Grays Harbor Health & Rehabilitation Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Aberdeen, Washington.
- Location
- 920 Anderson Drive, Aberdeen, Washington 98520
- CMS Provider Number
- 505016
- Inspections on file
- 30
- Latest survey
- March 24, 2026
- Citations (last 12 mo.)
- 4
Citation history
Health deficiencies cited at Grays Harbor Health & Rehabilitation Center during CMS and state inspections, most recent first.
A resident with moderate cognitive impairment and ADL needs had a care plan stating that staff would provide bathing assistance, but the plan did not reflect the documented arrangement and preference for the resident’s spouse to perform showers. Progress notes indicated the spouse would be present on shower days to assist, and the resident reported that staff did not shower him while admitted. An LPN and the RN care manager confirmed the spouse insisted on providing showers and did not want staff involved, yet there was no documented orientation of the spouse to the shower room and no completed safety assessment, despite acknowledged fall risk. The Administrator later stated that the spouse-provided showers were not sanctioned and that the required safety assessment for showering had not been completed.
A resident who required assistance with ADLs and had moderate cognitive impairment was care planned for OT involvement and had physician orders for OT evaluation and treatment two times per week. The resident received only an initial OT evaluation, with no follow-up treatment sessions provided, and reported not recalling working with therapy staff. The rehab director confirmed the lack of ongoing OT services and noted reliance on part-time and PRN OT staff while therapy positions were being advertised.
A resident with severe cognitive impairment and an order for continuous oxygen therapy was observed without oxygen in use; the concentrator was off, the nasal cannula was not applied, and the oxygen tank on the wheelchair was empty. Both an LPN and the DON confirmed the resident was not receiving oxygen as ordered, and no changes to the physician's order had been made.
A resident with mild cognitive impairment had a physician-ordered UA that was not collected for three days after the order was placed. Nursing staff documented waiting for the sample, and interviews with the DON and other nurses confirmed that the delay was due to the order not being properly scheduled in the electronic medical record, resulting in the UA not being collected within the expected timeframe.
The facility failed to assist residents with completing advance directives (AD) and maintaining Durable Power of Attorney (DPOA) documentation. Several residents, including those with cognitive impairments, did not have their ADs properly documented in their electronic health records (EHRs). Staff acknowledged that ADs were not adequately addressed, and POLST forms were mistakenly used as substitutes, leading to a lack of proper AD documentation.
A facility failed to issue a Skilled Nursing Facility Advance Beneficiary Notice (SNF ABN) to a resident, who was moderately cognitively impaired, before the end of Medicare-covered services. Although a Notice of Medicare Non-Coverage (NOMNC) was provided, the SNF ABN, which details potential financial liability, was not given, as confirmed by the Social Services Director.
A facility failed to obtain consent and a physician's order for bed rails for a moderately cognitively impaired resident. Observations showed the resident with bed rails installed, but the electronic health record lacked the necessary documentation. Staff confirmed the oversight, acknowledging the failure to follow the facility's process.
A facility failed to complete a timely Level II PASRR referral for a resident with depression and anxiety. The initial Level I PASRR did not reflect the resident's diagnoses, and the necessary referral was delayed by over eight months. The Social Services Director admitted to missing the step, and the DON was aware of the oversight.
The facility failed to initiate bowel interventions for two residents who did not have bowel movements for extended periods, contrary to the facility's bowel management policy. Additionally, a resident requiring urology and vascular consultations did not have these appointments arranged, as there was no system in place to track and follow up on specialist referrals. Staff interviews confirmed the absence of documentation and a clear process for managing these referrals.
A resident with moderate cognitive impairment was found with loose bed rails, creating a gap between the mattress and rail. The resident struggled to use the rail for mobility, and staff interviews revealed a lack of timely reporting and maintenance checks. The maintenance director confirmed the need for tightening the rails.
