and was not assisted with shaving.
The facility failed to monitor a resident on anticoagulation therapy for signs of bleeding, as required by their care plan. The resident exhibited petechiae on their feet, which was not documented in a skin assessment, and no monitoring was recorded in the medication and treatment records.
The facility failed to provide adequate nutritional care for two residents, leading to significant weight loss. For one resident, the facility did not complete a timely nutrition assessment or develop a care plan, and failed to provide suitable food textures. Another resident, admitted without lower dentures, was unable to chew the provided food, and the facility did not offer appropriate meal replacements or downgrade the food texture. Both residents experienced significant weight loss due to these deficiencies.
The facility failed to properly document and track the tube feeding for a resident with multiple diagnoses, including malnutrition and a swallowing disorder. Incomplete documentation and conflicting orders led to inconsistencies in the administration of the tube feeding formula, placing the resident at risk for inadequate nutrition and hydration.
The facility failed to provide proper respiratory care for two residents. One resident did not receive ordered incentive spirometry treatments, and another received supplemental oxygen without a physician's order specifying the rate. Staff confirmed these deficiencies, which were contrary to the facility's policies.
The facility failed to provide appropriate treatment and services for a resident diagnosed with dementia. The resident's care plan was incomplete and not person-centered, lacking details about their mental condition, visual hallucinations, and non-pharmacologic interventions. Staff confirmed the deficiencies, emphasizing the importance of accurate and individualized care plans.
The facility failed to ensure that two residents were free from unnecessary psychotropic medications by not providing non-pharmacological interventions, not obtaining consent, and not documenting target behaviors. This placed the residents at risk of receiving unnecessary medications and experiencing adverse side effects.
The facility failed to ensure that one garbage dumpster and one recycling dumpster were properly covered and the surrounding areas were kept clean. The recycling dumpster was overflowing, the middle garbage dumpster's lid was not completely closed, and the area around the third dumpster was dirty. The Dietary Manager confirmed that staff are expected to keep these areas clean and sanitary.
A resident with a right hip fracture and other medical conditions did not receive the required frequency of PT and OT services due to inadequate scheduling around their Hemodialysis treatments. The facility lacked a proper system to ensure therapy services were provided as assessed.
The facility failed to ensure accurate and consistent medical records for two residents. One resident had conflicting dementia diagnoses, and another had an Advance Directive that was not properly documented. Staff acknowledged communication issues between departments.
The facility failed to administer a pneumococcal vaccine to a resident who had consented to receive it. The resident was scheduled to receive the vaccine but was out of the facility at the time, and there was no follow-up to re-offer the vaccine upon the resident's return, as confirmed by the DON.
Failure to Assess and Notify Physician for Ongoing Diarrhea
Penalty
Summary
Facility staff failed to provide care and treatment in accordance with a resident's assessed needs and professional standards of practice for bowel care. The resident, who had complex medical conditions including kidney and heart disease, unstable blood sugar, bone infection, and a recent toe amputation, began experiencing multiple episodes of loose bowel movements over a period of several days. Despite documentation of ongoing diarrhea and the resident expressing distress, fatigue, and lack of energy to therapy staff, there was no evidence that nursing staff assessed the resident's condition, addressed the symptoms, or notified the physician as required by the care plan. The care plan specifically indicated that timely communication with the physician or nurse practitioner was necessary for any change in the resident's condition. However, medical records and staff interviews confirmed that no assessment, intervention, or physician notification occurred regarding the resident's ongoing diarrhea. The Director of Nursing acknowledged the lack of documentation and stated that staff did not follow expected procedures. Additionally, the facility did not have a policy in place for managing residents with diarrhea.
Failure to Provide Skin and Bowel Care per Orders and Facility Protocol
Penalty
Summary
The facility failed to provide appropriate skin care and bowel management for several residents, as required by their own policies and physician orders. For one resident with a history of cancer and fractures, a skin impairment on the right elbow was observed and reported by the resident, but this impairment was not documented in the weekly skin assessment, nor was it identified by CNAs or addressed by nursing staff during routine care. The skin issue was only acknowledged after direct observation and inquiry, despite the facility's policy requiring comprehensive and weekly skin assessments with prompt reporting of changes. In addition, two residents with gastrointestinal diagnoses and specific physician orders for bowel management did not receive care according to the facility's bowel protocol. One resident, who was always incontinent of bowel and dependent on staff for toileting, went over seven days without a documented bowel movement. Although the resident received an initial dose of Milk of Magnesia (MOM), subsequent interventions such as a suppository or enema were not administered as ordered, and there was no documentation of the resident refusing care during this period. Another resident, who required moderate assistance with toileting and had no memory impairment, also experienced a seven-day period without a bowel movement. Despite clear physician orders for a stepwise bowel protocol, including MOM, suppository, and enema as needed, staff did not administer these interventions. Staff interviews confirmed that the bowel protocol was not followed, and the required medications were not given as ordered.
Failure to Maintain Sanitary Kitchen Conditions
Penalty
Summary
The facility failed to maintain sanitary conditions in the kitchen, as evidenced by the lack of effective surface sanitizer and the presence of dirty exhaust fans. During an observation, two red buckets of surface sanitizer were found to be at an ineffective concentration, as confirmed by test strips that did not change color as expected. The Food Service Manager acknowledged that the kitchen had run out of sanitizer concentrate and that weekend staff had not communicated this shortage, resulting in the inability to properly sanitize surfaces. Additionally, four ceiling exhaust fans in the steam table area, where resident meals are assembled, were observed to have significant accumulations of dirt, dust, and grime. One fan, located directly above the steam table, had visible debris, including a hanging piece of dust, increasing the risk of contamination. The Food Service Manager confirmed the buildup and stated that maintenance was responsible for cleaning the fans, but noted that the fan surfaces allowed dust to accumulate easily.
