Judson Park Health Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Des Moines, Washington.
- Location
- 23620 Marine View Drive South, Des Moines, Washington 98198
- CMS Provider Number
- 505455
- Inspections on file
- 20
- Latest survey
- August 28, 2025
- Citations (last 12 mo.)
- 50
Citation history
Health deficiencies cited at Judson Park Health Center during CMS and state inspections, most recent first.
The facility did not obtain or maintain required advance directive and guardianship documentation for several residents with cognitive impairment or complex medical needs. Despite verbal reports and admission paperwork indicating the existence of such documents, staff failed to ensure these were present in the medical records, and care plans lacked specific information about advance directives or decision-makers. Staff interviews confirmed that there was no consistent follow-up to secure or file these critical documents.
The facility did not consistently provide or document required written transfer/discharge notices, bed hold policies, or notification of appeal rights and LTCO contact information to residents being transferred to hospitals. In several cases, forms were unsigned or missing, and staff were unaware of the requirements. Additionally, discharge planning was inadequately documented for some residents who wished to return to the community, with gaps in communication and progress notes.
The facility did not ensure accurate PASRR screenings or timely Level II referrals for several residents with serious mental illness indicators, including those admitted under hospital exemptions who remained beyond 30 days. Residents with diagnoses such as depression and anxiety, and who were receiving psychotropic medications, were not properly identified or referred for further evaluation as required.
Several residents did not receive timely care conferences or have their care plans updated as required, with documentation missing for quarterly or admission care conferences and incomplete care plan revisions following changes in condition. Residents with complex medical needs were not given opportunities to participate in care planning, and staff did not consistently document or conduct these processes according to facility policy.
The facility did not follow physician orders or professional standards for wound care, skin assessments, and documentation for several residents, including those with abrasions, surgical wounds, and on anticoagulant therapy. Staff also failed to monitor and notify providers about low blood pressure readings for a resident with a pacemaker, with unclear care plan parameters and lack of documentation of interventions or notifications.
A resident with neurological and memory impairments reported that their roommate's belongings blocked access to shared spaces, but staff did not initiate or document a grievance as required by policy. Multiple staff members were either unaware of the complaint or did not act on it, resulting in the resident's concerns remaining unresolved and unaddressed.
Three residents received psychotropic medications without required monitoring for target behaviors, nonpharmacological interventions, or documented consent. Staff did not document behavior monitoring or obtain consent for antianxiety medication, and care plans lacked nonpharmacological approaches, as confirmed by nurse supervisors.
The facility did not ensure accurate MDS assessments for several residents, resulting in discrepancies between documented clinical events—such as falls, depression diagnoses, behavioral issues, and cognitive changes—and what was recorded in the MDS. Staff interviews confirmed that updates were not made to reflect residents' actual conditions, despite supporting documentation in medical records and care plans.
The facility did not complete required PASRR Level II evaluations for three residents who exhibited or developed signs of serious mental illness or behavioral issues. Despite documented cognitive impairment, behavioral changes, and new psychiatric symptoms, staff did not initiate updated screenings or referrals as required by policy. Staff interviews revealed a lack of understanding of when to repeat the PASRR process after changes in condition.
Surveyors found that staff did not clarify or follow physician orders for several residents, including missing medication parameters, incomplete dosage instructions, and failure to document required assessments before medication administration. Staff also signed off on tasks that were not performed, such as removing a brace from a resident who was no longer using it and documenting infection control precautions that were not in place. These deficiencies were confirmed through interviews and record reviews.
The facility did not ensure that activity programs met the individualized needs of several residents, resulting in minimal participation, lack of invitations or assistance to attend activities, and insufficient documentation of engagement or refusals. Residents who valued music, reading, socializing, and pet visits were often left without meaningful activities, leading to boredom and reduced quality of life.
A resident did not receive appropriate care for existing pressure ulcers, and the facility failed to implement effective measures to prevent new ulcers from developing. Surveyors found that necessary interventions, assessments, and monitoring were not consistently provided, resulting in the occurrence and worsening of pressure ulcers.
Surveyors found that the facility did not keep an area free from accident hazards and failed to provide adequate supervision to prevent accidents, resulting in a deficiency.
Three residents with complex medical conditions and pain from fractures or catheter issues did not receive comprehensive pain management. Staff administered pain medications but failed to assess pain thoroughly, investigate underlying causes, or offer non-pharmacological interventions as required by facility policy. Care plans and medication records lacked documentation of alternative pain relief methods, and staff interviews confirmed these omissions.
A resident with a history of trauma, depression, and moderate memory impairment did not have a trauma-informed care plan developed, despite documented assessments and recommendations. The care plan failed to address the resident's trauma history, identify triggers, or include prevention strategies, and staff confirmed that trauma-informed interventions were not initiated as expected.
Surveyors found that medications were not properly labeled, stored, or secured in the facility. Expired and undated medications were observed in medication rooms and carts, and a resident had unsecured prescription eye drops at their bedside. Staff confirmed these practices did not follow facility policy for medication labeling, expiration, and security.
A resident with significant dental issues, including broken and decayed teeth and mouth pain, did not receive timely dental services despite a care plan and physician order for a dental consult. Although a referral for dental evaluation and extractions was made, there was no documentation that the referral was sent or that an appointment was scheduled, resulting in a prolonged lack of follow-up.
Surveyors found that food items in both the skilled nursing and main kitchens were not properly labeled with expiration or open dates, and some were past their expiration date. Several staff members with facial hair were observed preparing food without required beard nets. Staff interviews confirmed these practices were not in line with facility policy, which mandates proper labeling and use of hair restraints to prevent contamination.
Nurses failed to sign the MAR for a resident's scheduled thyroid medication on two occasions, resulting in incomplete documentation. Additionally, hospice provider notes were not added in a timely manner for two residents receiving hospice care, with the last available notes being over three weeks old despite ongoing visits. Staff confirmed the expectation for timely and complete recordkeeping.
Staff did not consistently use required PPE or perform proper hand hygiene for residents on Enhanced Barrier Precautions and Transmission Based Precautions, including those with feeding tubes, indwelling catheters, and C. difficile infection. Staff entered rooms without donning gowns and gloves, failed to wash hands with soap and water as directed, and did not change gloves between care tasks. Additionally, a resident used a wheelchair with uncleanable, damaged surfaces, further compromising infection control.
