Highland Health And Rehabilitation Of Cascadia
Inspection history, citations, penalties and survey trends for this long-term care facility in Bellingham, Washington.
- Location
- 2400 Samish Way, Bellingham, Washington 98229
- CMS Provider Number
- 505140
- Inspections on file
- 32
- Latest survey
- February 13, 2026
- Citations (last 12 mo.)
- 31
Citation history
Health deficiencies cited at Highland Health And Rehabilitation Of Cascadia during CMS and state inspections, most recent first.
A resident with osteomyelitis, diabetes, and a left-arm PICC line for IV antibiotics experienced harm when an RN used unsterile wound care scissors during a weekly PICC dressing change, cutting the line instead of safely removing the dressing per facility policy. The resident reported bleeding and discomfort, and was emergently transferred to the ED where the PICC was removed and replaced after ultrasound and X-ray. Record review showed the facility’s policy required careful, non-sharp removal of dressings and use of alcohol to loosen adhesive, and the facility’s assessment identified IV and central line care as needed services. Multiple nurses’ competencies for central/PICC/CVAD care and central line dressing changes were past due, and interviews with staff, the resident, and family indicated limited training and frequent problems with IV antibiotic administration and pump management, leading to concerns about staff ability to safely manage the resident’s PICC line.
Surveyors found that the facility repeatedly failed to administer physician‑ordered medications over multiple days because drugs were not available, affecting numerous residents and a wide range of treatments including respiratory, cardiac, thyroid, diabetic, pain, GI, psychiatric, hormone, and supplement therapies. Review of the Medication Not Available report showed that some medications had been previously delivered in 7‑ to 30‑day supplies or were stocked OTC or in the pyxis, yet were still not given, and refill requests were often submitted after supplies should have run out. RNs, LPNs, and agency staff reported frequent shortages of OTC medications, barriers to pyxis access, confusion over who was responsible for ordering, and management discouraging documentation of unavailable meds. Staff described ongoing problems with pharmacy deliveries, late or missing orders, and high‑cost medications requiring administrative approval, while the consulting pharmacist reported a 5–7 day refill turnaround, noted late refill requests, and identified instances where medications should have been on hand or available in pyxis but were not used, resulting in missed doses, including at admission.
A resident’s PICC line was accidentally cut by an RN during a dressing change, leading to transfer to the ED, but the facility did not initiate an incident report or conduct a thorough investigation as required by its abuse prevention and reporting policy. Incident logs contained no entry for the event, and interviews with the interim CNO, a resident care manager, and the interim administrator showed that staff considered the occurrence a mistake, believed education of the nurse was sufficient, or incorrectly assumed an incident report and investigation had been completed. Leadership later stated they would have expected an investigation into what happened, but no formal incident report or documented investigation was found.
The facility did not update and post accurate daily nurse staffing information, including actual nursing hours worked and the current resident census, for an extended period. Surveyors repeatedly observed that the posted staffing sheet displayed an outdated date, and an interim CNO confirmed that the posting had not been updated as required. This failure prevented residents and visitors from readily viewing current nurse staffing levels.
A resident at risk for pressure injuries did not receive consistent preventive interventions, such as off-loading heels and use of heel protective devices, as outlined in the care plan. Documentation showed these measures were not regularly implemented, resulting in the development of a deep tissue injury on the resident's heel, significant discomfort, and improper wound care practices by staff.
Staff did not consistently perform hand hygiene during meal tray delivery, failed to use appropriate PPE when caring for a resident on enhanced precautions, and did not properly store or maintain oxygen and nebulizer equipment for a resident. These lapses were observed during direct care activities and confirmed through staff interviews and record review.
A resident with a history of hypersexuality and inappropriate touching was inadequately supervised, resulting in inappropriate contact with another resident who had dementia. Despite having a care plan to manage these behaviors, the facility failed to document and implement necessary interventions, leading to a lapse in supervision and protection.
The facility failed to provide adequate nursing staff, resulting in unmet needs for three residents. A resident with severe cognitive impairment was found undressed and unable to reach their call light or drinks. Another resident, at risk for falls, reported long delays in call light responses, leading to accidents. A third resident, also at risk for falls, had their call light turned off without assistance, prompting unsafe self-transfer attempts. Staff confirmed insufficient staffing levels.
The facility failed to meet professional standards in medication administration and physician consultations. During an internet outage, printed MARs were incomplete, leading to potential medication errors for residents. Staff relied on pharmacy labels instead of accurate physician orders. Additionally, a resident's GI specialist referral was not completed, despite a physician's order, leaving the resident's symptoms unaddressed.
The facility failed to ensure that NACs had the necessary competencies to provide nursing services, as five staff members lacked documented assessments of their skills. Despite policies requiring validation of competencies, interviews revealed that these assessments were not completed, placing residents at risk for unmet care needs.