Failure to Adhere to Infection Control Protocols and Precautions
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by multiple instances where staff did not adhere to established protocols for Transmission-Based Precautions (TBP) and Enhanced Barrier Precautions (EBP). Observations revealed that staff entered rooms of residents on Contact Precautions without donning required personal protective equipment (PPE) such as gowns and gloves, despite clear signage and facility policy. For example, a Certified Occupational Therapy Assistant entered a resident's room without PPE, and a Certified Nurse's Assistant delivered a meal tray without performing hand hygiene or wearing PPE as directed by posted instructions. Further deficiencies were noted in the application of EBP and the management of residents with specific infection risks. One resident with a PICC line was observed with an incorrect Contact Precautions sign instead of the required EBP sign, and both staff and the resident did not consistently use PPE when outside the resident's room. Another resident with a urostomy bag experienced ongoing leakage, with soiled linens left in the room and not promptly removed, contrary to infection control expectations. Family members also reported and observed lapses in maintaining a clean and sanitary environment for this resident. Additional lapses included improper handling of shared equipment, such as an ice scoop being used by visitors without hand hygiene or gloves, and staff confusion regarding the correct application of precautions for both residents and housekeeping tasks. Interviews with staff confirmed a lack of understanding and inconsistent implementation of the facility's infection control policies, including the use of correct signage and PPE requirements for both staff and visitors.
Failure to Provide Required Medicare Non-Coverage Notice Prior to Discharge
Penalty
Summary
The facility failed to provide a required Notification of Medicare Non-Coverage (NOMNC) letter to a resident prior to discharge. Record review showed that the resident was readmitted and later discharged home after meeting their goals and completing antibiotic treatment. Although the facility provided a Nursing Home Transfer or Discharge notice and notified the local Long Term Care Ombuds about the discharge, there was no documentation that the NOMNC letter was given to the resident. Staff confirmed during an interview that the NOMNC letter should have been provided but was not.
Failure to Maintain Homelike Environment and Cleanliness in Resident Rooms
Penalty
Summary
The facility failed to maintain a homelike environment in five resident rooms, as evidenced by multiple observations of unblended white paint splotches, scratches, chipped and soiled baseboards, and a soiled privacy curtain. Specifically, rooms 111, 112, 113, 116, and 120 were found to have walls with visible paint patches that did not match the original wall color, as well as scratches and unpainted, dirty baseboards. In one room, a privacy curtain was observed to be soiled with dark brown and red spots and brown liquid stains, and a resident expressed dissatisfaction with the cleanliness and appearance of their room. Staff interviews confirmed that maintenance was aware of the incomplete paint repairs and the need to replace the soiled privacy curtain to maintain a homelike setting, but these actions had not been completed. The facility's policy requires all staff to ensure a safe, clean, and comfortable environment and to promptly address cleaning needs, but these standards were not met in the sampled rooms.
Failure to Initiate, Investigate, and Resolve Resident Grievances
Penalty
Summary
The facility failed to properly initiate, investigate, and resolve grievances for three residents, as required by its grievance policy. For one resident with memory impairment and dependence on staff for daily living activities, the family repeatedly reported missing clothing to staff over several days. Despite these reports, no concern or comment form was completed, and the missing items were not found or replaced in a timely manner. Staff interviews confirmed that the appropriate grievance process was not followed, and the Director of Nursing acknowledged that a concern form should have been completed but was not. Another resident, who had no cognitive impairment and was able to communicate clearly, lost their dentures in the facility. The resident reported the loss to staff, and a staff member stated they completed a concern and comment form, but there was no documentation of the grievance in the facility's log or the resident's record. The administrator confirmed that the grievance was not logged as required, and staff did not follow up with the grievance process. A third resident, who used glasses and experienced frequent pain, submitted a grievance alleging that a nurse had swapped their pain medication for a different pill. The concern and comment form was incomplete, lacking staff signatures and dates, and the summary response did not indicate whether the resident was satisfied with the outcome or who authored the summary. Staff interviews confirmed that the grievance documentation was incomplete and did not meet policy requirements.
Failure to Investigate Alleged Drug Diversion
Penalty
Summary
The facility failed to thoroughly investigate an allegation of drug diversion involving a resident who reported that a nurse had exchanged their pain medication for a different pill on two occasions. The resident, who had intact memory and was familiar with their prescribed pain medication, documented their concerns in a grievance form, stating that they recognized the difference in the medication's appearance and suspected theft. The facility's investigation was limited to a review of the Medication Administration Record (MAR), narcotic sheet, and progress notes, which indicated the medication was administered and effective. However, the investigation did not include interviews with the resident regarding the effectiveness of the medication, did not identify or interview the nurse alleged to have diverted the medication, and did not include interviews with other residents or staff who may have been witnesses or involved. The investigation summary lacked essential details, such as the identity of the staff member who wrote it, and failed to follow the facility's policy, which required comprehensive interviews and documentation. Both the Director of Nursing and the Administrator acknowledged that the investigation did not meet policy requirements, as it did not determine which nurse was involved or whether the resident's concerns were fully addressed. The incident was not reported on the facility's state reporting log, and the process for determining whether the concern was a grievance or a reportable allegation was not clearly documented.