The facility did not ensure that contact information for State regulatory and advocacy groups was accessible to residents, as observed during a Resident Council meeting. Despite being included in the admission packet, residents were unaware of where to find this information. Observations on two nursing units confirmed the absence of posted contact details, which staff attributed to oversight during a remodel. The DON acknowledged the requirement for visible posting of this information.
The facility failed to document and communicate necessary resident information to receiving healthcare institutions during transfers for three residents. This deficiency was identified through interviews and record reviews, revealing that required information was not provided during hospital transfers. Staff members, including the DON and Assistant DON, acknowledged the lack of communication and documentation in the residents' medical records.
The facility failed to provide required written transfer/discharge notifications to residents and their representatives, and did not notify the LTCO for five residents who were hospitalized. This deficiency was confirmed through interviews and record reviews, revealing a lack of documentation for these notifications.
The facility failed to provide written notice of its bed hold policy to residents or their representatives during hospital transfers, as required by their policy. This deficiency affected five residents who were hospitalized, with no documentation of bed hold discussions or offers. Staff interviews confirmed the lack of documentation and the importance of offering a bed hold as a resident right.
The facility failed to update care plans for three residents, leading to outdated or missing care instructions. A resident with a removed indwelling catheter still had outdated care instructions, another resident lacked a care plan for bowel and bladder needs despite observations of independent toileting attempts, and a third resident's care plan lacked specific instructions for catheter care. Additionally, a resident was not involved in a care conference, leaving them uninformed about their care interventions.
The facility failed to administer medications as ordered for two residents undergoing dialysis, missing doses due to the residents being out for treatment. There was no communication with the provider to adjust medication timing, as expected by staff.
The facility failed to ensure sanitary conditions in food storage and preparation. A resident's refrigerator contained spoiled food past the use-by date, and the main kitchen had unlabeled and improperly stored food items. Additionally, a Food Service Worker did not perform hand hygiene or change gloves between tasks, increasing the risk of food contamination.
The facility failed to timely investigate incidents involving two residents, one with stage three pressure ulcers and another with falls, contrary to policy requirements. Investigations were delayed beyond the five-day requirement, leaving potential risks of repeated incidents and unidentified abuse or neglect. Staff interviews confirmed the lack of timely and thorough investigations.
The facility failed to accurately complete MDS assessments for two residents, missing bilateral hand contractures in one and the use of a wander guard device in another. The MDS Coordinator confirmed these inaccuracies, which affected the residents' care plans and device use documentation.
The facility failed to provide necessary ADL assistance for two residents, leading to unmet care needs. A resident with heart failure and brain injury was left with food remnants on their face and bedding after a meal, while another resident with right-sided weakness had long fingernails growing into their palm, risking skin impairment. Staff acknowledged these oversights, highlighting the need for proper hygiene and grooming care.
A resident at risk for pressure ulcers did not receive physician-ordered off-loading boots, leading to the development and worsening of stage three pressure ulcers. Despite recommendations from the wound care team, the facility failed to implement the necessary interventions, and documentation was lacking to support any trial or failure of the boots. Staff interviews confirmed the oversight, and weekly skin assessments were delayed.
A resident with memory impairment and a history of hip fracture was inaccurately assessed for bowel and bladder needs, leading to unmet care requirements. Despite being assessed as occasionally incontinent and unable to reach the bathroom independently, the resident was observed attempting to crawl to the bathroom multiple times. Staff interviews confirmed the resident's confusion and failure to use the call light, but the assessment was not updated to reflect these needs.
The facility failed to attempt alternatives before using bed rails and did not conduct necessary assessments or obtain informed consent for three residents. One resident with a brain injury and contracted hands had side rails that were not appropriate for their condition. Another resident, capable of independent mobility, had side rails without updated evaluations. A third resident, also independent, had side rails despite a fall incident, with no recent assessment to justify their use.
The facility failed to maintain a medication error rate below 5%, resulting in an 8% error rate. A resident received blood pressure medication despite a heart rate below the prescribed parameter, and another resident was given incorrect eye drops. Staff acknowledged the errors, highlighting a need for better verification against physician orders.
The facility failed to provide correct meal portion sizes for therapeutic diets to two residents. One resident with unstable blood sugar levels received a full dessert portion instead of a half portion, and another resident was served mechanically soft ground meats without following portion size guidelines. Staff approximated serving sizes without proper guidance, leading to incorrect portions.
The facility failed to maintain complete and accurate records for two residents with memory impairments. Both residents had expired legal guardianship documents, yet the guardians were still listed as active in the records. This oversight was confirmed by the Social Service Director.
The facility failed to maintain proper infection control as staff did not adhere to hand hygiene protocols. A CNA provided care to a resident without changing contaminated gloves, and CNAs assisted residents with meals without washing hands after touching surfaces. The Infection Preventionist confirmed these lapses, highlighting the need for hand hygiene to prevent infection.
Failure to Obtain and Maintain Advance Directives and Guardianship Documentation
Penalty
Summary
The facility failed to obtain, maintain, or renew guardianship papers and advance directive (AD) documentation for six residents reviewed for these requirements. According to facility policy, the social services director or designee is responsible for inquiring about and obtaining ADs prior to admission, maintaining these documents in the medical record, and ensuring the care plan reflects the resident's preferences. However, for multiple residents with cognitive impairments, complex medical conditions, or on hospice care, there was no evidence in their records of the required AD or durable power of attorney (DPOA) paperwork, despite documentation or verbal reports indicating such documents existed or were in process. For example, one resident with non-Alzheimer’s dementia stated their daughter was their DPOA, but the facility did not have the paperwork on file, even though a physician's note referenced consulting the DPOA. Another resident on hospice care had a consent form indicating a POA, but no POA paperwork was found in the record. In several cases, admission or social service assessments noted that a family member was the POA or that AD documents were being provided, but there was no follow-up or documentation that these documents were ever received or maintained in the resident's file. Care plans often referenced following resident preferences, but lacked specific documentation of ADs or who to contact for health decisions. Interviews with staff revealed that while the admissions nurse or social worker was expected to obtain ADs, there was no consistent follow-up to ensure the documents were actually received and filed. Staff acknowledged that ADs were important for honoring resident preferences and for knowing who to contact in emergencies, but confirmed that the necessary paperwork was missing from the records of the affected residents. This lack of documentation was observed across multiple residents with varying degrees of cognitive impairment and medical complexity.