A facility failed to comply with infection control guidelines during medication administration and laundry handling. An LPN did not use barriers or perform hand hygiene while administering medications, and the laundry room lacked procedures for handling contaminated linens. The infection control program had not been reviewed since 2022, and staff were not adequately trained.
The facility did not ensure residents had access to Saturday mail deliveries, impacting two residents. Despite the facility's policy on communication rights, mail delivered on Saturdays was not distributed until Mondays. This was confirmed by staff interviews, with one resident having moderate cognitive impairment and another with no cognitive impairment reporting the delay.
The facility failed to ensure comprehensive Resident Assessment Instrument (RAI) summaries for three residents, leading to incomplete care planning. A resident's significant change MDS assessment lacked input from their representative and comprehensive assessments in key areas. Another resident's annual MDS assessment was similarly deficient. Additionally, a resident's dental issue was not properly documented, preventing necessary care coordination. Staff interviews revealed remote MDS completion and inadequate CAA documentation.
A facility failed to provide appropriate care for a resident with an indwelling urinary catheter, increasing the risk of CAUTIs. The facility did not develop individualized plans for catheter care, instead following routine procedures for changing and flushing the catheter system, contrary to CDC guidelines and facility policy. The resident, with a chronic suprapubic catheter, was readmitted after a UTI, and observations showed potential issues with catheter care. Staff confirmed routine practices were not aligned with best practices, and the resident was not informed of the infection risk.
The facility failed to prevent unnecessary drug administration for two residents. One resident received PRN pain medication without documented non-pharmacological interventions, despite having a care plan requiring such attempts. Another resident with IBS and frequent diarrhea was given bowel medications that were supposed to be held for loose stools, resulting in unnecessary administration. Staff interviews confirmed these oversights.
A facility failed to maintain accurate clinical records for a resident with a chronic suprapubic catheter. Despite an order to measure and record urinary output every shift, documentation was missing for six shifts. An LPN was unable to provide information about the missing records.
A facility failed to implement its Antibiotic Stewardship Program effectively, as demonstrated by a resident who was prescribed antibiotics without documented clinical indication or validation of an active infection. Interviews with staff revealed a lack of communication and verification processes, highlighting deficiencies in the program's execution.
The facility did not ensure that NACs completed the required 12 hours of annual training. Two NACs, hired in 2022 and 2023, did not meet the training requirement, with one lacking documentation and the other completing only 6.10 hours. This was confirmed by the DNS during an interview.
A resident with diabetes mellitus type 2 experienced a hypoglycemic episode with a blood glucose level as low as 47 mg/dL. Despite having a continuous glucose monitoring system, the incident was not documented, and the physician was notified 26 days later. The resident sought help independently after the glucose monitor alarmed, and staff inconsistencies in reporting and documentation were noted. The facility lacked a policy for using the monitoring system, leading to a deficiency in diabetic management.
The facility failed to address the behavioral health needs of a resident with multiple diagnoses, including hip fracture and adjustment disorder. Despite ongoing confusion, restlessness, and refusal of care, the facility did not implement effective person-centered interventions. Observations and interviews revealed the resident's distress and unmet needs, with staff failing to respond to calls for help and adequately document behavioral health issues.
The facility failed to provide timely pharmacy services for three residents upon admission, resulting in delayed administration of critical medications for pain management, diabetes, leukemia, and Parkinson's disease. Staff inconsistencies and lack of proper documentation contributed to these deficiencies.
The facility failed to maintain a clean and sanitary shower room, leading a resident to avoid bathing due to the filthy conditions, including black grout and debris. Staff confirmed minimal cleaning practices and acknowledged built-up grime and a non-functional tub.