Failure to Develop and Implement Comprehensive Care Plans for Multiple Residents
Penalty
Summary
The facility failed to develop and implement comprehensive, individualized care plans (CPs) for three residents with specific care needs. For one resident with pneumonia, asthma, and respiratory failure who required supplemental oxygen, there was no CP addressing respiratory conditions or oxygen use, despite observations of the resident using oxygen and staff confirming the absence of a relevant CP. Another resident with respiratory issues and kidney disease was observed with swollen feet, but no CP or physician's orders were in place to guide staff in monitoring or addressing the swelling, as confirmed by staff review. A third resident, who was blind in one eye and dependent on staff for daily care, was observed with multiple bruises on the arms, neck, and chest following a hospital readmission. There was no CP or physician's order directing staff to monitor or document changes in the bruises. Staff interviews confirmed the lack of care planning and monitoring instructions for these conditions, contrary to facility policy requiring comprehensive CPs to address all identified care needs.
Failure to Provide Required ADL Assistance to Dependent Residents
Penalty
Summary
The facility failed to provide necessary assistance with activities of daily living (ADLs) to residents who were dependent on staff for personal hygiene, grooming, and bathing. According to the facility's policy, residents unable to perform their own ADLs should receive services such as bathing, dressing, grooming, oral care, and fingernail care based on their comprehensive assessment and care plan. However, observations, interviews, and record reviews revealed that multiple residents did not receive the required assistance, despite being assessed as needing it and not refusing care. For example, one resident with respiratory issues required staff help for toileting, transferring, personal hygiene, and bathing, but was repeatedly observed with long, dirty fingernails and unshaven. The resident reported that staff did not assist with shaving or nail care, and staff interviews confirmed that care was not provided as expected. Another resident with lower body impairment after a stroke was dependent on staff for personal hygiene and bathing, yet was observed multiple times with long, dirty fingernails and stated that staff did not help with nail care. Staff acknowledged that care, including nail clipping and hygiene, was not consistently provided. Additional residents with anxiety, respiratory, and vision issues were also observed with poor hygiene, including long, dirty fingernails, greasy hair, and unshaven appearance. These residents required moderate to total assistance with ADLs and did not refuse care, but staff interviews and observations confirmed that morning care, showers, and nail care were not provided as scheduled or as needed. The facility's failure to follow its own policies and care plans resulted in residents not receiving the necessary assistance with ADLs.
Failure to Provide Individualized and Meaningful Activities for All Residents
Penalty
Summary
The facility failed to provide activity programs that met the individualized needs and interests of all residents, as required by its own policy and regulatory standards. Observations, interviews, and record reviews revealed that three residents did not receive meaningful or personalized activities. Activity calendars showed limited and repetitive offerings, such as nail painting and bingo, with little variation or consideration for residents' preferences, especially for those who were younger or had different interests. Residents reported boredom and dissatisfaction, noting that activities were primarily designed for older residents and that there were few options available on their unit. Resident records and care plans indicated that activities were important to the residents, including interests in music, news, group activities, religious services, reading, and educational programs. However, there was no documentation of activity participation for any of the three residents reviewed. Interviews with residents confirmed that they were not offered activities aligned with their interests, and some reported spending most of their time with little to do, such as working on puzzles alone or watching TV with no other options provided. Staff interviews confirmed that activity documentation was lacking and that one-on-one visits were inconsistently provided or tracked. The Activities Director acknowledged the limited activity schedule in certain units and the need to develop more appropriate options for younger residents. Census lists used by the activities team showed that some residents received few or no one-on-one visits, further demonstrating the facility's failure to implement an ongoing, individualized activities program as outlined in its policy.
Failure to Provide Behavioral Health Services Following Resident Request
Penalty
Summary
Resident 264, who had diagnoses of anxiety and depression, was admitted to the facility and was identified as being at risk for changes in mood or behavior due to their medical conditions. The resident's care plan included interventions for staff to provide a psychological evaluation consult as indicated. Documentation showed that the resident requested a referral for a psychological evaluation, but the status of this referral remained pending with no documented follow-up. Multiple progress notes and interviews indicated that the resident continued to express emotional distress, including tearfulness, sadness, and frustration about their mental health needs not being addressed. Despite repeated requests from the resident for a psychological evaluation and clear indications of ongoing emotional distress, there was no evidence that the facility made or completed the necessary referral for behavioral health services. Staff interviews confirmed that there was no documentation of a referral being made, and the Director of Nursing acknowledged that the order for a psychological evaluation was still pending without explanation. This lack of action resulted in the resident not receiving the behavioral health services required to address their mental health needs.
Medication Storage, Labeling, and Documentation Deficiencies
Penalty
Summary
Surveyors observed multiple deficiencies related to the storage and labeling of medications and biologicals. In the Tea Garden Unit's nourishment pantry freezer, an opened package of sterile glycerine swabs was found without a date indicating when it was opened or how long the swabs could safely be used. The packaging was intended for single-use sterility, and the lack of dating did not comply with the facility's policy for recording the date opened and expiration for such items. Additionally, on a medication cart, a steroid inhaler was found without a box, unlabeled, and with no resident name, while another inhaler was opened without an open or discard date. Staff interviews confirmed that medications should be labeled with the resident's name and dated to ensure safety and prevent errors. Further review of the narcotic logbook on the same medication cart revealed five instances in May where nurses failed to sign the logbook to confirm the narcotic count during shift changes. Staff acknowledged that signatures were missing and that it was expected practice to reconcile and sign the narcotic logbook at each shift change to ensure accuracy and prevent drug diversion. These findings demonstrate lapses in following established medication storage, labeling, and documentation procedures.
