Lea Hill Rehabilitation And Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Auburn, Washington.
- Location
- 32049 109th Pl Se, Auburn, Washington 98092
- CMS Provider Number
- 505528
- Inspections on file
- 17
- Latest survey
- September 19, 2025
- Citations (last 12 mo.)
- 61
Citation history
Health deficiencies cited at Lea Hill Rehabilitation And Care Center during CMS and state inspections, most recent first.
Two residents with limited English proficiency were not provided with the required interpreter services or communication aids as outlined in their care plans. Staff failed to use phone translators, language line services, or communication binders during care, resulting in ineffective communication and unmet needs for these residents.
Staff failed to maintain cold food at or below 41°F during meal service, as Jello dessert cups were served at temperatures of 45°F and 50°F, contrary to facility policy and food safety standards. Staff interviews confirmed the importance of proper cold food temperatures, but the deficiency was observed during lunch preparation.
A resident receiving medications via gastric tube did not have privacy maintained when a nurse left medical information unsecured and visible, left the room door open, and did not use the privacy curtain while exposing the resident's abdomen. Both the nurse and DON confirmed that privacy and confidentiality were not upheld as required by facility policy.
The facility did not provide or document nonpharmacological interventions before administering psychotropic medications to three residents with depression, anxiety, or mood disorders. Additionally, staff failed to complete required AIMS assessments and did not monitor for adverse side effects or target behaviors in a resident receiving antipsychotic and antidepressant medications, contrary to facility policy.
The facility did not provide required written notifications of hospital transfers to two residents and their representatives, nor did it consistently notify the Ombudsman as required. These residents, who had conditions such as stroke and heart failure, were transferred to the hospital without receiving timely written explanations or information about their appeal rights.
Surveyors identified that three residents' MDS assessments were not completed accurately, including failure to document participation in restorative nursing programs, omission of an anxiety diagnosis, and incorrect coding regarding pressure ulcer risk and presence. Staff confirmed these discrepancies after reviewing the residents' records.
A resident with depression and anxiety did not have their PASRR Level 1 assessment updated to reflect worsening mental health symptoms and ongoing treatment, despite facility policy requiring periodic review and revision. Staff acknowledged the need for a Level 2 evaluation but did not initiate it, resulting in the resident not being properly assessed for necessary behavioral health services.
Three residents did not have comprehensive care plans addressing their specific needs, including one on continuous oxygen therapy without a plan for respiratory care or Covid-19, another with hemiplegia lacking instructions on repositioning frequency, and a third with diabetes and insulin orders but no diabetes management plan. Staff confirmed these omissions and the absence of required documentation.
Surveyors found that staff did not clarify physician orders for pain medications, resulting in unclear dosing and pain level parameters for several residents. Medications were administered outside of prescribed guidelines, and necessary lab monitoring for medications such as cholesterol-lowering agents and thyroid medications was not completed. Staff also failed to implement nonpharmacological pain interventions and did not consistently monitor for signs of abnormal blood glucose in residents with diabetes.
Three residents dependent on staff for ADLs did not receive required assistance with personal hygiene, nail care, shaving, bathing, or getting out of bed. Observations showed residents remained in bed with unmet hygiene needs, and staff interviews confirmed that expected care, such as nail trimming and shaving, was not provided or documented as required by care plans.
Staff did not consistently complete required weekly skin assessments for two residents, failed to perform a post-fall assessment after a resident's fall, omitted a restorative nursing referral for a resident discharged from therapy, and did not monitor a tube-fed resident's weight as ordered. These deficiencies were confirmed through record review, observation, and staff interviews.
A resident receiving tube feeding did not have the amount of enteral formula and fluids accurately documented or reconciled with physician orders. Nursing staff failed to total and verify the amounts administered, and the feeding bottle lacked proper labeling. The DON confirmed that staff were expected to document these amounts each shift, but this was not done.
A registered nurse left medications unsecured on a medication cart during administration, and a supplement with an altered expiration date was found on a medication cart. Both the nurse and DON acknowledged that medications should be secured and properly labeled, and that expired medications should be discarded to ensure resident safety.
Staff did not consistently use PPE or follow Enhanced Barrier Precautions for residents with infection risks, failed to perform hand hygiene between resident contacts during meal service, and did not maintain sanitary practices when delivering food items. These actions were contrary to facility policy and placed residents at risk for infection.
The facility failed to provide required written transfer/discharge notices to two residents during hospitalizations, as per their policy. Resident 21 experienced multiple hospital transfers without receiving written notifications, and staff interviews revealed confusion about responsibility for these notices. Similarly, Resident 29 was transferred without documented notification, highlighting a systemic issue in the facility's discharge process.
The facility failed to maintain food safety standards in its kitchens, with ineffective surface sanitizer solutions, improperly sealed ice cream tubs, and dented cans stored improperly. Additionally, a contamination risk was identified due to dust and grime on a door mechanism above the meal preparation area. These deficiencies placed residents at risk for food contamination and foodborne illnesses.
The facility failed to clarify and follow Physician's Orders (POs) for several residents, leading to potential risks. A resident had unclarified pain medication orders, another directed ointment application against the PO, and a third had duplicate medication orders. Additionally, staff did not notify a physician of high blood sugar levels for a resident, administered pain medication incorrectly, and failed to document pain levels numerically. Furthermore, a staff member signed off on an incorrect air mattress setting for a resident.
The facility failed to maintain proper infection control practices, including hand hygiene and glove changes, during resident care and cleaning tasks. CNAs did not change gloves or perform hand hygiene between dirty and clean care, and a nurse did not use a barrier for a glucometer. A housekeeping aide also failed to change gloves or disinfect equipment, risking cross-contamination.