Improper PICC Line Dressing Change and Inadequate Nurse Competencies
Penalty
Summary
The deficiency involves the facility’s failure to ensure safe and appropriate administration of IV therapy by not following professional standards and aseptic technique during a PICC line dressing change for Resident 20. The facility’s own 2025 Facility Assessment identified that its resident population required nursing care for IV peripheral and central lines, and that competencies were to be monitored through leadership rounding, mentoring, skills checks, and annual staff competencies. The facility had a policy for central venous access device dressing changes that required careful removal of old dressings, stabilizing the catheter to minimize movement, and using alcohol to loosen adhesive. Resident 20 was admitted with osteomyelitis of the thoracic and lumbar vertebrae, type 2 diabetes, and vancomycin resistance, and had a PICC line in the left upper arm with care plan interventions for enhanced barrier precautions and dressing changes to maintain patency and keep the site infection-free. During a scheduled weekly PICC line dressing change, the nurse performing the procedure used general wound care scissors, which were unsterile, to cut tape on the dressing. The nurse reported attempting to cut the tape and believed they had cut the dressing, but the PICC line was in fact cut. The resident and collateral contact reported that the nurse took scissors from their scrub pocket and cut near the line while trying to remove “gummy stuff” from the dressing. After the dressing was mostly removed and a new dressing placed over the insertion site, the resident noticed bleeding and felt blood under the armpit. The nurse initially stated the line had “broke” or “snapped,” while the resident asserted that it had been cut. The facility’s progress note documented that the PICC line was accidentally cut during the dressing change and that a pressure dressing was applied before the resident was transferred emergently to the emergency department for PICC line replacement and additional diagnostic procedures, including ultrasound and X-ray. Interviews and record review showed that licensed nurse competencies related to central/PICC/CVAD care and central line/midline dressing changes for multiple nurses were past due as of the review date. One RN stated they were unaware of any in-service instructing staff not to use scissors during PICC line dressing changes, though they knew sharps should not be used. The RN who cut the line stated they had not received much training at the facility, were previously certified to insert IVs at another facility, and felt unsupported due to lack of education. The resident, their family member, and staff interviews indicated that few nurses were comfortable or experienced with PICC line care, that staff had difficulty managing IV antibiotics, IV pumps, and air bubbles, and that the resident’s PICC line care appeared problematic throughout the stay. The facility’s failure to ensure current nurse competencies and adherence to its own PICC dressing change policy resulted in the use of unsterile scissors during a PICC line dressing change, cutting the line and necessitating emergency transfer and replacement of the central line, and placed the resident at serious risk for central line–associated bloodstream infection as stated in the report. The report also documents that the resident and their family perceived that staff did not know how to care for the PICC line or administer IV antibiotics properly. The family member stated it appeared there was only one nurse who knew how to work with a PICC line and described wasted IV antibiotic while staff attempted to remove air bubbles, as well as a dropped and broken medication vial. The resident reported that staff repeatedly had problems with the IV pump jamming, excessive air bubbles, and understanding how the antibiotics were to be infused, and that staff told them they were the only resident with an IV like theirs. The resident described the nurse’s visible panic after cutting the line and uncertainty about what to do next, including the nurse asking about resuscitation preferences while the resident was bleeding and waiting for emergency services. These observations and statements, combined with the documented lapse in competencies and deviation from the facility’s dressing change procedure, form the factual basis for the cited deficiency.
Widespread Failure to Provide Ordered Medications Due to Stock, Ordering, and Coordination Breakdowns
Penalty
Summary
The deficiency involves the facility’s failure to provide all physician‑ordered medications to residents on 13 of 14 reviewed days for 20 residents, disrupting continuity of care and placing residents at risk of not having their medical needs met. Review of the facility’s Medication Not Available report for 01/30/2026 through 02/12/2026 showed numerous prescribed medications, including anticonvulsants, respiratory medications, gastrointestinal medications, antidepressants, antiplatelet agents, thyroid medications, diabetic medications, cardiac medications, hormone therapies, pain medications, supplements, and OTC products, were not administered because they were not available. The report also documented that some medications were available in the facility’s pyxis machine or should have been available as OTC facility stock, yet were still not given. The Medication Not Available report detailed repeated instances where residents’ medications were not administered despite prior deliveries or available stock. Examples included residents missing doses of gabapentin, albuterol inhalation, fluticasone‑salmeterol inhalers, metronidazole topical cream, ranitidine, duloxetine, levothyroxine, semaglutide, clopidogrel, diltiazem, oxybutynin, pantoprazole, estradiol, alendronate, and various vitamins, minerals, and protein supplements. In several cases, the pharmacy had delivered 7‑, 14‑, 28‑, or 30‑day supplies on earlier dates, but the medications were still documented as unavailable later, and refill requests were sometimes submitted after the expected depletion date. The consulting pharmacist later confirmed that many of the medications listed should have been on hand based on previous delivery dates and that some medications were available in pyxis at the time they were reported as not administered. Staff interviews described systemic problems with obtaining both pharmacy‑dispensed and OTC medications, as well as confusion and breakdowns in responsibility for ensuring medication availability. Nursing staff, including RNs and LPNs, reported that OTC medications were often not available, that management discouraged documenting unavailable medications, and that they were directed to speak with the Administrator or HR, who in turn reported not having a card to purchase needed OTC items. Agency nurses reported they could not access the pyxis and had to rely on regular staff to obtain medications, and that notifications to Resident Care Managers did not always result in orders being placed. Nursing staff and managers described ongoing issues with pharmacy deliveries, including medications not arriving despite being ordered, delays related to ordering cut‑off times, and high‑cost medications requiring administrative approval and signatures. The contracted pharmacist stated they were unaware of delivery difficulties, noted a 5–7 day refill turnaround time, and identified late refill requests and missed admission doses where orders were submitted late in the day and no rush requests were made, contributing to the pattern of unavailable medications. Additional interviews with leadership and clinical staff further illustrated the lack of clarity and follow‑through in the medication supply process. An interim CNO stated they did not know where the disconnect was in having medications available. A Resident Care Manager acknowledged continuous issues with the pharmacy and stated that medications listed on the Medication Not Available report were simply not available, whether pharmacy‑delivered or facility‑supplied OTCs, and that the problem had been ongoing. Nursing staff reported that when medications were not available for a day or two, they tried to notify providers, and that they often had to call the pharmacy multiple times, sometimes being told that medications had not been ordered even when staff believed they had been. The consulting pharmacist’s follow‑up email also noted that several medications on the report should have been available as OTC stock, that many should have been on hand based on prior deliveries, that refill requests were often delayed beyond the expected depletion date, and that for one admission, multiple ordered medications were available in pyxis but not used, and no rush request was submitted for the remaining medications, resulting in missing doses on the evening of arrival.