Failure to Provide Timely SLP Evaluation and Diet Upgrade
Penalty
Summary
The facility failed to ensure that a resident received timely specialized rehabilitative services, specifically a Speech Language Pathologist (SLP) evaluation, after admission. The resident was admitted with a moderate memory impairment and was placed on a mechanically altered diet, despite having no documented chewing or swallowing issues at the time of admission. The resident expressed dissatisfaction with the food texture and reported not understanding the reason for the modified diet. Observations confirmed that the resident was served ground meat, which was left untouched, and the resident voiced complaints to the registered dietician about the food. The SLP evaluation was not completed until eight days after admission, at which point the SLP assessed a mild swallowing impairment and upgraded the resident's diet. Interviews with staff revealed that there was a lack of timely referral and communication between the dietary and rehabilitation departments, which delayed the SLP assessment and subsequent dietary changes. The delay in providing specialized rehabilitative services resulted in the resident remaining on an unnecessarily restrictive diet for several days.
Failure to Follow Physician Orders and Monitor Resident Status
Penalty
Summary
The facility failed to ensure that physician-ordered parameters for medications were followed for several residents. For example, one resident with a history of stroke and arthritis, who frequently experienced severe pain, was administered as-needed pain medication for a pain level below the physician-ordered threshold. Another resident with a pain disorder and muscle weakness received pain medication outside the specified parameters on multiple occasions. These actions were confirmed through review of medication administration records and staff interviews, which acknowledged that medications were not always given according to the prescribed parameters. The facility also failed to clarify physician orders as needed for residents with complex medication regimens. In one case, a resident with anxiety and heart failure had an order for an antianxiety medication that did not specify when to administer one versus two tablets, and an order to monitor edema that lacked details on which body part to assess or actions to take for severe swelling. Staff interviews confirmed that these orders were unclear and should have been clarified with the provider, but this was not done. Another resident with insomnia had an as-needed supplement order for sleep that lacked clear administration parameters, which staff also failed to clarify. Additionally, the facility did not consistently monitor resident weights as ordered, particularly for residents at risk for malnutrition. One resident with cancer and heart disease experienced a significant, unverified weight loss over one week, with inconsistent weighing methods and no documented re-weigh or physician notification. The facility's policy required re-weighing for significant weight changes and consistent weighing practices, but these were not followed. Furthermore, staff failed to monitor and document edema as ordered for another resident with congestive heart failure, despite observable swelling and resident complaints. Staff interviews confirmed that required monitoring and documentation were not completed.
Failure to Provide Effective Pain Management
Penalty
Summary
The facility failed to provide effective pain management for residents experiencing significant pain, as evidenced by the care of two residents with complex medical conditions. One resident, who had a history of brain cancer, brain abscess, recent brain surgery, back pain, bilateral leg pain from blood clots, and generalized deconditioning, was not effectively managed for pain. Despite physician orders specifying the use of over-the-counter pain medication for mild pain and narcotic pain relievers for severe pain, the resident continued to experience unrelieved pain, particularly in the legs, and expressed distress. The care plan directed staff to notify the physician if interventions were unsuccessful, but the resident's representative reported ongoing inadequate pain control. Another resident with a bone infection and back pain had a care plan and physician orders that required staff to assess pain, attempt non-pharmacological interventions before administering pain medication, and provide specific dosages based on pain severity. However, documentation showed that the resident received a lower dose of pain medication than ordered for high pain levels, and non-pharmacological interventions were not provided as required. The resident reported not receiving the correct medication dose for several days and was offered an ineffective over-the-counter medication instead, leading to frustration and continued pain. Interviews with staff confirmed that pain management protocols were not consistently followed. Staff acknowledged that the pharmacy should have been contacted to obtain the correct medication and that the provider should have been notified to ensure orders were followed. The facility's policy required collaboration with healthcare professionals and the use of both pharmacological and non-pharmacological interventions, but these standards were not met, resulting in untreated pain and discomfort for the residents involved.
Failure to Implement Wound Care Orders
Penalty
Summary
The facility failed to provide necessary treatment and services consistent with professional standards of practice for a resident with a pressure ulcer. Resident 1, who had multiple medical conditions including memory impairment, unstable blood sugar levels, heart and kidney disease, malnutrition, and a surgically repaired hip fracture, was identified with a deep tissue injury on their buttocks during an admission assessment. Despite a wound care provider recommending a treatment using a medical-grade honey-based dressing, the treatment was not scheduled or carried out by the nursing staff as ordered. The delay in treatment was attributed to the facility receiving the wound care orders late on a Friday night, which were not processed until the following Monday morning. Interviews with staff revealed a lack of awareness regarding the treatment order, as it was not entered into the Treatment Administration Record. The Interim Director of Nursing confirmed that the treatment was not provided and emphasized the importance of implementing and following provider treatment orders for effective wound management and healing.
Failure to Implement Abuse and Neglect Policies
Penalty
Summary
The facility failed to implement its abuse and neglect policies and procedures, specifically in the prevention, identification, investigation, and reporting of abuse and/or neglect. This deficiency was highlighted by an incident involving a resident who experienced a dislocation of their left hip prosthesis during a rough and fast incontinent brief change by the staff. The resident, who had intact memory and was able to communicate their needs, reported severe pain during the process and noted that staff did not adhere to the care plan interventions, such as using pillows between the legs during repositioning. The facility's failure to investigate the incident thoroughly was evident as the Resident Care Manager did not inquire about the cause of the dislocation before the resident was sent to the hospital. Additionally, the Director of Nursing and Administrator-In-Training were unaware of the incident and did not conduct an investigation to rule out abuse or neglect. The resident's care plan also lacked instructions for non-weight bearing restrictions on the left lower extremity, as indicated in the hospital discharge orders, further demonstrating the facility's oversight in ensuring the resident's safety and adherence to care protocols.