The facility failed to maintain Advanced Directives (ADs) in the records of four residents, compromising their right to have their care preferences honored. Despite residents having ADs and designated Powers of Attorney (POA), the documents were not readily available in their records, as expected by facility policy. Staff interviews confirmed that ADs should be scanned into records promptly, but this was not done, leaving the facility without essential documentation for emergent and end-of-life care decisions.
The facility failed to thoroughly investigate unwitnessed falls for two residents, leading to incomplete documentation and risk of further falls. A resident with severe memory impairment experienced an unwitnessed fall, but the investigation lacked key details and witness statements. Another resident with progressive memory loss had an incomplete incident report after a fall, with sections left blank. The Nursing Services Director expected thorough investigations, but no further information was provided.
A facility failed to update the PASRR assessment for a resident with depression, who was receiving antidepressant medication. The initial Level 1 PASRR did not reflect the resident's mental health condition, and the facility staff did not update it upon admission. The Social Services Director confirmed the inaccuracy and the need for an update.
The facility failed to update care plans for two residents, leading to discrepancies in care. One resident's plan was outdated regarding fall risk interventions, while another's plan inaccurately reflected medication orders and fall mat placement. Staff acknowledged the need for updates, but the care plans remained unchanged.
A resident with severe memory impairment and dementia was not assisted with their hearing aids (HAs) as required by their care plan, leading to communication difficulties. Observations showed the resident without HAs during meals and interactions, despite staff acknowledging the importance of HAs for effective communication.
The facility failed to provide adequate mealtime supervision for a resident with swallowing difficulties, leading to unsupervised eating with straws present, contrary to care plan instructions. Additionally, fall prevention measures were not implemented for two residents, as non-slip film was missing from a resident's chairs and another resident's bed was not kept in the lowest position as required.
The facility failed to provide appropriate toileting care for continent residents, leading to dignity issues and increased risk of UTIs. A resident with a history of UTIs was directed to use their brief, delaying diagnosis and treatment due to an expired urine collection container. Additionally, improper catheter care was observed for a resident with a suprapubic catheter, with staff showing a lack of training and understanding of care procedures.
A facility failed to document the enteral feeding intake for a resident with a feeding tube, leading to the administration of more formula and water than prescribed. The care plan required specific amounts of formula and water, but staff only marked check marks instead of recording actual amounts. Observations showed the resident received excess nutrition, and staff interviews confirmed the lack of documentation and deviation from the feeding schedule.
The facility failed to provide proper oxygen care and signage for three residents, leading to potential risks. A resident with COPD received oxygen therapy against physician orders, while another had their oxygen tubing not changed as scheduled. Additionally, rooms of residents using supplemental oxygen lacked required warning signs, posing safety risks.
A resident with memory loss was prescribed a sleep aid without proper monitoring or non-pharmacological interventions. Staff interviews confirmed the lack of a sleep monitor and non-drug interventions, risking unnecessary medication use.
The facility failed to ensure two residents were free from unnecessary psychotropic medications. One resident's antidepressant dosage was increased without attempting a Gradual Dose Reduction (GDR) or documenting behavioral concerns, despite no symptoms of depression. Another resident's antidepressant effectiveness and side effects were not monitored or documented as required.
Failure to Provide Functional Communication Systems for Non-English Speaking Residents
Penalty
Summary
The facility failed to ensure that two residents with limited English proficiency were provided with effective communication systems as required by their care plans and facility policy. Both residents had documented needs for interpreter services or communication aids due to language barriers, but staff did not consistently use the available resources such as phone translators, language line services, or communication binders during care interactions. Observations showed that staff attempted to communicate with the residents in English, which the residents did not understand, and did not utilize the prescribed communication methods. For one resident with multiple medical conditions and no memory issues, the care plan specified the use of phone translators and interpretive services. Despite this, staff were observed providing care and medications without using any translation devices, resulting in the resident being unable to communicate their needs effectively. On several occasions, the resident was observed calling out in their preferred language, and staff responded in English without using translation aids. The resident had to resort to using simple English words and gestures to communicate basic needs, and staff acknowledged not using the required communication tools. The second resident, whose primary language was not English, also had a care plan intervention for a communication binder, but repeated observations confirmed that no such binder was available. Staff did not attempt to use interpreter services or communication boards, and instead communicated in English or assumed the resident did not need anything. Interviews with staff and the resident's representative confirmed that the prescribed communication aids were not being used, and the resident's needs may not have been adequately assessed or met due to the language barrier.
Cold Food Served Above Safe Temperature During Meal Service
Penalty
Summary
During lunch preparation, staff failed to maintain cold food at the required temperature of 41 degrees Fahrenheit or lower, as specified in the facility's Food Temperature Policy. Observations showed that Jello dessert cups were removed from the pantry refrigerator and placed on trays, while another tray of Jello cups was sitting on ice outside the pantry. When temperatures were checked, the Jello from the refrigerator measured 45 degrees Fahrenheit, and the Jello on ice in the cart measured 50 degrees Fahrenheit. Staff interviews confirmed that maintaining cold food temperatures below 41 degrees Fahrenheit is essential for food safety and to reduce the risk of foodborne illness. However, the Jello served to residents did not meet this standard, as it was above the required temperature at the time of service. The deficiency was identified through observation, temperature checks, and staff interviews, in accordance with the facility's policy and regulatory requirements.