Failure to Implement and Document ADL Care Plan for Resident Showering by Family
Penalty
Summary
The deficiency involves the facility’s failure to implement and update a complete, individualized ADL care plan and corresponding interventions for a resident whose wife was providing showers. Facility policy titled "Quality of Life" required development and implementation of care plans and interventions to maintain, improve, or prevent avoidable decline in ADLs based on assessed needs, goals, and preferences. The resident was admitted with moderate cognitive impairment and required assistance with ADLs. The 5‑day admission MDS documented these needs, and the ADL care plan initiated the day before the MDS specified that one staff member would provide bathing/showering assistance as needed. However, the care plan did not document the resident’s or wife’s preference for the wife to provide showers. Progress notes documented that the wife would do the resident’s laundry and would be present in the evenings to shower him on his shower days. The resident later stated that while he was in the facility, staff did not shower him and that his wife assisted him instead. An LPN and the Residential Care Manager/RN both reported that the wife was insistent on showering the resident and did not want staff involved, and the RN acknowledged there was no documentation of any orientation to the shower room for the wife. The RN also acknowledged a fall risk associated with family members showering residents. The Administrator stated she learned after the fact that the wife had been showering the resident, that this was not sanctioned by the facility, and that an assessment to verify safety with showering, which should have been completed, was not done for this resident.
Failure to Provide Ordered Occupational Therapy Services
Penalty
Summary
Failure to provide specialized rehabilitative services occurred when a resident with physician orders for occupational therapy (OT) evaluation and treatment did not receive ordered OT services beyond the initial evaluation. The resident was admitted with needs for assistance with activities of daily living (ADLs) and was documented as moderately cognitively impaired on the 5-day admission MDS. The resident’s fall risk care plan included an intervention to refer to OT as needed per orders, and physician orders dated 02/24/2026 specified OT evaluation and treatment as indicated. The Director of Rehabilitation Services reported that OT was ordered two times per week and confirmed that the resident was evaluated for OT on 02/25/2026 but did not receive any subsequent OT treatments. The resident also stated he did not recall working with therapy staff while admitted. Facility staff reported that there was no full-time occupational therapist on staff and that OT coverage was being provided by a part-time weekend therapist and PRN COTAs, with ongoing efforts to recruit additional therapy staff.
Failure to Provide Continuous Oxygen Therapy as Ordered
Penalty
Summary
A resident who was admitted to the facility with severe cognitive impairment had physician orders and a care plan in place for continuous oxygen therapy at 2 liters per minute via nasal cannula for dyspnea. Despite these orders, during an observation, the resident was found in bed without oxygen in use; the oxygen concentrator was turned off and the nasal cannula was not applied. Additionally, the oxygen tank attached to the resident's wheelchair was empty. Interviews with facility staff revealed a lack of awareness regarding any changes to the resident's oxygen orders, and upon review, staff confirmed that the order for continuous oxygen therapy remained in effect. Both the LPN and the DON acknowledged that the resident was not receiving oxygen as prescribed at the time of observation, and the DON confirmed that the expectation was for the resident to have oxygen applied at all times per the current orders.
Delayed Collection of Physician-Ordered Urinalysis
Penalty
Summary
The facility failed to ensure the timely completion of a physician-ordered urinalysis (UA) for one resident. The resident, who was mildly cognitively impaired, had a physician's order for a UA with culture and sensitivity if indicated. The order, dated 07/18/2025, did not specify collection instructions. Nursing documentation on the same day noted that staff were awaiting a urine sample from the resident. The UA was not collected until 07/21/2025, three days after the order was placed, and was then sent to the lab. Interviews with facility staff revealed that standard practice was to collect UAs within the same shift or within 24 hours of the order. Staff indicated that a three-day delay in collection was not considered timely. The Director of Nursing identified that the order was entered but not scheduled in the electronic medical record, which prevented the system from alerting nurses to complete the lab. This resulted in the UA not being collected in a timely manner as required.
Failure to Properly Document and Assist with Advance Directives
Penalty
Summary
The facility failed to have procedures in place to assist residents with completing advance directives (AD) and obtaining and maintaining Durable Power of Attorney (DPOA) documentation. This deficiency was identified for five residents who were part of a sample review. The facility's policy required that upon admission, residents should be informed of their right to establish advance directives and be provided assistance if needed. However, the facility did not adhere to this policy, as evidenced by the lack of documentation in the residents' electronic health records (EHR) regarding discussions or assistance offered for ADs. Several residents, including those who were moderately cognitively impaired, did not have their ADs properly documented or maintained in their EHRs. Staff members, including the Social Services Director and the Director of Nursing Services, acknowledged that ADs were not being adequately addressed and that POLST forms were mistakenly used as substitutes for ADs. This misunderstanding led to the absence of proper AD documentation for the residents, placing them at risk of not having their healthcare preferences honored.