Failure to Provide Written Transfer/Discharge Notices
Penalty
Summary
The facility failed to provide written transfer or discharge notices as required for three residents who were hospitalized. For Resident 1, the facility did not complete or provide a written notice of transfer or discharge to the resident or their representative when the resident was transferred to the hospital due to increased confusion, elevated body temperature, and high pulse rate. The facility staff was unable to reach the resident's representative, and the representative only learned of the transfer from the hospital staff. The facility's Executive Director and Director of Nursing confirmed that the Social Services Director, who was responsible for completing the notice, did not do so for Resident 1's transfer. Similarly, for Residents 6 and 7, the facility did not provide written notices of transfer or discharge to the residents or their representatives when they were discharged to the hospital. The facility was unable to provide documentation to support that the required notices were completed for these residents. The Executive Director acknowledged that the oversight occurred during a transition of staff in social services, which led to the transfer/discharge process being overlooked.
Failure to Prevent Falls for High-Risk Resident
Penalty
Summary
The facility failed to provide an environment free from accident hazards and did not ensure adequate supervision for a resident identified as a high-fall risk. The resident, who had a history of falls and multiple medical conditions including COVID-19, was found on the floor in their room. The resident's care plan did not include specific interventions such as positioning the bed in a low position or conducting frequent visual checks, despite the resident's high-fall risk status and the need to keep their room door closed due to COVID-19. The facility's fall prevention guidelines emphasize the importance of individualized care plans and frequent monitoring for residents at risk of falls. However, the resident's care plan lacked documentation of necessary interventions, and there was no safety assessment for the bed's low position. Staff interviews confirmed the absence of orders for frequent visual checks and the lack of documentation supporting active monitoring of the resident. The incident report and staff interviews revealed that the resident's discomfort from COVID-19 and loose bowel movements led them to attempt to get up independently, resulting in a fall. The facility's infection preventionist noted that dedicated rooms for COVID-19 positive residents who were high-fall risks were fully occupied, necessitating the resident's isolation in their current room. This situation, combined with the lack of appropriate interventions, contributed to the resident's fall.
Facility Fails to Maintain Sanitary Conditions in Kitchen and Resident Refrigerators
Penalty
Summary
The facility failed to ensure the physical environment was kept clean and food was stored under sanitary conditions in the kitchen and resident refrigerators. Observations revealed that food items in the kitchen were not labeled or dated, damaged or spoiled food was not discarded, and the kitchen vents were not kept free from dirt and dust build-up. Additionally, handwashing sinks and garbage bins were not maintained in a clean state. These lapses were confirmed by the Dietary Manager, who acknowledged the expectations for dietary staff to maintain food safety standards and the cleanliness of the kitchen environment. In the resident units, specifically Lily Garden and Tea Garden, the facility failed to monitor and manage the cleanliness and safety of resident refrigerators. Observations showed opened and undated food items, partially-eaten and spoiled food brought in from outside sources, and dirty refrigerator interiors. Staff interviews confirmed that nursing and dietary staff were responsible for labeling, dating, and discarding food items according to facility policy, but these practices were not consistently followed. These failures contributed to an unsanitary kitchen environment and unsafe storage of food and drinks, placing residents at risk for food-borne illness. The facility policies on sanitation, food from outside sources, and resident refrigerators were not adhered to, leading to the observed deficiencies in food safety and cleanliness.
Failure to Provide Bed Hold Policy Notification
Penalty
Summary
The facility failed to provide residents and/or their representatives with a written notice of the facility's bed hold policy at the time of transfer or within 24 hours, as required. This deficiency was identified through interviews and record reviews for three residents who were hospitalized. Resident 21 was sent to the hospital due to a change in their level of consciousness and swallowing issues, but there was no documentation indicating that a bed hold was offered. Staff F, responsible for offering bed holds, confirmed that a written bed hold was not provided to Resident 21 as required. Similarly, Resident 43 was hospitalized twice, but their records contained no information indicating that a bed hold was offered for either hospitalization. Staff N confirmed this oversight. Resident 41 was also sent to the hospital and returned to the facility, but there was no documentation of a bed hold being offered. Staff P confirmed that a bed hold was not provided to Resident 41 or their representative. The Executive Director acknowledged the importance of bed holds for residents' well-being and confirmed that the responsibility lies with the UCCs, but it was not being done. This failure placed residents and their representatives at risk of not being informed of their right to hold the resident's bed while hospitalized.
Failure to Develop Comprehensive Care Plans
Penalty
Summary
The facility failed to develop comprehensive care plans (CPs) for seven residents, leading to unmet care needs. Resident 264 was admitted without lower dentures and was unable to chew food, resulting in significant weight loss and malnutrition. Despite multiple notifications to staff, no CP was developed to address the resident's missing teeth or malnutrition. Similarly, Resident 25, who was diagnosed with depression and anxiety and was on related medications, did not have a CP addressing these conditions, which was confirmed by staff interviews and medication records review. Resident 163, who had broken teeth and difficulty chewing, was assessed to be at risk for malnutrition, but no CP was developed to address these issues. Resident 167, who had respiratory failure, malnutrition, and muscle weakness, used bilateral side rails for bed mobility, but this was not captured in their CP. Additionally, Resident 2, who had a left heel pressure ulcer (PU), did not have this condition or the related interventions documented in their CP, despite an incident report indicating the need for such updates. Resident 43, who had a brain bleed and a swallowing disorder, received more than 51% of their nutrition via a surgically implanted tube but had conflicting goals in their CP regarding weight gain and loss, with no specific interventions related to tube feeding. Lastly, Resident 46, who had an amputation and difficulty walking, experienced two unwitnessed falls, but their CP was not updated with new interventions to prevent future falls. Staff interviews confirmed that these deficiencies in CP development and implementation were not in line with the facility's policy and expectations.