Failure to Ensure Privacy During Medication Administration
Penalty
Summary
Staff failed to ensure privacy and confidentiality for a resident during medication administration via gastric tube. During observation, a registered nurse left the medication cart unattended with the resident's medical information visible and unsecured on the computer. The nurse then entered the resident's room, left the door open to the hallway, and did not pull the privacy curtain. While administering medications through the resident's gastric tube, the nurse exposed the resident's abdomen and GT site without providing privacy. Interviews with the nurse and the Director of Nursing confirmed that staff are expected to protect resident health information and provide privacy during care by closing doors or pulling privacy curtains. Both staff members acknowledged the importance of maintaining resident privacy and confidentiality, as outlined in facility policies and resident rights documentation. The incident was found to be inconsistent with facility policies regarding HIPAA compliance and resident dignity.
Failure to Provide Nonpharmacological Interventions and Monitor Psychotropic Medication Use
Penalty
Summary
The facility failed to implement and document nonpharmacological interventions prior to administering psychotropic medications for three residents diagnosed with depression, anxiety, or mood disorders. Specifically, two residents received daily antidepressant medications without any documented physician orders for nonpharmacological interventions, and staff confirmed that such interventions should have been in place. Additionally, for one resident receiving both an antipsychotic and an antidepressant, there was no evidence that staff attempted nonpharmacological interventions prior to medication administration. Further deficiencies were identified in the monitoring and assessment of residents receiving psychotropic medications. For one resident on an antipsychotic, staff did not complete the required Abnormal Involuntary Movement Scale (AIMS) assessment, nor did they monitor for adverse side effects or specific target behaviors associated with the medications. Interviews with facility staff confirmed the absence of required documentation and monitoring, which was expected according to facility policy.
Failure to Provide Required Written Transfer/Discharge Notifications
Penalty
Summary
The facility failed to provide required written notifications regarding transfer or discharge to the hospital for two residents. Specifically, the facility did not give written notice to the residents and/or their representatives at the time of transfer or within 24 hours, as mandated by policy and regulation. For one resident, written notification was only provided for one of several hospital transfers, and for another resident, no written notification was provided for either of their hospitalizations. The facility's policy requires that such notifications include the reason and basis for transfer, the effective date, the location, and an explanation of appeal rights, and that evidence of notification to the Ombudsman be maintained. Record reviews and staff interviews confirmed that the required notifications were not consistently provided to the residents, their representatives, or the Ombudsman. The Director of Nursing acknowledged that written notifications were not given for certain transfers, and the Social Services Director confirmed that the Ombudsman was not notified in at least one instance. The residents involved had significant medical conditions, including stroke and heart failure, and were transferred to the hospital due to changes in their medical status.
Inaccurate MDS Assessments for Multiple Residents
Penalty
Summary
The facility failed to ensure accurate completion of the Minimum Data Set (MDS) assessments for three residents, resulting in discrepancies between the residents' actual conditions and what was documented. For one resident with a history of brain bleed and right side weakness, the MDS did not reflect participation in a Restorative Nursing Program (RNP) for range of motion, despite documentation and care plans indicating that such services were provided up to five times a week. Staff confirmed the inaccuracy upon review of the resident's record. Another resident with diagnoses of depression and anxiety was not accurately coded for anxiety on the MDS, even though psychiatric notes and preadmission screening documented both conditions and ongoing treatment needs. Additionally, a third resident with malnutrition and cancer was documented on the MDS as not having or being at risk for pressure ulcers, despite staff identifying and treating a pressure injury to the resident's tailbone. Staff acknowledged that the resident should have been coded as at risk for pressure ulcers and that the MDS required modification.
Failure to Update PASRR Assessment for Mental Health Changes
Penalty
Summary
The facility failed to ensure that Pre-admission Screening and Resident Review (PASRR) assessments were updated to reflect changes in a resident's mental health status. According to facility policy, staff are required to review and update PASRR screenings periodically and as needed, based on changes in a resident's condition. For one resident with a diagnosis of depression and anxiety, the PASRR Level 1 screening was not revised despite evidence of worsening symptoms and ongoing treatment with antidepressant medication. The resident's medical record and a psychiatrist's note indicated a gradual worsening of depression and anxiety, necessitating further evaluation. During an interview, the Social Services Director acknowledged responsibility for reviewing and correcting PASRR Level 1 and 2 assessments and confirmed that the PASRR Level 1 for this resident was inaccurate. The staff member stated that a PASRR Level 2 evaluation was required but was not initiated, and the Level 1 screening was not updated to reflect the resident's current mental health needs. This oversight resulted in the resident not being properly assessed for necessary mental health services as required by facility policy and regulatory standards.
Failure to Develop and Implement Comprehensive Care Plans
Penalty
Summary
The facility failed to develop and implement comprehensive, individualized care plans for three residents, as required by policy and regulation. For one resident with continuous high-concentration oxygen therapy and a recent history of Covid-19, there was no care plan addressing either the oxygen therapy or Covid-19 precautions, despite physician orders and ongoing respiratory care needs. Staff confirmed that these care plans were missing and acknowledged their importance for ensuring appropriate respiratory care. Another resident with a history of stroke and hemiplegia required two-person assistance for mobility and repositioning. While the care plan instructed staff to use two people for repositioning, it did not specify the frequency of repositioning, nor was there documentation that repositioning was being offered or performed as needed. A third resident with diabetes and unstable blood glucose levels had physician orders for two types of insulin but lacked a care plan addressing diabetes management. This resident reported frequent symptoms of low blood glucose and expressed concern about insulin orders. Staff interviews confirmed that care plans for these conditions were not in place, contrary to facility policy.