Failure to Provide Required Transfer Notices, Bed Hold Policies, and Discharge Planning Documentation
Penalty
Summary
The facility failed to provide required written notices and documentation to residents at the time of transfer or discharge, as well as to offer bed hold policies and notify the Long Term Care Ombudsman (LTCO) as required. In several instances, residents were transferred to hospitals without receiving signed transfer or discharge notices. For example, one resident was discharged to the hospital, but the transfer notice was not signed by either the administrator or the resident/representative, and staff could not locate a signed form. In other cases, transfer/discharge forms were signed only by facility staff, with no evidence that the resident or their representative received or acknowledged the notice. Staff interviews confirmed that the expected process was not consistently followed, and some staff were unaware of the requirements for providing these notices. The facility also failed to provide or document the offering of bed hold notices to residents or their representatives when residents were transferred to hospitals. In multiple cases, there was no evidence in the medical records that bed hold policies were discussed or offered, and staff interviews confirmed that these forms were not completed or could not be located. Additionally, one resident was transferred to an acute care hospital without being provided a notice of transfer that included appeal rights and LTCO contact information. Staff acknowledged that it was not their practice to provide such notices, indicating a lack of awareness of regulatory requirements. Discharge planning was also insufficiently documented for some residents who expressed a desire to return to the community. In these cases, initial assessments indicated discharge goals and potential barriers, but there was no ongoing documentation of pre-discharge planning or progress notes by social services. Residents reported not being informed about their discharge plans, and staff confirmed that expected documentation and communication regarding discharge planning were missing from the records.
Failure to Complete Accurate PASRR Assessments and Timely Level II Referrals
Penalty
Summary
The facility failed to ensure that Pre-admission Screening and Resident Review (PASRR) assessments were accurate, revised, or submitted for Level II evaluation as required for several residents with indicators of Serious Mental Illness (SMI) or related conditions. In multiple cases, residents were admitted with documented diagnoses such as depression, anxiety, and mood disorders, and were receiving psychotropic medications, yet their Level I PASRR screenings either did not identify these SMI indicators or, when identified, did not result in the required Level II referral. For example, one resident with a mood disorder and on antidepressant medication was not referred for a Level II PASRR despite the SMI indicator being present on the Level I screening. Staff interviews confirmed that these referrals should have been made but were not completed as required. Additionally, the facility did not submit new or revised PASRR Level I screenings for residents who were admitted under a 30-day hospital exemption but remained in the facility beyond the exemption period. In these cases, residents with SMI indicators, such as mood or anxiety disorders and use of psychotropic medications, were not referred for Level II PASRR evaluations after their stays extended past 30 days. Staff acknowledged that the process required a new Level I PASRR and referral for Level II evaluation in such situations, but this was not done for the affected residents. Record reviews and staff interviews consistently showed that the facility's PASRR process failed to accurately identify residents with SMI indicators and did not ensure timely referrals for Level II evaluations as required by regulation. This resulted in residents with mental health needs not being properly assessed for appropriate placement and services during their stay.
Failure to Conduct Timely Care Conferences and Update Care Plans
Penalty
Summary
The facility failed to conduct timely and comprehensive care conferences and to update care plans as required, resulting in deficiencies in person-centered care for several residents. For three residents, there was no evidence that care conferences were held quarterly or upon admission, as required by facility policy. One resident reported not having a care conference for nearly nine months, and another did not recall any care plan meeting since admission. Documentation for these residents lacked input from all relevant departments, such as therapy, dietary, and nursing, and did not address all aspects of their care needs and preferences. Additionally, the facility did not ensure that care plans were updated and revised as needed for two residents. In one case, a care plan revision following a fall did not specify the frequency of range of motion checks or neurological assessments, leaving staff without clear guidance on the resident's care requirements. Staff interviews confirmed that care conferences and care plan updates were not consistently documented or conducted according to policy, and that these processes are essential for ensuring all departments and the resident are informed and able to address concerns. The residents involved had complex medical histories, including recent admissions with conditions such as hip fractures, malnutrition, major infections, and wounds. Despite being cognitively intact and able to participate in care planning, these residents were not provided with the opportunity to engage in care conferences or have their care plans updated to reflect their current needs. Facility policy required resident and representative participation in care planning, with advanced notice and documentation, but these procedures were not followed.
Failure to Provide Person-Centered Care and Monitoring for Skin Conditions and Low Blood Pressure
Penalty
Summary
The facility failed to provide care and services in accordance with residents' goals and professional standards of practice in several areas, including the management of non-pressure skin conditions and monitoring of low blood pressure. For multiple residents, staff did not follow physician orders or facility policy regarding wound care, skin assessments, and documentation. One resident was found with a bandage on their elbow that had not been changed for nine days after the treatment order was discontinued, and staff failed to document weekly skin assessments as required. Another resident on anticoagulant therapy exhibited multiple bruises, but staff did not document or report these as adverse reactions, nor did they clarify or follow orders for skin checks and provider notification. A resident with a surgical wound did not have weekly skin assessments or wound measurements documented for nearly four weeks, despite orders and care plan directives. Another resident, who was on hospice and at risk for pressure ulcers, had a bandage on their forehead, but staff did not include this resident in weekly wound rounds or document required skin assessments, wound measurements, or refusals. The documentation in the treatment administration record was unclear, and staff could not provide evidence that assessments were completed as expected. Additionally, the facility failed to monitor and notify the provider regarding low blood pressure readings for a resident with a history of low BP and a pacemaker. The care plan lacked clear parameters for when to notify the provider, and staff did not document interventions or notifications for multiple low BP readings. Interviews with staff revealed a lack of understanding about when to notify the provider and an absence of instructions in the care plan or medication administration record. No documentation was provided to show that the provider was informed or that interventions were implemented in response to low BP readings.
Failure to Initiate and Resolve Resident Grievance Regarding Roommate Encroachment
Penalty
Summary
The facility failed to initiate, investigate, and resolve a grievance for a resident who reported ongoing issues with their roommate encroaching on their personal space and cluttering shared areas. The resident, who had neurological conditions, memory impairment, and required assistance with personal hygiene, stated that their access to the closet, sink, and bathroom was obstructed by their roommate's belongings. Despite informing nursing staff on several occasions, the resident received no follow-up or resolution, and no grievance report was completed as required by facility policy. Observations confirmed the clutter and obstruction in the room, and interviews with staff revealed a lack of awareness or action regarding the resident's complaints. Staff members, including a CNA, social services, nurse supervisor, and DON, acknowledged either being unaware of the specific grievance or failing to complete the necessary grievance documentation. The facility's policy required staff to complete a grievance form for any resident concern or complaint, forward it to appropriate departments, and provide feedback to the resident. However, in this case, the process was not followed, and the resident's concerns were not formally addressed or tracked, resulting in unresolved issues and lack of communication with the resident.