Failure to Investigate PICC Line Injury Incident
Penalty
Summary
The deficiency involves the facility’s failure to conduct a complete and thorough investigation of an incident in which a resident’s peripherally inserted central catheter (PICC) line was accidentally cut by an RN during a dressing change, resulting in the resident being sent to the emergency department. The facility’s abuse prevention and reporting policy required investigation of events suggesting possible abuse or neglect and documentation of such events, including appropriate corrective action if an allegation was verified. However, review of the facility’s incident logs for January and February 2026 showed no incident related to this PICC line event, despite a progress note documenting that the PICC line was accidentally cut and the resident was transferred to the hospital. Interviews with multiple staff revealed that no incident report or formal investigation was initiated at the time of the event. The interim CNO acknowledged that no incident report was completed because the resident was discharged home from the hospital and stated they were only going to complete an incident report on the day of the survey. The interim CNO also reported that, after reviewing internal guidance (“Purple Book”) with the intradisciplinary team, they had determined the event did not meet the definition requiring an incident report. A resident care manager stated that incident reports were usually started by the cart nurse or nursing managers, but in this case they were never directed to complete one and viewed the event as a mistake for which the nurse was educated. The interim administrator believed an incident report existed in the risk management system or had been reviewed in stand-up, but none was found, and stated they would have expected an investigation. The company lead CNO also stated they had been told an investigation was being conducted and would have expected one to be done.
Failure to Update and Post Daily Nurse Staffing Information
Penalty
Summary
The facility failed to post accurate daily nurse staffing information, including the total number of actual nursing hours worked and the resident census, for a continuous period from 01/07/2026 through 02/13/2026, totaling 37 days. Surveyor observations on 02/11/2026 at 12:22 PM and on 02/12/2026 at 12:40 PM showed that the daily nurse staffing posting remained dated 01/07/2026. During an observation and interview on 02/13/2026 at 3:10 PM, the Interim Chief Nursing Officer confirmed that the nurse daily staffing posting was still dated 01/07/2026 and acknowledged that it should be updated daily to reflect the actual nurse staffing hours and the facility’s current census. This failure prevented residents and visitors from being able to readily view current nurse staffing information.
Failure to Implement Pressure Injury Prevention Leading to Deep Tissue Injury
Penalty
Summary
A resident with a history of fractured left hip, morbid obesity, and neuropathy was admitted to the facility without any existing pressure injuries but was identified as being at risk for developing them due to limited mobility and incontinence. The care plan specified the use of heel protective devices and off-loading of heels when in bed, and the initial skin inspection documented that green heel boots were placed on both feet. However, subsequent documentation and direct care staff records showed that these interventions were not consistently implemented or documented, and there was no evidence that the resident's heels were off-loaded or that heel protective devices were used as required. Over the course of the resident's stay, staff noted a boggy/soft spot on the left heel, which remained closed and painless initially. Despite this early sign, there was no documentation of preventive interventions being carried out. The resident eventually developed a large, closed blister on the left heel, which was later identified as a deep tissue injury (DTI). The root cause analysis indicated that the injury was due to the resident's heel rubbing on the bed, exacerbated by immobility and the use of a bed that was too small for proper positioning. Interviews and emails from a collateral contact and staff confirmed that heel boots were often not applied, and the resident's heels were observed rubbing against the bed, leading to further skin breakdown. The resident reported significant discomfort and pain from the heel wound, which interfered with rehabilitation efforts. Additional concerns were raised about improper wound care, including staff peeling back dead skin and applying socks over the open wound, which became stuck to the wound. Staff interviews confirmed lapses in documentation and implementation of ordered interventions, and the resident's care records did not reflect consistent use of off-loading boots or other preventive measures as outlined in the care plan.