Failure to Clarify Medication Orders and Monitor Labs
Penalty
Summary
Surveyors identified that the facility failed to ensure physician orders for pain medications were clear and included necessary parameters, such as dosing and pain level indications, for multiple residents. For example, one resident had orders for both over-the-counter and opioid pain medications, but the orders did not specify at what pain levels each medication should be administered. Staff administered medications outside of the prescribed parameters and did not clarify ambiguous orders with the provider. Another resident had a pain patch order lacking dosage and application site instructions, which staff also failed to clarify. Additionally, the facility did not obtain or monitor laboratory values for medications that require lab monitoring. Residents receiving cholesterol-lowering medications, high-dose supplements, and thyroid medications did not have corresponding lab results in their records to ensure the medications were safe and effective. Staff interviews confirmed that these labs were not obtained, despite the expectation that they should be. The facility also failed to ensure that pain management included nonpharmacological interventions and that staff monitored for signs and symptoms of hypo- or hyperglycemia in residents with diabetes. One resident with diabetes reported frequent symptoms of low blood glucose, and there was no documentation of staff monitoring for these symptoms or implementing nonpharmacological pain interventions. Staff confirmed that these practices were expected but not followed.
Failure to Provide Required ADL Assistance to Dependent Residents
Penalty
Summary
The facility failed to provide necessary assistance with activities of daily living (ADLs) for three residents who were dependent on staff for personal hygiene and mobility. For one resident with right-sided weakness, observations over several days showed they remained in bed with long fingernails containing black debris, despite care plans indicating staff should assist with personal hygiene and provide nail care weekly and as needed. Staff interviews confirmed that expected ADL assistance, including nail care, was not provided as required. Another resident with bilateral arm weakness required staff assistance for personal hygiene, including bathing, oral care, and shaving. Observations revealed the resident had long facial hair, and staff interviews indicated that shaving was not performed or documented as expected. A third resident, dependent on two staff for hygiene, bathing, transfers, and positioning, was observed lying in bed on multiple occasions, with no documentation of being offered showers or assistance to get out of bed, despite care plans and family preferences for daily mobility and showers. Staff interviews confirmed that bed baths were offered instead of showers and that there was no place in the records to document these activities.
Failure to Complete Required Assessments and Care Interventions
Penalty
Summary
The facility failed to provide appropriate treatment and care according to physician orders and residents’ care plans in several areas. For two residents, staff did not complete weekly skin assessments as required. One resident with malnutrition and cancer had a care plan intervention for weekly skin checks, but there were gaps of up to three weeks between documented assessments, and some skin checks were recorded on the treatment administration record without corresponding assessment forms. Another resident, at risk for pressure ulcers following major surgery, also did not receive weekly skin checks as ordered, with a gap of nearly five weeks between documented assessments. In another instance, staff did not complete a post-fall assessment for a resident who experienced a fall in the bathroom while being assisted by staff. The resident was at moderate risk for falls, and facility policy required a fall assessment after each incident, but no updated assessment was found in the records following the event. Additionally, a resident discharged from therapy services did not receive a referral to a restorative nursing program to maintain range of motion, despite the therapy department’s usual practice and the resident’s ongoing need for assistance with daily activities. The therapy discharge summary lacked documentation of a referral, and both the restorative coordinator and rehab director confirmed the omission. The facility also failed to monitor a resident’s weight according to physician orders. One resident receiving tube feeding had a physician order for monthly weight monitoring, but records showed missing weights for several months. The care plan included an intervention to monitor weight per order, but this was not consistently implemented. These failures were confirmed by staff interviews and record reviews.
Failure to Accurately Document and Administer Ordered Enteral Nutrition
Penalty
Summary
The facility failed to ensure that enteral nutrition was administered in accordance with physician orders and professional standards for a resident receiving tube feeding. Specifically, the staff did not accurately document or reconcile the amount of enteral formula and fluids administered with the amounts ordered by the physician. The facility's policy required that tube feedings be administered per physician orders and that staff evaluate the amount of feeding to ensure the resident received the correct nutrition and hydration. However, review of the resident's health records showed discrepancies between the ordered and administered amounts, and staff did not total or verify the amounts delivered as required. Observation and interviews revealed that a registered nurse stopped the tube feeding pump without verifying or documenting the total amount of formula and water administered, and the feeding bottle lacked a start date or time. The nurse admitted to not calculating the total administered and relied solely on the order for guidance. The Director of Nursing confirmed that staff were expected to total and document the amounts each shift, but this was not done. The resident involved was dependent on tube feeding for more than half of their daily caloric intake and required specific amounts of formula and water as ordered by the physician.
Failure to Secure and Properly Label Medications During Administration and Storage
Penalty
Summary
Staff failed to ensure proper storage and labeling of medications during medication administration and storage review. On two separate occasions, a registered nurse dispensed pills and liquid medications into a cup and left them, along with respiratory inhaled medications, unsecured on top of the medication cart before walking away. The nurse acknowledged that medications should be secured in a locked cart before leaving them unattended, and the DON confirmed that staff are expected to secure medications to ensure resident safety. Additionally, a review of the West Medication Cart revealed a supplement bottle with its original expiration date crossed off and a new date handwritten next to it. A licensed practical nurse stated that the supplement was brought in by a family member and that staff should not accept medications with altered expiration dates. The DON stated that expired medications should be discarded to ensure residents receive medications with the correct potency.