Failure to Monitor and Document Psychotropic Medication Use
Penalty
Summary
The facility failed to ensure that residents were free from unnecessary psychotropic medications, as evidenced by the lack of monitoring for target behaviors, absence of nonpharmacological interventions, and missing consent for medication use in three out of five residents reviewed. For one resident with depression, records showed daily administration of an antidepressant without documentation of target behaviors or nonpharmacological interventions, and the care plan did not address these areas. A nurse supervisor confirmed that staff were not monitoring or implementing nonpharmacological approaches for this resident. Another resident with depression received an antidepressant daily, but staff did not document behavior monitoring as required, despite the care plan directing such monitoring. The resident expressed emotional distress during an interview, and a nurse supervisor acknowledged the absence of behavior monitoring documentation. A third resident with anxiety and depression was administered both antidepressant and antianxiety medications without behavior monitoring or documented consent for the antianxiety medication. Staff interviews confirmed the lack of required documentation and consent for these psychotropic medications.
Inaccurate MDS Assessments for Multiple Residents
Penalty
Summary
The facility failed to ensure that the Minimum Data Set (MDS) assessments accurately reflected the clinical status and care needs of five residents. For one resident, the MDS incorrectly documented multiple falls, including injury and major injury falls, when the incident reports only supported one fall and one non-fall injury. Additionally, the MDS did not accurately reflect the resident's active diagnosis of depression, despite physician documentation and ongoing antidepressant therapy. Another resident's MDS failed to include an active diagnosis of depression, even though the care plan and medication administration records indicated daily antidepressant use for depression. For a third resident, the MDS did not capture behavioral issues or cognitive changes, despite progress notes and assessments indicating confusion, hallucinations, and serious mental illness indicators. Staff interviews confirmed a lack of awareness and failure to update the MDS in response to these documented changes. Two additional residents had MDS assessments that did not reflect significant behavioral incidents or cognitive changes. One resident had documented episodes of attempted elopement, verbal and physical aggression, and medication non-compliance, none of which were captured in the MDS. Another resident with intermittent confusion, delusional thought content, and a diagnosis of moderate dementia with psychotic disturbance was not accurately represented in the MDS regarding behaviors and cognition. Staff interviews revealed that updates to the MDS were not made despite clear documentation of these issues in the residents' records.
Failure to Complete Required PASRR Level II Evaluations for Residents with Mental Health Indicators
Penalty
Summary
The facility failed to ensure that Pre-admission Screening and Resident Review (PASRR) Level II comprehensive evaluations were obtained for three residents who exhibited or developed indicators of serious mental illness or behavioral issues. According to facility policy, all new admissions and readmissions should be screened for mental, intellectual, or related disorders, and if a Level I PASRR indicates possible mental health needs, a referral for a Level II evaluation must be made. However, for three residents, this process was not followed as required. One resident with cognitive impairment and depression had documented behavioral issues, confusion, and hallucinations, but no Level II PASRR referral was made despite these indicators. Another resident with chronic medical conditions and a history of behavioral problems, including elopement attempts, aggression, and medication refusal, was not rescreened or referred for a Level II PASRR after significant changes in behavior. Staff interviews revealed a lack of awareness regarding the need to repeat the PASRR process following changes in condition. A third resident with impaired cognitive function and delusional thoughts, including recent psychotic disturbances, was also not rescreened or referred for a Level II PASRR after new symptoms emerged. Staff acknowledged uncertainty about the requirements for rescreening and the Level II PASRR process, and confirmed that screenings and referrals should have been completed for these residents but were not. This failure was identified through observation, interview, and record review, and was found to be inconsistent with both facility policy and regulatory requirements.
Failure to Clarify and Follow Physician Orders and Accurate Documentation
Penalty
Summary
The facility failed to ensure that physician orders were properly clarified and followed, and that staff only signed for tasks that were actually completed, as evidenced by multiple observations, interviews, and record reviews. For several residents, medication orders lacked necessary parameters or dosage information, such as pain medication orders without pain level parameters, a suppository order referencing a laxative that was not ordered, and supplement orders missing dosage amounts. Additionally, there was a failure to document required assessments, such as not recording heart rates before administering blood pressure medication, and staff confirmed that these orders required clarification. Further deficiencies included staff administering medication outside of prescribed parameters, such as giving blood pressure medication when a resident's heart rate was below the specified threshold. Staff also documented completion of tasks that were not performed, including recording the removal of a chest brace for a resident who was no longer using it and documenting contact precautions for a resident who was not on such precautions. These actions were confirmed through staff interviews and record reviews, indicating a lack of adherence to professional standards and facility policy.
Failure to Provide Individualized Activity Programs
Penalty
Summary
The facility failed to ensure that activity programs met the individualized needs and preferences of five out of seven residents reviewed for activities. According to facility policy, each resident should have an activity evaluation incorporated into their care plan, facilitating participation in preferred activities. However, multiple residents expressed that they were not invited to activities, were unaware of scheduled events, or did not receive materials or assistance to participate in their chosen activities. Documentation showed minimal or no activity participation for these residents over a 30-day period, with no refusals recorded. Specific observations and interviews revealed that residents who valued activities such as listening to music, being around animals, reading, socializing, and attending religious services were often left in their rooms without engagement. For example, one resident was observed lying in bed and stated that lying in bed all day was not fulfilling, while another resident expressed boredom and a desire for more reading materials and pet visits. Several residents were not present at group activities, and staff interviews confirmed that there was a lack of consistent invitation and assistance for residents to attend scheduled activities, especially for those dependent on staff support. Activity documentation was inconsistent, with some residents only receiving one-to-one activities on rare occasions and others having no documented participation or refusals. Staff interviews indicated that the process for inviting and assisting residents to activities relied heavily on nursing assistants, and there was a lack of clear communication and follow-through. Additionally, scheduled activities sometimes started earlier than posted, causing residents to miss out. The failure to provide meaningful and individualized activities as outlined in care plans resulted in residents experiencing boredom and a diminished quality of life.
Failure to Provide and Prevent Pressure Ulcer Care
Penalty
Summary
The facility failed to provide appropriate care for pressure ulcers and did not implement effective measures to prevent the development of new ulcers. This deficiency was identified through surveyor observations and documentation review, which indicated that residents were not consistently receiving necessary interventions to manage existing pressure ulcers or to prevent new ones from forming. The lack of proper assessment, monitoring, and timely intervention contributed to the occurrence and worsening of pressure ulcers among residents.