Failure to Provide SNF ABN to Resident
Penalty
Summary
The facility failed to provide a resident with the required Skilled Nursing Facility Advance Beneficiary Notice (SNF ABN), which is necessary to inform residents of their potential financial liability when Medicare services are ending. Resident 34, who was moderately cognitively impaired and admitted with diagnoses including abnormalities of gait and mobility, was issued a Notice of Medicare Non-Coverage (NOMNC) on 01/31/2025, indicating that skilled nursing services would end on 02/02/2025. However, the SNF ABN, which should have been provided before the last covered day to explain the financial implications of continuing care, was not issued to the resident or their representative. This oversight was confirmed by the Social Services Director during an interview on 03/19/2025.
Failure to Obtain Consent and Physician's Order for Bed Rails
Penalty
Summary
The facility failed to obtain consent and a physician's order for the use of physical restraints, specifically bed rails, for a resident identified as moderately cognitively impaired. The resident was admitted to the facility and had an assessment indicating the use of assist rails for bed mobility. However, observations on multiple occasions revealed the resident lying in bed with quarter bed rails installed, without any documented consent or physician's order in the resident's electronic health record. Staff interviews confirmed the oversight, with the Unit Manager and LPN acknowledging the absence of necessary consent and physician orders for the bed rails. The Director of Nursing also stated that it was expected for consent and physician orders to be obtained prior to the installation of bed rails, indicating a failure to follow the facility's established process for this resident.
Failure to Complete Timely PASRR Level II Referral
Penalty
Summary
The facility failed to accurately complete a Level I Pre-Admission Screening and Resident Review (PASRR) and ensure a referral for a Level II evaluation for one of the sampled residents. This resident was admitted with diagnoses of depression and anxiety, and the initial Level I PASRR did not reflect these diagnoses. Despite being prescribed Duloxetine for depressive symptoms, the necessary Level II referral was not completed until over eight months after admission. Staff F, the Social Services Director, acknowledged missing the step of sending off the Level II referral within the required timeframe. The Director of Nursing Services was aware of the oversight and expected PASRR processes to be followed according to facility policy.
Failure to Initiate Bowel Protocol and Arrange Consultations
Penalty
Summary
The facility failed to initiate bowel interventions for two residents, identified as Resident 18 and Resident 42, who were reviewed for bowel management. According to the facility's bowel management policy, residents who do not have a bowel movement for more than three days should be assessed and the bowel protocol should be initiated. Resident 18 did not have a bowel movement for over 81 hours, and Resident 42 did not have a bowel movement for over 128 hours. Despite these extended periods without bowel movements, the bowel protocol was not initiated for either resident, as confirmed by the lack of documentation in their Medication Administration Reports (MARs). Additionally, the facility failed to arrange necessary consultations for Resident 55, who was reviewed for physician orders for urology and vascular consults. Resident 55 was admitted with an indwelling foley catheter, and a urology consult was ordered to address urinary retention. Furthermore, a vascular consult was ordered following the discovery of a full-thickness wound and moderate stenosis in the resident's lower extremities. However, there was no documentation to confirm that these consultations were scheduled, and staff members were unable to verify if the appointments had been arranged. Interviews with staff members revealed a lack of a clear process for tracking and following up on specialist referrals. Staff members, including unit managers and the Director of Nursing Services, acknowledged the absence of a system to ensure that referrals were completed and appointments were scheduled. This lack of organization and documentation contributed to the failure to provide timely and appropriate care for the residents involved.
Failure to Securely Fasten Bed Rails
Penalty
Summary
The facility failed to ensure that bed rails were securely fastened and without gaps between the mattress and bed rail for a resident reviewed for accident hazards. The resident, who was moderately cognitively impaired, was observed with loose bed rails on both sides of the bed. The right bed rail was leaning outward and had significant movement, with a noticeable gap between the mattress and the rail, where a box of tissues had fallen. The left bed rail also exhibited movement. The resident expressed difficulty using the loose rail to get in and out of bed and to move around, indicating that the rail had been loose for a long time. Staff interviews revealed that maintenance was responsible for installing and checking bed rails, with checks scheduled twice a year. However, the staff did not report any current issues with bed rails, and the maintenance director confirmed that the rails needed tightening after observing the resident's bed. The Director of Nursing stated that staff should report loose bed rails through the electronic work order system, TELS, and expected that bed rails would be maintained properly.
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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