Infection Control Failures in Hand Hygiene, PPE Use, and Respiratory Equipment Maintenance
Penalty
Summary
Staff failed to comply with infection prevention and control guidelines, as evidenced by multiple observations of a nursing assistant not performing hand hygiene during meal tray delivery. The staff member was seen handling meal trays, touching residents’ personal items and silverware, and assisting with resident care activities without performing hand hygiene before or after these tasks. The staff member also did not demonstrate knowledge of when hand hygiene should be performed during meal pass, and admitted to not performing hand hygiene while passing lunch trays. In another instance, a staff member did not use appropriate personal protective equipment (PPE) when providing care to a resident on enhanced based precautions (EBP) due to an indwelling device. The staff member only wore gloves, despite facility policy and signage indicating the need for additional PPE such as gowns, masks, and eye protection during high-contact care activities. The staff member was unable to explain the purpose of EBP or when it should be implemented, and reported only using gloves when assisting the resident with toileting. Additionally, the facility failed to ensure proper storage and maintenance of oxygen and nebulizer tubing for a resident. Observations revealed that oxygen tubing and a nasal cannula were left touching the floor or stored inappropriately, and nebulizer equipment appeared dirty, was not dated, and was not stored in a plastic bag. Staff interviews indicated inconsistent practices regarding labeling, dating, and storing respiratory equipment, and documentation of tubing changes was not found in the treatment administration record.
Inadequate Supervision Leads to Resident-to-Resident Contact
Penalty
Summary
The facility failed to ensure adequate supervision for a resident with a history of hypersexuality and inappropriate touching, leading to a resident-to-resident sexual contact. Resident 1, who had diagnoses including Parkinson's disease, dementia, and other behavioral disturbances, was on medications known to have side effects that could exacerbate impulsive behaviors. Despite having a care plan in place to manage these behaviors, the facility did not effectively implement the necessary interventions to prevent inappropriate interactions. Resident 1's care plan included interventions such as diverting attention, removing them from situations, and offering activities to minimize disruptive behaviors. However, documentation showed multiple episodes of sexually inappropriate behavior by Resident 1 that were not recorded in the nursing progress notes. This lack of documentation and follow-through on the care plan interventions contributed to the failure to prevent the incident of inappropriate contact with Resident 2, who had dementia and was unable to consent. Interviews with staff revealed that there was a lack of consistent supervision and intervention when Resident 1 was around other residents, particularly female residents. Staff were aware of the need for enhanced supervision but did not consistently maintain line of sight or redirect Resident 1 as required. This oversight allowed Resident 1 to engage in inappropriate contact with Resident 2, highlighting a significant lapse in the facility's duty to protect residents from harm.
Insufficient Nursing Staff Leads to Unmet Resident Needs
Penalty
Summary
The facility failed to provide sufficient nursing staff to meet the needs of residents, as evidenced by the experiences of three residents. Resident 1, who has severe cognitive impairment and is dependent on staff for personal care, was found in a state of undress with their call light and drinks out of reach. Despite the resident's known behavior of rejecting care and language barriers, the situation was not addressed promptly, leaving the resident's needs unmet. Resident 2, who has no cognitive impairment but is at risk for falls due to impaired mobility, reported that their call light went unanswered for over an hour, resulting in an accident. The facility's investigation attributed this to staff miscommunication during breaks. The resident expressed that delays in responding to call lights were frequent, indicating a systemic issue with staffing levels. Resident 4, who has a history of falls and requires assistance for mobility, experienced a similar issue. Their call light was turned off without their needs being addressed, leading them to attempt self-transfer, which is against their care plan. Staff interviews confirmed that there was insufficient staffing to meet residents' needs, with some staff being pulled from their designated duties to cover shortages.
Medication Administration and Physician Consultation Deficiencies
Penalty
Summary
The facility failed to ensure professional standards were met in medication administration and physician consultations, leading to deficiencies in care. During an internet outage, the facility resorted to using printed medication administration records (MARs) instead of electronic records. However, the printed MARs were incomplete, with the first letters of each medication cut off, making it difficult for licensed staff to accurately administer medications. This issue was observed on both the North and South Halls, affecting multiple residents, including Resident 13 and Resident 10. Staff were observed administering medications based on incomplete MARs, relying on pharmacy labels to verify medication orders, which were not a reliable source for confirming physician orders. Resident 13 was administered medications with incomplete MARs, where the names of medications were partially missing, leading to potential medication errors. Staff involved in the medication pass were unaware of the printing issue until it was brought to their attention. Similarly, Resident 10's medication administration was compromised due to the incomplete MARs, with missing parts of physician orders such as medication names, routes, doses, and directions. Staff had to rely on medication labels to identify the correct medications, which posed a risk of errors. Additionally, the facility failed to follow through on a physician's order for a specialist referral for Resident 27, who was experiencing chronic diarrhea. Despite the physician's note indicating the need for a gastrointestinal (GI) specialist consultation, the order was not completed. Staff were unaware of the consultation order, and the resident continued to experience symptoms without appropriate specialist intervention. This oversight further highlights the facility's failure to adhere to professional standards and ensure residents' needs were met.