Failure to Follow Infection Control Protocols and Sanitary Practices
Penalty
Summary
Staff failed to use appropriate Personal Protective Equipment (PPE) and follow Enhanced Barrier Precautions (EBP) for residents with indwelling urinary catheters and other infection risks. For one resident with a urinary catheter, there was no EBP signage or PPE available at the room, contrary to facility policy. Another resident with an EBP sign posted had medications administered by a nurse who did not wear the required PPE, despite acknowledging the expectation to do so. A third resident with a catheter and EBP signage had their catheter bag emptied by a CNA who did not wear a gown as required, later admitting to forgetting the precaution. Hand hygiene (HH) practices were not consistently followed during meal service. One CNA delivered meal trays to multiple resident rooms, handled used items, and moved between rooms without performing HH between resident contacts or after touching items in the rooms. Another CNA also failed to perform HH between resident contacts during meal delivery, acknowledging the expectation but stating they forgot. Sanitary practices were not maintained during meal service, as one CNA dropped a mustard packet on the floor and then delivered it to a resident without cleaning or replacing it. The CNA recognized this was not appropriate for infection prevention. These observed failures were in direct violation of the facility's infection prevention and control policies, as well as state regulations.
Failure to Provide Written Transfer/Discharge Notices
Penalty
Summary
The facility failed to implement a system to ensure residents received the required written notices at the time of transfer or discharge, or as soon as practicable. This deficiency was identified for two residents who were reviewed for hospitalizations. The facility's policy, revised on 09/06/2023, required that a written transfer notification be provided to the resident or their representative in a language and manner they could understand, including the reason for transfer, effective date, and location. However, this policy was not followed, as evidenced by the lack of written notifications for the residents involved. Resident 21 was transferred to the hospital multiple times for various medical issues, including lethargy, diaphoresis, blood in urine, a fall, and blood in stool. Despite these transfers, there was no evidence that written notifications were provided. Interviews with staff revealed confusion about who was responsible for sending these notices, with different staff members assuming it was the responsibility of others. Similarly, Resident 29 was transferred to an acute care hospital, but there was no documentation of written notification being provided. Staff interviews confirmed that written notices were not given for hospital discharges, indicating a systemic issue in the facility's discharge notification process.
Food Safety Deficiencies in Facility Kitchens
Penalty
Summary
The facility failed to ensure that resident meals were prepared in accordance with professional standards of food safety in both of its kitchens. During an observation, it was noted that the surface sanitizer solutions were not maintained at effective concentrations, as indicated by test strips that failed to change color. The Dining Services Director, Staff P, confirmed the importance of maintaining the correct concentration for effectiveness and acknowledged the absence of readily available test strips. Additionally, the facility's storage practices were inadequate, with ice cream tubs in a freezer not properly sealed, risking deterioration, and dented cans of fruit cocktail and peaches stored with other cans, which Staff P admitted should be returned to the vendor due to potential spoilage. Further observations revealed that the lunch service area had a contamination risk due to a buildup of dust and grime on a slatted metal door and its mechanism, located directly above the steam table where meals were prepared. Staff P acknowledged the contamination risk posed by the unclean door and mechanism. These deficiencies in food safety practices placed residents at risk for food contamination, foodborne illnesses, and spoiled food, as the facility did not adhere to professional standards for food storage, preparation, and cleanliness.
Deficiencies in Physician's Orders and Documentation
Penalty
Summary
The facility failed to ensure that Physician's Orders (POs) were clarified and followed correctly for several residents, leading to potential risks for unmet care needs and other negative health outcomes. For Resident 2, there were two pain medication orders without parameters to guide staff on which medication to administer, as confirmed by Staff E, the Resident Care Manager. Similarly, Resident 242 had an order for a non-steroidal ointment that was not clarified, resulting in the resident directing the application areas, which was not in line with the order. Resident 238 had duplicate orders for pain and nausea medications without clear instructions, increasing the risk of incorrect administration. The facility also failed to follow POs for other residents. Resident 13 had a PO to notify the physician if blood sugar levels were between 351 and 400, which was not done on nine occasions. Additionally, Resident 240 received a narcotic pain medication for a pain level lower than the prescribed threshold. Furthermore, the facility did not document pain levels numerically for Residents 13, 8, 28, 238, and 240, instead using checkmarks, which was against the expected documentation practice. Lastly, the facility failed to ensure that staff signed only for care provided. For Resident 8, a PO required the air mattress to be set to a specific comfort level, but it was observed at an incorrect setting. Despite this, Staff F signed off on the treatment administration record as if the correct setting was verified. This discrepancy was confirmed during an interview with Staff F, highlighting a failure in accurately documenting care provided.
Infection Control and Hand Hygiene Deficiencies
Penalty
Summary
The facility failed to consistently adhere to proper hand hygiene and glove-changing protocols, as well as maintaining cleanliness of shared medical equipment, which placed residents at risk for healthcare-associated infections. During an observation, two CNAs were seen providing pericare to a resident with diarrhea without changing gloves or performing hand hygiene between dirty and clean care. The CNAs acknowledged the lapse in protocol, which was confirmed by the Infection Control Nurse as a breach of expected practices to prevent infections. Additionally, a registered nurse failed to use a barrier between a shared glucometer and a resident's over-the-bed table during a blood sugar check, and did not clean the table afterward. This was acknowledged by the nurse as a failure to follow proper procedures. Furthermore, a housekeeping aide was observed cleaning a public bathroom and a resident's bathroom without changing gloves or performing hand hygiene between tasks, leading to potential cross-contamination. The aide also failed to disinfect equipment before reuse, further compromising infection control measures.