Inadequate Pain Management for Residents
Penalty
Summary
The facility failed to provide appropriate pain management for residents, as evidenced by the lack of nonpharmacological interventions, failure to identify pain parameters for PRN medications, and failure to document the location of pain. Resident 167, who had multiple medical conditions including severe bladder infection and heart failure, reported pain affecting their sleep and daily activities. Despite physician orders to identify pain location and provide nonpharmacological interventions before administering PRN pain medications, the staff did not follow these instructions on multiple occasions, as documented in the Medication Administration Record (MAR) and progress notes. Resident 18, admitted for treatment following a hip fracture, also did not receive nonpharmacological interventions for pain. The physician orders did not include parameters for administering different pain medications based on pain levels, and there were no orders to monitor the resident's pain level. Staff confirmed that pain levels should be assessed every shift and that nonpharmacological interventions should be attempted before administering PRN pain medications, but these steps were not documented. Similarly, Resident 13 and Resident 213 experienced inadequate pain management. Resident 13, admitted for a hip fracture, received PRN opioid pain medication without documented nonpharmacological interventions or parameters for medication administration. Resident 213, with neck and shoulder pain, had multiple PRN pain medication orders without specific parameters, leading to inconsistent administration of pain medications. Staff confirmed the need for clarified pain medication orders and specific parameters for administering PRN medications, which were not in place for these residents.
Infection Control and Hand Hygiene Deficiencies
Penalty
Summary
The facility failed to maintain an infection prevention and control program designed to provide a sanitary environment to help prevent the transmission of communicable diseases. Specifically, the facility did not implement or follow isolation precautions for five residents reviewed for Transmission-Based Precautions (TBP) and did not consistently perform hand hygiene (HH) during meal service on two resident units. These failures placed the residents at risk for facility-acquired or healthcare-associated infections and related complications. Resident 31 had a Stage 3 pressure ulcer and a physician order to implement Enhanced Barrier Precautions (EBP). However, there was no isolation cart or EBP sign outside their room. Staff confirmed that Resident 31 should have been on EBP but was not. Similarly, Resident 32, who also had a Stage 3 pressure ulcer, did not have an isolation cart or EBP sign outside their room, despite physician orders. Staff confirmed that Resident 32 should have been on EBP but was not. Resident 43 was incorrectly placed on droplet/contact precautions instead of EBP, as confirmed by staff. Resident 167 had a bladder infection and was frequently incontinent. The TBP sign outside their door was inconsistently changed between Contact Precaution and EBP, leading to confusion among staff. Resident 2 had an EBP sign posted outside their room, but staff were unsure which resident in the shared room required the precaution. During meal service, staff failed to perform HH between assisting residents, as observed in both the Lily Garden dining room and another resident unit. Staff acknowledged the importance of HH but did not follow the protocol.
Failure to Transmit Resident Assessment Data Timely
Penalty
Summary
The facility failed to encode and transmit resident assessment data to the Centers for Medicare & Medicaid Services (CMS) within the required timeframe for Resident 9. The discharge assessment for Resident 9, who was discharged on an unspecified date, was completed on December 5, 2023, but was not transmitted until April 10, 2024, which is four months after the completion date and well past the required 14-day transmission period. This delay was identified during a review of the facility's records and was confirmed by the Executive Director and the Director of Nursing during an interview on April 11, 2024. Staff B, the Director of Nursing, acknowledged the importance of timely MDS assessments for individualized care planning and the facility's financial stability. However, they were unaware that Resident 9's assessment had not been transmitted on time. The MDS nurse, Staff C, confirmed in a written response that the assessment was not transmitted as required and was found missing during a preliminary report review. This oversight placed residents at risk for inaccurate monitoring of their health status and compromised the quality of care provided.
Inaccurate MDS Assessments for Two Residents
Penalty
Summary
The facility failed to ensure the Minimum Data Set (MDS) assessments for two residents were completed accurately to reflect their conditions and overall health status. For Resident 28, the MDS did not identify the resident's poor dental status, despite observations of missing, chipped, and decayed teeth, and the resident's own admission of poor dental health and difficulty chewing harder foods. The admission nurse documented missing teeth but did not note chewing difficulties, and the resident's care plan did not address their poor oral health. Staff C, the MDS nurse, confirmed the inaccuracy and admitted to not performing an oral inspection due to being off at the time of the assessment. The Director of Nursing emphasized the importance of accurate MDS assessments for proper care planning but acknowledged the failure in this case. For Resident 166, the MDS failed to capture the resident's active diagnosis of dementia, despite the resident's diagnosis being documented in their medical records and physician notes. The resident was observed to be non-communicative and had a blank stare, consistent with their dementia diagnosis. The care plan noted impaired cognitive ability but did not specify dementia as the cause. Staff C admitted to missing the dementia diagnosis in the MDS, which is crucial for monitoring and care planning. The facility's policy requires that the MDS accurately reflect the resident's status, which was not adhered to in these cases.
Failure to Provide Necessary ADL Assistance
Penalty
Summary
The facility failed to ensure residents who were dependent on staff for assistance with Activities of Daily Living (ADLs) received the necessary help. Resident 166, who had severe memory impairment and swallowing difficulties, was observed multiple times eating alone and struggling with their meal, despite being assessed to require one-person moderate assistance during meals. Staff interviews confirmed that Resident 166 needed assistance to avoid risks such as choking and malnutrition, but this assistance was not provided as required by the resident's care plan and assessment. Resident 32, who was totally dependent on staff for personal hygiene and bathing needs following a hip fracture, did not receive a bath for 24 days according to task documentation. Additionally, Resident 32 was observed with long facial stubble and reported not receiving assistance with shaving, despite expressing a preference for being clean-shaven. Staff interviews confirmed that the expected bathing and shaving assistance was not provided, as documented in the resident's care plan and task documentation.