Failure to Maintain Safe Environment and Adequate Supervision
Penalty
Summary
The facility failed to ensure that an area was free from accident hazards and did not provide adequate supervision to prevent accidents. This deficiency was identified based on observations and findings by surveyors, indicating that the environment posed risks for accidents and that supervision measures in place were insufficient to prevent such incidents. No specific details about the residents involved, their medical history, or their condition at the time of the deficiency are provided in the report.
Failure to Provide Effective Pain Management and Non-Pharmacological Interventions
Penalty
Summary
The facility failed to provide effective pain management consistent with professional standards of practice for three residents reviewed for pain management. Staff did not offer non-pharmacological interventions or investigate the underlying causes of pain, as required by facility policy. The policy specified that staff should conduct comprehensive pain assessments, address underlying causes, and implement both pharmacological and non-pharmacological interventions, but these steps were not followed. One resident with a neurological condition, feeding tube, and indwelling catheter experienced pain related to kidney stones and catheter issues. The care plan did not address the resident's history of kidney stones or include interventions for this pain. Despite receiving narcotic pain medication, the resident reported ongoing pain, and staff did not offer alternative interventions or promptly assess the cause, which was later found to be a kinked catheter. Staff interviews confirmed that non-pharmacological interventions were missing from the care plan and medication record, and that pain assessment was inadequate. Another resident with a right arm fracture and a third resident with a leg fracture both received pain medications, but their care plans and medication records lacked documentation of non-pharmacological interventions. Staff provided medications without specifying the type or location of pain and did not document or offer alternative pain relief methods. Staff interviews confirmed that non-pharmacological interventions were not included or documented, and that pain assessments and care plans were incomplete.
Failure to Develop Trauma-Informed Care Plan for Resident with Trauma History
Penalty
Summary
The facility failed to identify triggers and develop a care plan with goals and interventions for a resident with a history of trauma. Despite documentation in a trauma-informed screening form that the resident had experienced abuse in the past and could experience mood swings, confusion, disorientation, and depression, the resident's comprehensive care plan did not include trauma-informed care planning, did not address the resident's trauma history, and did not identify any triggers or prevention strategies. Recommendations for trauma-informed care planning and specific interventions were documented in a spiritual care progress note, but these were not incorporated into the resident's care plan. Interviews with staff confirmed that the expectation was to develop individualized care plans with triggers and interventions for residents with a history of trauma, but this was not done for the resident in question. The resident had a diagnosis of depression and moderate memory impairment, and had reported an incident of being punched by staff, which was documented and discussed with the family. However, the lack of a trauma-informed care plan persisted despite these assessments and recommendations.
Medication Storage and Labeling Deficiencies
Penalty
Summary
Surveyors observed that the facility failed to ensure proper storage and labeling of medications in multiple areas, including the Cascade Hall medication storage room, two medication carts, and at a resident's bedside. In the Cascade Hall medication room, an open bottle of tuberculosis testing solution was found with an open date exceeding the 28-day discard policy, and another vial lacked an open date entirely. On the Cascade Hall medication cart, an injectable medication and a blood sugar control solution were both found to be expired based on their open dates and manufacturer instructions. Similarly, on the Shoreline Hall medication cart, an injectable medication was found to be kept beyond the 28-day discard period. Staff interviews confirmed that these medications should have been discarded according to facility policy and manufacturer guidelines. Additionally, a resident was found to have two prescription eye drop medications unsecured at their bedside on two separate observations. Staff confirmed that these medications should not have been left unsecured in the resident's room. The facility's policy requires all medications to be labeled with expiration dates and stored securely, with multi-dose vials dated and discarded within 28 days of opening. These observations and staff confirmations demonstrate that the facility did not adhere to its own medication labeling and storage policies.
Failure to Provide Timely Dental Services
Penalty
Summary
The facility failed to ensure prompt dental services were provided for one resident who was assessed with obvious or likely tooth decay, broken teeth, and mouth or facial pain and discomfort or difficulty with chewing. Upon admission, the resident was noted to have clear speech and the ability to communicate needs. The resident reported ongoing dental discomfort, including cracked teeth down to the gum, a tooth with a hole, and the need to pick food out of the tooth after eating. Observations confirmed the presence of broken upper and lower teeth. The resident's care plan directed staff to coordinate dental care and transportation as needed. A physician order was in place for a dental consult, and the facility's visiting dentist evaluated the resident, recommending x-rays, evaluation, and extraction of all upper teeth due to several broken and decayed teeth, including an abscess. A referral request form was completed for these services, but there was no documentation indicating where the referral was sent. The staff member responsible for scheduling appointments could not find a fax confirmation or a scheduled dental appointment for the resident. Review of records confirmed that, for nearly seven months after the referral request, there was no evidence that the dental appointment was scheduled or that follow-up occurred.
Failure to Properly Store, Label, and Handle Food in Facility Kitchens
Penalty
Summary
Surveyors observed that the facility failed to properly store and label food items in both the skilled nursing and main kitchens. Opened boxes of snacks such as nacho chips, cheese crackers, and popcorn packages were found without expiration dates, and unopened frozen orange juice cartons in the walk-in freezer were also missing expiration labels. In the main kitchen, several items including tubs of bacon jam, cream cheese, uncooked eggs, corn tortillas, and an opened package of ham lunch meat were either not labeled with open or expiration dates or were past their labeled expiration date. Additional items in the walk-in freezer and small refrigerator, such as frozen french fries, bagels, chicken quarters, chopped lemons, and butter packets, were also not properly labeled or covered. Mayonnaise packets in dry storage lacked expiration dates as well. Interviews with staff confirmed that facility policy required all food to be labeled with either the manufacturer's expiration date or the date of receipt, and that this was not being consistently followed. Additionally, three kitchen staff members with facial beards were observed preparing food without wearing beard nets, contrary to facility policy requiring facial hair to be restrained to prevent contamination. The Director of Nutrition Systems acknowledged these lapses, stating that all food should be labeled and staff with facial hair should wear appropriate coverings when in the kitchen.
Incomplete Documentation of Care and Delayed Hospice Notes
Penalty
Summary
The facility failed to ensure timely and complete documentation of care and provider notes for multiple residents. For one resident with multiple complex medical conditions, nurses did not sign the Medication Administration Record (MAR) to indicate administration of a scheduled thyroid medication on two separate days, leaving the documentation incomplete. Staff confirmed that MARs should not be left blank and emphasized the importance of maintaining accurate and complete records. Additionally, for two residents receiving hospice care, the facility did not ensure that hospice provider notes were added to the residents' records in a timely manner. In both cases, the last hospice note available was from over three weeks prior, with no documentation of subsequent hospice visits. Staff interviews confirmed that hospice visits occurred more frequently and that it was expected for these notes to be promptly available in the residents' records to ensure accessibility for care staff and providers.