Failure to Maintain Advanced Directives in Resident Records
Penalty
Summary
The facility failed to obtain and have Advanced Directives (ADs) readily available in the records of four residents, which compromised their right to have their preferences and choices honored during emergent and end-of-life care. Resident 240, who was admitted with no memory impairment and clear communication abilities, stated they had an AD and a family member as their Power of Attorney (POA), but no ADs were found in their records. Similarly, Resident 241, with complex medical diagnoses, was identified to have an AD and a family member as their POA, but the ADs were not found in their records until later discovered in a pile of unprocessed documents. Resident 238, also with no memory impairment, had their admission documentation completed by a family member who was their POA, yet their ADs were missing from the records. Resident 13, who had impaired thinking abilities and a history of traumatic brain dysfunction, heart failure, and memory loss, was identified to have a legal health and financial care authority who signed their admission paperwork. However, no ADs were available in their records. Interviews with staff revealed that ADs were expected to be scanned into the resident's records promptly, but this was not done, leaving the facility without crucial documentation to guide care according to the residents' wishes. The deficiency was noted under WAC 388-97-0280(3)(c)(i-ii).
Incomplete Investigation of Resident Falls
Penalty
Summary
The facility failed to thoroughly investigate unwitnessed falls for two residents, which placed them at risk for further falls and other negative health outcomes. Resident 3, who had severe memory impairment and medically complex diagnoses, experienced an unwitnessed fall on April 6, 2024. The investigation into this fall was incomplete, as it did not identify when the resident last used the toilet, if the call light was on, or when the resident was last seen by staff. Additionally, no witness statements were obtained from the staff who found the resident or any other staff members. Resident 13, who had a diagnosis of progressive memory loss disease and a history of falls, experienced a fall on June 16, 2024. The incident report for this fall was incomplete, with several sections left blank, including the resident's level of pain, mental status, and predisposing environmental factors. Staff B, the Nursing Services Director, stated that they expected incident reports to be complete and thorough, but no further investigative information was provided.
Inaccurate PASRR Assessment for Resident with Depression
Penalty
Summary
The facility failed to ensure that the Pre-Admission Screening and Resident Review (PASRR) assessment accurately reflected the mental health conditions of Resident 238. The resident, who was admitted on June 25, 2024, had multiple medically complex diagnoses, including depression, and was receiving antidepressant medication. However, the Level 1 PASRR completed prior to admission on June 20, 2024, did not indicate any Serious Mental Illness (SMI) indicators. Upon admission, the facility staff did not update the Level 1 PASRR to include the resident's diagnosis of depression, which required treatment with medication. During an interview, the Social Services Director acknowledged the importance of accurate and updated Level 1 PASRRs for residents with SMI and confirmed that Resident 238's PASRR was not accurate and needed updating.
Failure to Update Care Plans for Residents
Penalty
Summary
The facility failed to ensure that care plans (CPs) were updated to reflect the current care needs of two residents, leading to potential risks for unmet care needs. For Resident 3, the CP was not updated despite changes in the resident's activity level and fall risk. The resident, who had severe memory impairment and a history of falls, was observed being taken to their room without encouragement to stay in a common area, contrary to the outdated intervention in their CP. Staff acknowledged that the intervention was no longer appropriate due to the resident's increased tiredness, but the CP had not been revised to reflect this change. Similarly, Resident 21's CP was not updated to accurately reflect their current medical orders and care needs. The resident, who had moderate memory impairment and was on anticoagulant medication, had discrepancies in their CP regarding the medication and the placement of a fall mat. Observations showed the fall mat was only on the left side of the bed, consistent with the physician's order, but the CP incorrectly indicated mats on both sides. Staff confirmed that the CP should have been updated to remove the anticoagulant medication and correct the fall mat placement, but it was not.
Failure to Assist Resident with Hearing Aids
Penalty
Summary
The facility failed to ensure that a resident, who was assessed to require hearing aids (HAs) for effective communication, was provided with the necessary assistance to use them. The resident, who had severe memory impairment and complex medical diagnoses including dementia, was observed on multiple occasions without their HAs, despite the facility's policy and the resident's care plan indicating the need for daily use of HAs. The care plan specifically required nursing staff to ensure the resident's HAs were in place every morning and functioning properly. Observations over three consecutive days showed the resident without their HAs during meals and interactions with staff, leading to communication difficulties. Staff, including the Nursing Services Director, acknowledged the importance of the HAs for the resident's communication and admitted that assistance should have been provided. Despite the presence of the HAs in the resident's room, staff did not offer help to the resident to use them, resulting in repeated communication attempts and unnecessary barriers to interaction.
Inadequate Supervision and Fall Prevention Measures
Penalty
Summary
The facility failed to provide adequate mealtime supervision for Resident 88, who had a history of severe memory impairment, dementia, and swallowing difficulties. Despite being assessed to require close supervision when eating and having a care plan that specified no straws and the need for assistance from a CNA, Resident 88 was observed eating breakfast unsupervised with straws in their beverages. This lack of supervision and the presence of straws contradicted the care plan and placed Resident 88 at risk for aspiration, as evidenced by their coughing during the observation. Additionally, the facility did not ensure fall interventions were in place for Resident 3, who had severe memory impairment and a history of repeated falls. The care plan required non-slip film on the resident's personal chairs to prevent falls, but observations on multiple occasions showed the non-slip film was not in place. Staff acknowledged the importance of this intervention and confirmed its absence during the survey. For Resident 21, who had moderate memory impairment and was at risk for falls, the facility failed to maintain the bed in the lowest position as required by the care plan. Observations showed the bed was raised higher than allowed, and staff admitted the bed was not kept in the lowest position due to practical issues with the over-bed table. This oversight was acknowledged by staff, who noted the bed should not have been raised so high.