Failure to Ensure Competency of Nursing Assistants
Penalty
Summary
The facility failed to ensure that Nursing Assistants Certified (NACs) possessed the necessary competencies, skills, and proficiencies to provide nursing and related services to residents. This deficiency was identified during interviews and record reviews, where it was found that five sampled staff members (Staff H, I, Q, R, and S) did not have documented assessments of their competencies to provide nursing services. The facility's policy, dated November 28, 2017, required validation of nurse aides' competencies in skills and techniques, but this was not adhered to. The facility's assessment, dated July 26, 2023, to July 25, 2024, indicated that education was provided through orientation, monthly competencies, and annual skills fairs, with monitoring through senior leader rounding and mentorship programs. However, interviews with Staff B, a Registered Nurse/Clinical Resource Nurse, and Staff A, the Director of Nursing Services, revealed that competencies for the staff had not been completed, and no documentation could be located for the five staff members. This lack of competency assessment placed residents at risk for unmet care needs and a diminished quality of life.
Infection Control Deficiencies in Medication Administration and Laundry Handling
Penalty
Summary
The facility failed to ensure compliance with Infection Prevention and Control Guidelines during medication administration by a Licensed Practical Nurse (LPN). The LPN did not use a barrier when placing medication items on a resident's bed and over the bed table, and failed to perform hand hygiene before and after administering medications, including insulin and nasal spray. The LPN admitted to forgetting to use a barrier and only performed hand hygiene after leaving the resident's room. In the laundry room, the facility did not have a system in place for handling potentially contaminated linens to prevent cross-contamination. The housekeeping attendant was observed sorting and loading dirty linen without a clear procedure for cleaning the washing machines between loads. The laundry room was cluttered, with limited space for clean linen, and the machines were covered in dust and debris. The housekeeping manager, recently promoted, was unaware of any infection control procedures related to laundry. The facility's infection control program had not been reviewed or revised since October 2022, and no risk assessment had been conducted. The Infection Preventionist acknowledged the lack of a risk assessment and the failure to educate staff on proper infection control practices. The Director of Nursing Services was unaware of the deficiencies in the infection control program and the lack of training for the housekeeping manager.
Failure to Provide Saturday Mail Access
Penalty
Summary
The facility failed to ensure residents had access to Saturday mail deliveries, affecting two of the six sampled residents. According to the facility's policy on Resident Rights, residents are entitled to private and unrestricted communication, including the right to receive sealed, unopened correspondence. Resident 27, who has moderate cognitive impairment, reported receiving an email notification about mail delivery on Saturday but was unable to access the mail until later. Resident 2, with no cognitive impairment, confirmed that while the postal service delivers mail on Saturdays, it is not distributed to residents until Mondays. Staff interviews corroborated that mail is retrieved on weekends but not distributed until the following Monday, as confirmed by Staff M from the Business Office and Staff N, a Hospitality Aide.
Deficiencies in Resident Assessment and Care Planning
Penalty
Summary
The facility failed to ensure that the Resident Assessment Instrument (RAI) included comprehensive summaries of the Care Area Assessments (CAA) for three residents, which are essential for analyzing and planning individualized care. For Resident 4, the significant change Minimum Data Set (MDS) assessment did not include input from the resident's representative and lacked a comprehensive assessment of the resident's needs, strengths, goals, life history, or preferences in areas such as cognitive loss/dementia, behavioral symptoms, mood state, and psychotropic drug use. Similarly, for Resident 9, the annual MDS assessment was missing input from the resident's representative and did not provide a comprehensive assessment in the cognitive loss/dementia and psychotropic drug use CAAs. Resident 33 experienced issues with their upper denture not fitting, which was not addressed in the admission MDS dental section, leading to the Dental CAA not being triggered or completed. This oversight occurred despite the resident's care plan indicating the need for dental care coordination. Interviews with staff revealed that the MDS assessments were completed remotely, and there was a lack of comprehensive documentation in the CAAs, with some staff unaware of the issues until recently. The failure to properly assess and document the residents' needs placed them at risk of not receiving appropriate services based on their individualized needs.