Failure to Monitor Anticoagulation Therapy
Penalty
Summary
The facility failed to identify and provide care and services in accordance with the resident's goals and professional standards of practice for a resident on anticoagulation (AC) therapy. Specifically, Resident 163, who was on AC therapy following a right hip fracture, exhibited scattered red petechiae on the top areas of their bilateral feet. Despite the resident's clear speech and intact memory, and the facility's policy requiring additional monitoring for residents on AC therapy, the facility did not monitor for signs and symptoms of bleeding as indicated in the resident's care plan. The April Medication and Treatment Administration Records lacked documentation of such monitoring, and a skin assessment conducted on April 5, 2024, failed to identify the presence of petechiae on the resident's feet. Staff F, the Resident Care Manager, acknowledged the importance of monitoring AC adverse side effects, particularly signs and symptoms of bleeding, due to the severe consequences it could lead to. Staff F confirmed that the 04/05/2024 skin assessment did not identify the petechiae and stated that a baseline measurement of the affected areas should have been obtained to track any worsening of the skin condition. This oversight placed Resident 163 at risk for unidentified and/or worsening bleeding and a decreased quality of life.
Failure to Address Nutritional Needs and Weight Loss
Penalty
Summary
The facility failed to provide care and services consistent with professional standards of practice to prevent weight loss for two residents. For Resident 163, the facility did not complete a comprehensive nutrition assessment within the required 72 hours of admission, nor did they develop and implement a nutrition care plan to address the resident's malnutrition risk, poor dental status, and chewing difficulties. Despite the resident's significant weight loss and requests for a more suitable diet, the facility did not make timely adjustments or provide adequate nutritional support. Additionally, the facility staff failed to document meal intake accurately and did not re-weigh the resident as required by the facility's protocol. Resident 264 also experienced significant weight loss due to the facility's failure to address their nutritional needs. The resident was admitted without lower dentures and was unable to chew the regular textured food provided. Despite multiple notifications from the resident about their inability to chew the food, the facility did not downgrade the food texture or offer appropriate meal replacements. The facility also failed to conduct a timely comprehensive nutrition assessment and did not hold weekly resident-at-risk meetings to review and address the resident's nutritional status. Both residents were at risk for malnutrition and experienced significant weight loss due to the facility's failure to follow its own policies and procedures. The lack of timely nutritional assessments, inadequate care planning, and failure to provide appropriate food textures and meal replacements contributed to the residents' compromised nutritional status and decreased quality of life.
Failure to Document and Track Tube Feeding for Resident
Penalty
Summary
The facility failed to implement proper care for a resident with a feeding tube, specifically in documenting and tracking the rate of tube feeding orders, and the amount of nutrition and water infused. Resident 43, who had multiple diagnoses including a brain bleed, malnutrition, and a swallowing disorder, required specific amounts of fluids and calories per day. However, the facility did not complete a readmission nutrition assessment until eight days after the resident's return from the hospital, and there were no orders to weigh the resident. Additionally, the facility did not document the total amount of water provided, the amount of tube feeding formula administered, or the rate at which it was administered, as required by the physician's orders. Observations showed inconsistencies in the administration rate of the tube feeding formula, and interviews with staff confirmed that the documentation was incomplete and conflicting. The Registered Dietician and the Director of Nursing both acknowledged that the lack of documentation made it difficult to ensure the resident received adequate nutrition and hydration. This failure placed Resident 43 at risk for inadequate calorie or protein intake and/or inadequate hydration.
Failure to Provide Proper Respiratory Care
Penalty
Summary
The facility failed to provide respiratory care consistent with professional standards of practice for two residents. Resident 167, who had a history of severe bladder infection, low blood count, heart, kidney, and respiratory failure, malnutrition, muscle weakness, and adult failure to thrive, was not provided with incentive spirometry (IS) breathing exercises as ordered by the physician. Despite documentation indicating that IS was provided four times a day, observations and interviews revealed that the resident did not receive the treatment, and the IS device was not found in the resident's room. Staff confirmed that the treatment was not administered as required, despite being signed off in the Treatment Administration Record (TAR). This failure left the resident without necessary respiratory support following a positive Covid-19 diagnosis and hospitalization for respiratory issues. Resident 31, who was admitted after sustaining a leg fracture and had no memory impairment, was observed receiving supplemental oxygen without a physician's order specifying the rate of administration. The oxygen tubing was undated, and staff confirmed that there were no physician orders to monitor the resident's blood-oxygen levels or administer oxygen. The Director of Nursing acknowledged that staff should have contacted the physician for proper orders but failed to do so. This oversight resulted in the resident receiving oxygen therapy without appropriate medical guidance and documentation, contrary to the facility's policy on oxygen administration.
Failure to Provide Person-Centered Dementia Care
Penalty
Summary
The facility failed to provide appropriate treatment and services for a resident diagnosed with dementia, specifically Resident 166. The resident had no verbal communication, was rarely or never understood, had both short-term and long-term memory problems, and was severely impaired with their daily decision-making. Despite being on an antipsychotic (AP) medication for dementia with behavioral disturbance, the resident's care plan (CP) was incomplete, not person-centered, and lacked necessary details about the resident's mental condition, visual hallucinations, and non-pharmacologic interventions. Observations showed Resident 166 sitting alone in the dining room, non-communicative, and not engaged in any meaningful activities, indicating a lack of individualized care and attention to their dementia needs. Interviews with staff confirmed the deficiencies in Resident 166's care plan. Staff F, the Resident Care Manager, acknowledged that the CP was incomplete and not person-centered, lacking resident-specific non-pharmacologic interventions. Staff B, the Director of Nursing, emphasized the importance of person-centered dementia care and the need for accurate care plans that reflect the residents' goals of care. The failure to develop and implement a comprehensive, person-centered care plan for Resident 166 placed the resident at risk for unmet care needs and a diminished quality of life.