Failure to Follow Infection Control Protocols and PPE Use
Penalty
Summary
Facility staff failed to adhere to infection prevention and control protocols for multiple residents requiring Enhanced Barrier Precautions (EBP), Transmission Based Precautions (TBP), and standard hand hygiene practices. For two residents with feeding tubes and immune deficiencies, staff did not consistently use required personal protective equipment (PPE) such as gowns, gloves, and masks during personal care. Staff were observed not changing gloves or performing hand hygiene between care tasks, and in some cases, did not wear masks or sanitize hands after removing PPE and before leaving the resident’s room. For a resident on contact enteric precautions due to a C. difficile infection, staff from various departments, including housekeeping and therapy, entered the room without donning gowns and gloves as required. Staff also failed to wash hands with soap and water upon exiting the room, instead using only hand sanitizer, contrary to posted instructions. Staff were observed moving between rooms and handling items for other residents without performing appropriate hand hygiene after contact with the resident on TBP. During wound care for another resident, a nurse supervisor did not change gloves or perform hand hygiene between removing soiled dressings and applying clean ones, and touched multiple surfaces and other residents’ rooms before sanitizing hands. Additionally, a resident was observed using a wheelchair with cracked and peeling armrests, which staff acknowledged could not be properly cleaned, increasing the risk of infection transmission.
Failure to Post Contact Information for Advocacy Groups
Penalty
Summary
The facility failed to ensure that contact information for all pertinent State regulatory and informational agencies and advocacy groups was provided and/or posted in areas accessible to residents in a format and language they understood. This deficiency was identified for eight residents during a Resident Council meeting. The facility's admission packet did include a Supplement to Health Facility Admission Agreement outlining resident rights and contact information for State and local advocacy organizations, including the State Survey Agency and the State Long-Term Care Ombudsman (LTCO) program. However, during the Resident Council meeting, attendees stated they did not know the State and/or LTCO contact number or where to find the contact information. Observations and interviews conducted on the 2nd and 3rd floor nursing units revealed that the State and/or LTCO contact information was not posted or accessible to residents. Staff members responsible for oversight and administrative assistance on these units confirmed the absence of the contact information. Staff V mentioned that the sign might have been removed during a remodel and was not reposted. The Director of Nursing acknowledged that the contact information should be posted and visible to residents as it is a resident right, but it was not.
Failure to Communicate Resident Information During Transfers
Penalty
Summary
The facility failed to document and communicate necessary resident information to the receiving healthcare institution during transfers or discharges for three of the five sampled residents. This deficiency was identified through interviews and record reviews. For Resident 56, there was no documentation of necessary information being provided to the hospital during a transfer on January 18, 2024. The Director of Nursing admitted to not knowing the requirement to report resident information to the receiving hospital. Similarly, Resident 2 was transferred to the hospital on two occasions, September 7, 2023, and November 24, 2023, without the necessary documentation being provided to the hospital. The Resident Care Manager confirmed the absence of documentation for these transfers. Additionally, Resident 51 was sent to the hospital due to low blood pressure on August 10, 2023, but there was no documentation of communication to the hospital regarding the resident's health status and information. The Assistant Director of Nursing acknowledged the lack of communication in the resident's medical records.
Failure to Provide Required Transfer/Discharge Notifications
Penalty
Summary
The facility failed to ensure that residents received the required written notices at the time of transfer or discharge, and also failed to notify the Office of the State Long Term Care Ombudsman (LTCO) of these events. This deficiency was identified for five residents who were hospitalized. The facility's policy required that residents or their representatives be given a notice of transfer as soon as practicable, and that all resident transfers be reported to the LTCO monthly. However, the facility did not adhere to this policy, as evidenced by the lack of documentation for the required notifications. Resident 54 was transferred to the hospital from a dialysis center due to a change in condition, but neither the resident nor their representative received a written notification of the transfer. Similarly, Resident 28, who had end-stage kidney failure, was hospitalized due to increased confusion, yet there was no documentation of a written transfer notice or LTCO notification. Resident 51, with heart and kidney failure, was sent to the hospital for low blood pressure, but again, no written notice or LTCO notification was documented. The same issue was observed with Resident 56, who was transferred to the hospital emergently, and Resident 2, who was transferred twice without the required notifications. Interviews with facility staff, including the Resident Care Manager, Social Services, and Medical Records, confirmed the absence of documentation for these notifications. Staff acknowledged the need for education on providing written transfer/discharge notices and notifying the LTCO, but no corrective actions were mentioned in the report.
Failure to Provide Bed Hold Policy Notification
Penalty
Summary
The facility failed to provide written notice of its bed hold policy to residents or their representatives at the time of transfer to a hospital or within 24 hours, as required by their policy. This deficiency was identified for five residents who were reviewed for hospitalization. The facility's policy, revised in October 2022, mandates that residents receive a copy of the bed hold paperwork, including reserve bed payment information and agreement, during emergent transfers or within 24 hours. However, the facility did not adhere to this policy for any of the five residents reviewed. For Resident 54, there was no documentation of a bed hold discussion or offer during their transfer to the hospital for further evaluation after a dialysis session. Similarly, Resident 28, who was hospitalized after returning from dialysis confused and disoriented, did not have documentation of a bed hold offer. Resident 51, hospitalized due to low blood pressure, also lacked such documentation. Resident 56 and Resident 2, both discharged to the hospital on separate occasions, did not receive the required bed hold policy or agreement documentation within the stipulated time frame. Interviews with staff confirmed the absence of documentation and acknowledged the importance of offering a bed hold as a resident right.