Deficiencies in Toileting and Catheter Care
Penalty
Summary
The facility failed to provide appropriate toileting care for continent residents, leading to dignity issues and increased risk of urinary tract infections (UTIs). Resident 339, who required maximum assistance with toileting due to irritable bowel syndrome and other health issues, reported that staff directed them to use their brief instead of assisting them to the toilet. This was observed when staff instructed Resident 339 to defecate in their brief, contrary to the resident's preference and the facility's policy. Resident 340, who had a history of kidney failure and frequent UTIs, also reported being directed to use their brief despite being aware of their need to use the bathroom. This resident expressed concerns about the risk of developing another UTI due to this practice. A urine sample collected for Resident 340 was not processed because the collection container was expired, delaying diagnosis and treatment. Staff interviews confirmed that the facility's policy was to assist continent residents to the toilet, but this was not consistently practiced. Additionally, the facility failed to provide proper catheter care for Resident 18, who had a suprapubic catheter. Observations showed the catheter bag was uncovered and touching the floor, and the resident reported pain at the catheter site. Staff were observed to be unsure of proper care procedures for suprapubic catheters, and the catheter bag was not placed in a privacy bag as required. Staff interviews revealed a lack of training and understanding of catheter care, contributing to inadequate care and potential risk of infection.
Failure to Document Enteral Feeding Intake
Penalty
Summary
The facility failed to properly assess, monitor, and document the enteral feeding intake for Resident 8, who was receiving nutrition through a feeding tube due to difficulty swallowing and impaired mobility following a stroke. The resident's care plan specified that they were to receive 720 mL of enteral feeding formula and 547 mL of free water over 12 hours, with staff required to document the amounts administered. However, the Medication Administration Record (MAR) showed that staff only marked check marks instead of recording the actual amounts of residuals and enteral nutrition administered, which was against the physician's orders. Observations revealed that Resident 8 received more enteral formula and water than prescribed, as the feeding pump indicated 1004 mL of formula and 720 mL of water were administered, exceeding the prescribed amounts. Interviews with staff, including a Licensed Practical Nurse, a Registered Dietician, and the Nursing Services Director, confirmed the lack of documentation and the deviation from the prescribed feeding schedule. The staff acknowledged the importance of documenting the total amounts of enteral formula and water to monitor the resident's nutritional intake and potential weight changes or edema.
Failure to Provide Proper Oxygen Care and Signage
Penalty
Summary
The facility failed to provide oxygen treatments as ordered for three residents, leading to potential risks for over or under oxygenation, respiratory discomfort, and oxygen-related accidents. Resident 2, who had cardiorespiratory diagnoses including heart failure, high blood pressure, COPD, fluid in the lungs, and respiratory failure, was provided oxygen therapy when their oxygen saturation was 93% or higher on multiple occasions, contrary to the physician's order to hold oxygen therapy if saturation surpassed 92%. Resident 241, with chronic respiratory failure and COPD, had their oxygen tubing not changed as scheduled, with no date on the tubing observed, despite a physician's order to change it weekly. Additionally, the facility did not place oxygen warning signs outside the rooms of residents using supplemental oxygen, as required by their policy. Observations showed that the rooms of Residents 2, 88, and 241 lacked signage indicating oxygen use. Staff interviews confirmed the importance of such signage for emergency response and to prevent oxygen-related accidents, as oxygen is combustible. The absence of these signs was a direct violation of the facility's policy and posed a safety risk.
Failure to Monitor and Address Resident's Sleep Medication Use
Penalty
Summary
The facility failed to ensure that a resident's drug regimen was free from unnecessary medications, specifically in the case of a resident with a progressive memory loss disease. The resident was prescribed an over-the-counter sleep aid medication for difficulty sleeping, as per a physician's order. However, there were no instructions for staff to monitor the number of hours the resident slept each night, nor was there a comprehensive care plan goal developed to address the resident's sleeping problem. Additionally, there were no interventions in place to guide staff on non-pharmacological methods to assist the resident with sleep or to monitor the effectiveness of the sleep aid medication. Interviews with facility staff revealed that a sleep monitor should have been implemented to track the effectiveness of the sleep aid, and non-pharmacological interventions should have been provided, but these measures were not in place. Both the Resident Care Manager and the Nursing Services Director acknowledged the absence of these necessary interventions and monitoring procedures. This oversight placed the resident at risk of receiving unnecessary medications and potential adverse side effects.
Failure to Monitor and Reduce Psychotropic Medications
Penalty
Summary
The facility failed to ensure that two residents, identified as Residents 21 and 238, were free from unnecessary psychotropic medications. For Resident 21, the facility did not attempt a Gradual Dose Reduction (GDR) for an antidepressant medication despite the resident not exhibiting symptoms of depression. The resident's medication was increased twice without documented behavioral concerns or justification for the continued dosage. Psychiatry consultation notes indicated that Resident 21 was calm, pleasant, and did not present with symptoms of depression, yet no GDR was attempted, and no justification was documented for the continued use of the antidepressant. For Resident 238, the facility did not monitor or document the effectiveness or side effects of the antidepressant medication as required. The resident had multiple complex medical diagnoses, including depression, and was receiving an antidepressant. However, there was no evidence of behavior monitoring or documentation to assess the medication's effectiveness. Staff E acknowledged that behavior monitoring should have been conducted to determine the medication's effectiveness, but it was not done.
Latest citations in Washington
Inaccurate PASARR screening affected two residents. One resident with vascular dementia, depression, and adjustment disorder had a PASARR level one that did not reflect mental health diagnoses, and staff stated it was inaccurate. Another resident with PTSD had a PASARR level one that did not include the PTSD diagnosis, with no additional PASARR level one or level two found in the EHR; staff stated the screening was not accurate and should have been repeated.
Undated open meds were found on 2 medication carts, including an open insulin vial and multiple open eye drop bottles with no dates. An LPN and an RN both stated the items should have been dated when opened, and the DON stated open multidose vials or bottles found without a date should be discarded immediately.