Failure to Ensure Residents are Free from Unnecessary Psychotropic Medications
Penalty
Summary
The facility failed to ensure that two residents were free from unnecessary psychotropic medications. For Resident 18, the facility did not provide non-pharmacological interventions prior to administering an as-needed antipsychotic (AP) medication. Additionally, the facility did not re-evaluate and document the specific condition being treated with the as-needed AP medication, nor did they obtain consent prior to administering the psychotropic medication. The care plan for Resident 18 did not identify non-pharmacological interventions, and the physician did not justify the continued use of the as-needed AP medication despite recommendations from the facility's pharmacist. Observations showed Resident 18 was calm and did not exhibit behaviors that would necessitate the use of the AP medication, and there was no consent for the medication in the resident's records, as confirmed by the Director of Nursing and the Regional Director of Clinical Services. For Resident 13, the facility did not identify target behaviors for staff to monitor related to the use of an antidepressant (AD) medication. The care plan for Resident 13 lacked specific behaviors to monitor, and there was no consent for the AD medication in the resident's records. The Director of Nursing and the Regional Director of Clinical Services confirmed the absence of consent and stated that consent should be obtained and documented before administering psychotropic medications. The Director of Nursing also confirmed that target behaviors should be monitored and included in the care plan to assess the effectiveness of the medication and interventions. These deficiencies indicate that the facility did not adhere to its policy of obtaining informed consent before administering psychotropic medications and failed to implement non-pharmacological interventions and proper documentation. This placed the residents at risk of receiving unnecessary medications and experiencing adverse side effects, while also detracting from their ability to exercise their right to decline treatment.
Improper Disposal of Garbage and Refuse
Penalty
Summary
The facility failed to ensure that one of two garbage dumpsters and one recycling dumpster were properly covered and the surrounding areas were kept clean. During an observation and interview with the Dietary Manager, it was noted that the recycling dumpster lid was open and overflowing with boxes and recyclable materials. Additionally, the middle garbage dumpster's lid was not completely closed, with a clear plastic bag containing leftover food wedged in between and partially hanging out. The area around the third garbage dumpster was dirty, with trash and garbage debris, including a cigarette butt and several used surgical masks. The Dietary Manager confirmed that all staff are expected to keep the dumpsters covered, lids secured at all times, and surrounding areas clean to prevent insect and rodent infestations that could cause residents to get sick. The facility's policy on the disposal of garbage and refuse, dated 04/25/2024, mandates that all waste should be properly contained in the dumpsters and covered appropriately, and that all areas where garbage/refuse are located should be kept clean and maintained in a sanitary condition to prevent the harborage and feeding of pests.
Failure to Provide Required Rehabilitative Services
Penalty
Summary
The facility failed to provide specialized rehabilitative services as required for Resident 265, who was admitted with a right hip fracture and required both Physical Therapy (PT) and Occupational Therapy (OT) five times a week. Despite the assessment and care plan indicating the need for these services, Resident 265 reported receiving therapy only about three times a week. Therapy notes confirmed that for two consecutive weeks, the resident received OT and PT services fewer times than required. This discrepancy was further highlighted by a sign created by the resident's family to track therapy sessions, which indicated inconsistencies in the provision of therapy services. Interviews with Resident 265 and the Rehab Director revealed that the therapy schedule was not adequately coordinated with the resident's Hemodialysis (HD) treatments, which occurred three times a week. The Rehab Director acknowledged the lack of a proper system to ensure that residents who go out for HD receive their required therapy services. The family of Resident 265 expressed concerns about the missed therapy sessions and requested a revised schedule to accommodate the HD treatments, but the facility had not yet implemented an effective solution to address this issue.
Inconsistent Medical Records and Advance Directives Documentation
Penalty
Summary
The facility failed to ensure resident medical records were accurate and consistent for two residents. For Resident 166, the medical records showed conflicting information regarding the type of dementia diagnosis. The resident's diagnosis list indicated dementia without behavioral disturbance, while the Medication Administration Record (MAR) showed the resident was being treated with an antipsychotic medication for dementia with behavioral disturbance. This inconsistency was not clarified with the provider, leading to potential mismanagement of the resident's care needs. Staff F, the Resident Care Manager, acknowledged the documentation conflict but did not take steps to resolve it. For Resident 167, the facility failed to accurately document the resident's Advance Directives (AD) status. Although the resident had formulated an AD and designated a Durable Power of Attorney (DPOA) for healthcare decisions, this information was not reflected in the medical records. The Social Services (SS) progress notes initially indicated that the resident did not have a DPOA, and it was only after a delay that the AD was received and placed in the resident's records. Staff I, the Social Services Director, and Staff Q, the Admission Director, both acknowledged the lack of communication between their departments, which contributed to the inconsistency in the resident's records.
Failure to Administer Pneumococcal Vaccine
Penalty
Summary
The facility failed to administer a pneumococcal vaccine to Resident 213, who was one of five residents reviewed for vaccinations. According to the facility's policy, each resident should be offered a pneumococcal vaccine if eligible, and the vaccine should be administered per Physician Orders. Resident 213, who was admitted to the facility and not up to date on the pneumococcal vaccine, consented to receive the vaccine on 03/27/2024. The resident was scheduled to receive the vaccine on 04/11/2024, but it was not administered because the resident was out of the facility at that time. There was no follow-up to re-offer the vaccine when the resident returned, as confirmed by the Director of Nursing during an interview.
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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