Care Plan Deficiencies and Lack of Resident Involvement
Penalty
Summary
The facility failed to update and revise care plans for three residents, leading to deficiencies in care. Resident 20, who was admitted with a breathing problem and had an indwelling catheter (IC), had their IC removed in April 2024, but the care plan was not updated to reflect this change. Observations and interviews confirmed the absence of the IC, yet the care plan still directed staff to use protective gear for IC care, indicating a lack of timely updates. Resident 54, with impaired memory and chronic kidney failure requiring dialysis, was observed attempting to manage their toileting needs independently, including crawling on the floor. Despite these observations, there was no care plan addressing their bowel and bladder needs. Additionally, the dialysis care plan was outdated, lacking necessary communication sheets, which staff confirmed were not available, highlighting inaccuracies in the care plan. Resident 18, who had an IC due to urinary issues, had a care plan that acknowledged the presence of the IC but lacked specific care instructions for staff. This omission was confirmed by the Assistant Director of Nursing, who acknowledged the need for detailed interventions. Furthermore, Resident 40 was not provided an opportunity for a care conference, as there was no documentation of such an event, leaving them uninformed about their care plan interventions.
Failure to Administer Dialysis Medications as Ordered
Penalty
Summary
The facility failed to administer medications as ordered and did not communicate with the provider to adjust medication timing for residents undergoing dialysis. Resident 28, who has end-stage kidney failure, was hospitalized due to increased confusion related to kidney disease. The resident had physician orders for a bowel medication and a phosphate binder, both to be taken three times daily. However, on two occasions, the 12:00 PM doses were missed because the resident was out of the facility for dialysis. There was no documentation indicating that staff communicated with the provider to adjust the medication schedule on dialysis days. Similarly, Resident 54, who has chronic kidney failure and receives dialysis treatment, had a physician order for a phosphate binder to be administered with meals three times daily. The 5:00 PM doses were missed on multiple occasions when the resident was out for dialysis. Again, there was no documentation of communication with the provider to adjust the medication timing. Staff interviews revealed an expectation for staff to notify the provider of missed medications, which was not done.
Food Storage and Preparation Deficiencies
Penalty
Summary
The facility failed to maintain sanitary conditions in food storage and preparation, as observed in the kitchen and resident areas. In the Cascadia Neighborhood, a resident's refrigerator contained food brought from outside that was not consumed within the facility's policy of three days, leading to spoiled items like wilted carrots and mushed berries. The Dietary Manager confirmed that the food was past the use-by date and should have been discarded. Additionally, in the main kitchen, several food items were found unlabeled, undated, and improperly stored, including uncovered biscuits, open bags of peas, tater tots, burger patties, pie crusts, and sausages with freezer burn. The Dietary Manager acknowledged that these items should have been labeled and dated according to the facility's policy. Unsanitary food preparation practices were also noted, with a Food Service Worker failing to perform hand hygiene or change gloves between handling different food items and surfaces. The worker used the same gloves to handle baked chicken, frozen hotdogs, and various kitchen equipment, and even checked their cellphone without changing gloves. The Dietary Manager stated that staff are expected to wash hands and change gloves between clean and dirty areas to prevent food contamination. These lapses in hygiene and food safety practices contributed to an unsanitary environment, increasing the risk of food-borne illness among residents.
Failure to Timely Investigate Pressure Ulcers and Falls
Penalty
Summary
The facility failed to initiate and thoroughly investigate incidents in a timely manner for two residents, leading to potential risks of repeated incidents and unidentified abuse or neglect. Resident 40, who had a brain injury, heart failure, and malnutrition, developed two stage three pressure ulcers (PUs) while in the facility. Despite the facility's policy requiring investigations to be completed within five days, the investigation into Resident 40's PUs was not completed until a month later, and the root cause was not identified. Interviews with staff confirmed that the investigation was neither thorough nor timely. Resident 54, admitted for a fall with a hip fracture and assessed to have memory impairment, experienced two falls in their room while attempting to go to the bathroom unassisted. The facility's investigation into these falls was completed 12 days after the incidents, contrary to the policy of completing investigations within five days. Staff interviews revealed that the investigations were not completed on time, and the importance of timely investigations to rule out abuse and neglect was acknowledged but not adhered to.
Inaccurate MDS Assessments for Two Residents
Penalty
Summary
The facility failed to ensure the Minimum Data Set (MDS) assessments for two residents were completed accurately, reflecting their true health status and conditions. Resident 40's MDS did not identify bilateral hand contractures, which limited their functional range of motion. This oversight was confirmed by the MDS Coordinator, who acknowledged the inaccuracy and the importance of accurate MDS assessments for updating care plans. Observations showed Resident 40 had contracted hands, requiring assistance with personal care and the use of a soft splint to prevent further contractures. Resident 7's MDS failed to capture the use of a wander guard device, despite the resident wearing it daily. Interviews with staff revealed a lack of awareness about the device's presence and its necessity, as the resident did not exhibit wandering behaviors for months. The Charge Nurse and Social Services staff confirmed the resident's improved behavior, and the Assistant Director of Nursing stated the appropriateness of the device was evaluated quarterly. However, there was no documentation to support the continued need for the wander guard, and the MDS Coordinator later confirmed the device should have been coded under Alarms in the MDS.
Failure to Assist Residents with ADLs
Penalty
Summary
The facility failed to provide necessary assistance with Activities of Daily Living (ADLs) for two residents, leading to unmet care needs. Resident 18, who had medical conditions including heart failure, brain injury, and malnutrition, required substantial assistance with personal hygiene. Despite being assisted with lunch, Resident 18 was observed with food remnants on their face, chest, and bedding, indicating a lack of clean-up care post-meal. Staff D, a Resident Care Manager, acknowledged the oversight and stated that the condition was unacceptable, emphasizing the importance of maintaining the resident's dignity. Resident 40, with a history of brain injury and right-sided weakness, also required substantial assistance with personal hygiene. Observations revealed that Resident 40's fingernails were long and growing into their palm, posing a risk for skin impairment. Staff O, a Charge Nurse, confirmed the need for nail trimming to prevent potential skin breakdown and infection. The facility's failure to adhere to care plans and provide adequate grooming assistance for these residents was noted as a deficiency.
Failure to Implement Pressure Relief Interventions
Penalty
Summary
The facility failed to provide physician-ordered pressure relief interventions for a resident, identified as Resident 40, who was at risk for developing pressure ulcers (PUs) due to immobility and other medical conditions, including a brain injury resulting in right-sided weakness. Despite the wound care team's recommendation to use off-loading boots to prevent further deterioration of the resident's condition, the facility did not implement this intervention. Observations over several days confirmed that the resident's feet were not in off-loading boots, and the resident reported never having them applied. The facility's documentation did not support any trial use of the boots or reasons for their ineffectiveness. The resident developed new stage three PUs on both heels, which were not present upon admission, and the wounds increased in size over time. The facility's skin management assessments were delayed, with weekly assessments not initiated until more than two months after the PUs were discovered. Interviews with staff, including the Assistant Director of Nursing and the Director of Nursing, revealed that the nursing staff did not follow the wound care team's recommendations, and the resident's PUs were not addressed properly. The facility was unable to provide documentation to justify the lack of implementation of the recommended interventions.