Inadequate Catheter Care Increases Risk of CAUTIs
Penalty
Summary
The facility failed to provide appropriate care for a resident with an indwelling urinary catheter, leading to an increased risk of catheter-associated urinary tract infections (CAUTIs). The facility did not develop individualized plans for the prevention of CAUTIs, including specific clinical indications for changing catheters and catheter bags. Instead, the facility followed routine procedures for changing catheters and flushing the catheter system, which is contrary to the guidelines provided by the Centers for Disease Control (CDC) and the facility's own policy. These guidelines recommend changing catheters and drainage bags based on clinical indications such as infection or obstruction, rather than at routine, fixed intervals. Resident 3, who had a chronic suprapubic catheter due to a neuromuscular dysfunction of the bladder, was readmitted to the facility after hospitalization for a urinary tract infection. Observations revealed that the resident's urine was dark yellow with sediment, indicating potential issues with catheter care. The facility's records showed that the resident's catheter was changed monthly and flushed three times a week without documented clinical indications. Interviews with staff confirmed that these routine practices were not aligned with best practices for preventing CAUTIs, and the resident was not informed about the increased risk of infection due to these practices.
Failure to Prevent Unnecessary Drug Administration
Penalty
Summary
The facility failed to ensure that Resident 10's drug regimen was free from unnecessary medications by not documenting the use of non-pharmacological interventions before administering PRN pain medication. Resident 10, who was admitted with severe cognitive impairment and diagnoses including cancer of the pancreas and malignant neuroendocrine tumors, had a care plan that required non-pharmacological interventions to be attempted prior to administering Morphine Sulfate for pain. However, records from June and July 2024 showed multiple instances where the medication was administered without documentation of such interventions. Interviews with staff indicated that while non-pharmacological methods were reportedly attempted, they were not consistently documented as required. Additionally, the facility failed to follow hold orders for bowel medications for Resident 3, who had irritable bowel syndrome with diarrhea. Despite the resident experiencing frequent diarrhea, facility nurses continued to administer Senna and Docusate Sodium, which were ordered to be held in the presence of loose stools. This resulted in the resident receiving unnecessary bowel medications. Interviews with staff confirmed that the medications should have been held according to the orders, but this was not done, leading to the administration of 29 doses of Senna and 56 doses of Docusate Sodium unnecessarily.
Failure to Document Urinary Catheter Output
Penalty
Summary
The facility failed to maintain complete and accurate clinical records for a resident who was reviewed for urinary catheter care and services. The resident, who had no cognitive impairment and was diagnosed with neuromuscular dysfunction of the bladder, was readmitted to the facility after hospitalization for a urinary tract infection secondary to a chronic suprapubic catheter. An order was placed on the resident's Treatment Administration Records (TARs) to measure and record the indwelling catheter urinary output every shift for hydration purposes. However, from July 14 to July 25, 2024, there was no documentation of urinary output for six shifts. During an interview, a Licensed Practical Nurse/Resident Care Manager was unable to provide information about the missing documentation for these six shifts and stated they would need to look into it, but no additional information was provided.
Failure in Antibiotic Stewardship Program Implementation
Penalty
Summary
The facility failed to implement its Antibiotic Stewardship Program (ASP) effectively, as evidenced by the case of Resident 3. Resident 3 was readmitted to the facility after a hospitalization for a urinary tract infection (UTI) related to a chronic suprapubic catheter. Upon discharge, the resident was prescribed amoxicillin-clavulanate, an antibiotic, to be taken twice daily for five days. However, the facility's medical records lacked any clinical indication, laboratory, or culture results to justify the use of this antibiotic. There was no analysis or validation to confirm the presence of an active infection, which is a critical step in the ASP to prevent unnecessary antibiotic use. Interviews with facility staff revealed gaps in the ASP's implementation. Staff G, the LPN/Infection Preventionist, acknowledged their responsibility to ensure proper antibiotic usage and indication but admitted to being unable to locate any documentation or analysis for Resident 3's antibiotic use. Furthermore, Staff A, the Director of Nursing Services, was unaware that the prescribed antibiotic for Resident 3 had not been reviewed for proper indication. This oversight indicates a failure in the communication and verification processes between the infection preventionist, resident care manager, and providers, which are essential components of the ASP.
Deficiency in NAC Annual Training Hours
Penalty
Summary
The facility failed to develop, implement, and maintain an in-service training program to ensure that Nursing Assistants Certified (NACs) received the required 12 hours of annual training. Specifically, two NACs, Staff H and Staff I, did not complete the mandated training hours. Staff H, hired in February 2022, lacked documentation of completing the required 12 hours of training for the period from February 2023 to February 2024. Similarly, Staff I, hired in August 2023, had only completed 6.10 hours of education by July 30, 2024, falling short of the required 12 hours. This deficiency was identified through a review of employee records and confirmed in an interview with the Director of Nursing Services (DNS), who acknowledged the expectation for NACs to complete the annual training requirement.
Deficiency in Diabetic Management for a Resident
Penalty
Summary
The facility failed to provide adequate care and services for a resident with diabetes mellitus type 2, resulting in a significant deficiency in managing the resident's blood glucose levels. The resident, who was cognitively intact, experienced a hypoglycemic episode with a blood glucose level as low as 47 mg/dL. Despite having a continuous glucose monitoring system, the resident's hypoglycemic episode was not documented in the progress notes, and the physician was not notified until 26 days later, leading to a delay in adjusting the resident's insulin order. The resident reported feeling fearful during the hypoglycemic episode, which occurred in the early morning hours. The resident's glucose monitor alarmed, but no staff responded to the call light, prompting the resident to seek help independently. The resident wheeled themselves to the nurse's station, where they were given juice and a peanut butter and jelly sandwich, but it took about an hour for their blood glucose to return to an acceptable range. The incident was not documented in the resident's clinical record, and the continuous glucose monitoring system's data was not cross-referenced with the medical record. Interviews with staff revealed inconsistencies in the reporting and documentation of the resident's low blood glucose levels. Staff members were unable to recall specific details of the incident, and there was no policy or procedure in place for using or gathering information from the continuous glucose monitoring system. The lack of documentation and timely notification to the physician placed the resident at risk for further complications and highlighted a deficiency in the facility's diabetic management practices.
Failure to Address Behavioral Health Needs
Penalty
Summary
The facility failed to ensure the behavioral health needs of Resident 2 were identified and met. Resident 2, who was admitted with diagnoses including hip fracture, leukemia, chronic pain, anxiety disorder, and adjustment disorder with depressed mood, exhibited significant post-operative disorientation, agitation, and confusion. Despite these symptoms, the facility did not adequately address Resident 2's behavioral health needs. The resident's care plan included interventions for antidepressant and hypnotic medication use, but non-pharmacological interventions were not documented, and episodes of restless agitation were not reported to the provider. Additionally, Resident 2 experienced multiple episodes of depressive statements, refusal of care, withdrawal from activities, and disrobing, which were not effectively managed or documented by the staff. Resident 2's behavioral health concerns were not consistently addressed by the facility's medical staff. Progress notes from various medical professionals, including doctors and nurse practitioners, did not document or address Resident 2's behavioral health symptoms. Despite the resident's ongoing confusion, restlessness, and refusal of care, the facility's staff did not implement or document effective person-centered behavioral interventions. Interviews with staff members revealed a lack of consistent reporting and documentation of Resident 2's behavioral health issues, with some staff members stating that interventions were vague and not specific to the resident's needs. Observations and interviews with Resident 2 and staff members highlighted the resident's ongoing distress and unmet needs. Resident 2 was frequently found lying in bed uncovered and undressed, with their call light out of reach. The resident reported feeling neglected and in pain, with staff members failing to respond to their calls for help. Staff interviews indicated that behavioral interventions were not effectively communicated or implemented, and the resident's refusal of care and other behavioral symptoms were not adequately addressed. The facility's failure to identify and meet Resident 2's behavioral health needs resulted in a diminished quality of life for the resident.
Failure to Ensure Timely Medication Administration for New Admissions
Penalty
Summary
The facility failed to ensure pharmacy services were provided to meet the needs of three residents upon their admission. Resident 1, who was admitted with diagnoses including aftercare for heart bypass surgery, anxiety, and depression, did not receive their prescribed tramadol for pain management on the day of admission. The medication was only administered the following day, causing the resident to experience significant pain. The facility's process for acquiring and administering the medication was not followed, leading to a delay in pain relief for the resident. Resident 2, admitted with diagnoses including diabetes and leukemia, did not receive their prescribed medications, Steglatro and Imatinib Mesylate, on the scheduled dates. The MAR showed that the medications were not administered due to a need for prior authorization and high cost, which was only approved later in the day. This delay in medication administration was not properly documented or communicated, resulting in missed doses for the resident. Resident 3, admitted with a diagnosis of Parkinson's disease, did not receive their prescribed carbidopa-levodopa medication until the day after admission. The facility's staff failed to ensure the timely administration of this critical medication, which is essential for managing the resident's condition. Interviews with staff revealed inconsistencies in the medication administration process and a lack of proper documentation, contributing to the deficiencies observed in the care of these residents.
Unsanitary Shower Room Conditions
Penalty
Summary
The facility failed to provide a clean and sanitary environment in the residents' shower room, which negatively impacted Resident 4's desire to bathe. During an interview, Resident 4 described the shower room as filthy, with black grout and a dirty tub, leading them to prefer bed baths over showers. Observations confirmed the presence of black debris on the threshold and north wall of the shower room. Staff C, a Nursing Assistant Certified, mentioned that they only wiped down the shower stall with sanitizer wipes after each use and noted that housekeeping cleaned the shower room weekly. Staff D from housekeeping acknowledged the presence of built-up grime and attributed it to the building's age. The tub was also noted to be non-functional, contributing to the unsanitary conditions.
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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