Inaccurate Bowel and Bladder Assessment for a Resident
Penalty
Summary
The facility failed to accurately assess and provide appropriate care for a resident's bowel and bladder (B/B) needs, leading to a deficiency. Resident 54, who was admitted for a fall with a hip fracture and had memory impairment, was assessed as incontinent of B/B and required total assistance for toileting. However, a subsequent B/B assessment indicated the resident was occasionally incontinent and unable to get to the bathroom independently. Despite this, observations showed the resident attempting to get out of bed and crawl on the floor multiple times to reach the bathroom, indicating a discrepancy between the assessment and the resident's actual needs. Interviews with facility staff revealed that the resident was confused and did not use the call light for help, instead crawling on the floor to reach the bathroom. Staff members acknowledged that they took the resident to the bathroom when asked but failed to update the B/B assessment to reflect the resident's needs accurately. The Resident Care Manager confirmed that the assessment should have been updated once staff became aware of the resident's behavior, but this was not done, resulting in unmet care needs and a diminished quality of life for the resident.
Failure to Assess and Obtain Consent for Bed Rail Use
Penalty
Summary
The facility failed to ensure that appropriate alternatives were attempted before installing bed side rails for residents, and did not conduct necessary assessments, evaluations, or obtain informed consent for their use. This deficiency was identified for three residents who were reviewed for accident hazards. The facility's policy required that bed side rails should only be used if specific criteria were met, including attempts to use alternatives, interdisciplinary evaluation, resident assessment, and informed consent. However, these steps were not followed, placing residents at risk for harm and significant injury. Resident 40, who had a brain injury resulting in right-sided weakness and contracted hands, was observed with bilateral side rails in the up position. The resident stated they could barely use their hands to grab the side rails. The medical records did not show an assistive device assessment or informed consent for the use of side rails. Staff confirmed that the quarterly side rails evaluation was not completed, and the side rails were not appropriate for the resident's condition. Resident 28, who had a brain disorder and was capable of independent bed mobility, was also observed with side rails in the up position, despite stating they did not use them. The side rail evaluation section of their quarterly nursing assessment was not updated. Similarly, Resident 51, who was independent with bed mobility, had side rails in use without a recent assessment to justify their necessity. A fall incident report indicated that Resident 51 had rolled out of bed, highlighting the potential risk posed by the side rails. Staff confirmed that the quarterly assessment regarding side rails use was not completed for Resident 51.
Medication Error Rate Exceeds Acceptable Threshold
Penalty
Summary
The facility failed to maintain a medication error rate of less than 5%, resulting in an observed error rate of 8% during a medication pass. This deficiency involved two residents, Resident 70 and Resident 9, and was identified through observation, interview, and record review. For Resident 70, a registered nurse, Staff BB, under the training of Staff S, administered a blood pressure medication despite the resident's heart rate being below the prescribed parameter of 60 beats per minute. The resident's heart rate was recorded at 56 beats per minute prior to administration, and Staff S acknowledged the error, stating that the medication should have been held according to the physician's order. For Resident 9, Staff CC, an LPN, prepared and administered the wrong eye drops, using a redness reliever instead of the prescribed artificial tears. Staff CC admitted to not verifying the medication against the physician's order, which was a repeated error. The Director of Nursing, Staff B, confirmed that staff are expected to verify all aspects of medication administration, including the resident's name, medication name, form, dosage, route, and timing, against the physician's orders to ensure accuracy.
Failure to Provide Correct Meal Portions for Therapeutic Diets
Penalty
Summary
The facility failed to ensure that residents were provided with the correct meal portion sizes as part of their prescribed therapeutic diets. This deficiency was observed in the cases of two residents. Resident 7, who had unstable blood sugar levels and was on a low concentration sweets, small portions diet, was served a full portion of dessert pie instead of the prescribed half portion. This occurred despite clear instructions on the meal ticket for dietary staff to provide half portions of desserts or fresh fruits. Staff W, responsible for preparing the meal, incorrectly provided a full slice of pie, believing it to be a smaller cut piece. Staff L, a corporate dietary personnel, confirmed that the portion served was incorrect. Similarly, Resident 1, who had a diet order for small portions of mechanically soft ground meats, was served without adherence to portion size guidelines. Staff W prepared the resident's lunch tray by approximating the amount of ground meat without measuring or following any guide for small portion sizes. The Menu/Diet Spread Sheet Report available to Staff W did not include portion size guidelines for mechanically altered meats, leading to the incorrect serving size. Staff L emphasized the importance of serving residents their therapeutic diets in the correct portion sizes to meet their nutritional and dietary needs.
Incomplete and Inaccurate Resident Records
Penalty
Summary
The facility failed to maintain complete, accurate, and readily accessible resident records for two residents, which is a violation of accepted professional standards. For Resident 1, the records indicated that Abacus Guardianship Incorporated was listed as the financial power of attorney, but the legal guardianship documents had expired. Despite this expiration, Abacus was still listed as an active legal guardian, which was incorrect. Resident 1 had memory impairment, as noted in their Annual Minimum Data Set (MDS) assessment. Similarly, Resident 21's records showed an agent/attorney listed as responsible for healthcare and financial power of attorney, but the legal guardianship documents had also expired. Despite the expiration, the agent/attorney was still listed as the resident's legal guardian. Resident 21 had severe memory impairment, as indicated in their MDS assessment. The Social Service Director confirmed that the guardianship documents for both residents were expired and should not have been listed as active.
Inadequate Hand Hygiene Practices
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by multiple instances of staff not adhering to proper hand hygiene protocols. During an observation, a CNA provided peri care to a resident and assisted with wound dressing without changing contaminated gloves, subsequently touching clean areas and items in the resident's environment. The CNA admitted to forgetting to change gloves, and the LPN present confirmed the lapse in protocol. The Infection Preventionist also acknowledged that the CNA should have changed gloves after providing peri care. In another instance, CNAs were observed assisting residents with meals without performing hand hygiene after passing meal trays and touching various surfaces. One CNA assisted a resident with their meal without washing hands, while another CNA assisted two residents simultaneously, touching one resident's hands and then feeding the other without hand hygiene. The Infection Preventionist emphasized the importance of hand hygiene before dining assistance to prevent infection and expected CNAs to assist residents one at a time to avoid cross-contamination.
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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