A resident with respiratory failure, HTN, and anxiety became SOB and diaphoretic, received a breathing tx, and was sent by EMS to the hospital. The facility could not locate the required SNF/NF to Hospital Transfer form or other transfer records showing what information was communicated to the receiving provider.
Care plans for two residents were not updated to match their current status and care needs. One resident had PTSD and generalized anxiety disorder and was receiving a psychotropic medication, but the care plan listed monitoring for antipsychotic and anticonvulsant meds that were not prescribed and did not include the anxiety diagnosis or related behaviors and interventions. Another resident had new upper and lower dentures, but the oral/dental care plan only noted edentulous status and difficulty chewing, with no mention of dentures or denture-related interventions.
Failure to Provide Individualized Activities: A resident with anxiety, depression, and weakness was cognitively intact but said they could not attend group activities because of leg problems and wanted more in-room activities. The resident mostly stayed in bed watching TV, and staff documentation showed only limited room visits with no consistent activity documentation despite a care plan goal for participation two to three times per week.
Failure to maintain heel offloading for a resident with a reopened DFU. A resident with dementia and dependence for mobility had a left heel wound that had healed and then reopened; the wound care provider recommended heel floating and pressure relieving boots at all times, but observations showed the resident in bed with heels on the mattress and later reclined in a wheelchair with the heel resting on the footrest strap and no boots in place. Staff stated the resident had not refused the boots or heel floating, and the care plan was not updated after the wound reopened.
Failure to Address Hearing and Vision Services for a Resident: A resident with dementia, bilateral hearing loss, and impaired vision was observed without eyeglasses or a hearing device, despite records showing admission with eyeglasses and a personal sound amplifier. The care plan addressed vision only and did not include hearing-related interventions, while staff interviews confirmed the resident’s hearing was strained and that the resident’s device use and vision needs were not fully reflected in the plan of care.
Respiratory care was not provided consistently for two residents receiving O2. One resident with COPD and chronic respiratory failure had an O2 order missing the indication for use and Sats parameters, no MAR documentation of O2 therapy, and inconsistent Sats charting. Another resident with respiratory failure was observed on continuous O2 via NC, but provider orders for O2 therapy and tubing changes were not present after readmission, despite the care plan stating the resident was dependent on O2.
A resident with dementia, hearing loss, and missing lower teeth had an MDS showing obvious or likely cavities or broken natural teeth, and the care plan identified oral/dental health problems with an intervention to coordinate dental care and transportation. Staff stated the resident’s dental needs were captured on the MDS, but no referral was made for dental services or follow-up with the dentist, and the DON said the lack of referral did not meet expectations.
Inaccurate Meal Intake Documentation: A resident with DM, dysphagia, and protein-calorie malnutrition was observed eating less than 25% of a meal, but the POC documented 76-100% intake. The CNA said the resident usually ate only 25-50% of meals and that intake was sometimes documented based on what a coworker reported. The LPN/RCM and DON stated meal intake should be documented accurately.
Inaccurate PASARR Screening for Two Residents
Penalty
Summary
The facility failed to ensure that two residents were screened for additional mental health supports through the PASARR process. Resident 97 was admitted with diagnoses including vascular dementia, depression, and adjustment disorder, and was able to make needs known. Review of the PASARR level one dated 04/10/2026 showed no mental health diagnoses and no need for a PASARR level two, even though the resident’s record included mental health diagnoses. During interview, the Regional Social Services staff and the Administrator stated the PASARR was inaccurate, needed modifications, and did not meet expectations. Resident 6 was admitted with diagnoses including heart failure, respiratory failure, and PTSD, and was able to make needs known. Review of the PASARR level one dated 03/30/2026 showed no serious mental illness indicators marked and no PASARR level two indicated, and the EHR contained no other documented PASARR level one or level two. The Social Services Director stated the hospital-provided PASARR was reviewed for accuracy and, if inaccurate, another level one would be completed, and stated this resident’s PASARR did not include PTSD and should have had another level one completed. The Administrator also stated the PASARR was not accurate and another level one needed to be conducted, but none could be located in the EHR.
Undated Open Medications on Medication Carts
Penalty
Summary
The facility failed to ensure proper storage and labeling of medications for 2 of 3 sampled medication carts reviewed for medication storage and labeling, including carts on the 400 and 500 halls. On the 500 hall medication cart, an open vial of insulin and an open bottle of eye drops were observed with no dates. During interview, an LPN stated that when an insulin vial or bottle of eye drops is opened, it should be dated immediately and said both items should have been dated upon opening; the LPN stated they would dispose of the undated vial and bottle. On the 400 hall medication cart, two open bottles of eye drops were observed with no dates. During interview, an RN stated both bottles should have been dated as soon as they were opened and said they would get new eye drops and dispose of the undated bottles. The DNS/RN stated that if an eye drop was opened it should have been dated immediately and that any open multidose vial or bottle found without a date should be discarded immediately.
Missing Hospital Transfer Documentation
Penalty
Summary
The facility failed to ensure hospital transfer documentation was completed for one resident who was transferred to the hospital after complaining of not being able to breathe and appearing diaphoretic. The resident had diagnoses of respiratory failure, high blood pressure, and anxiety disorder, and was able to make needs known. A breathing treatment was provided, and the provider agreed to send the resident out for further evaluation, after which emergency transportation took the resident to the hospital. Record review found no documentation showing what information was provided or communicated to the receiving facility for the transfer. Staff stated that transfer documentation should have included a SNF/NF to Hospital Transfer form, the resident's face sheet, and the medication and treatment administration records, but they were unable to locate documentation showing these items were completed or sent for the resident's hospital transfer.
Care plans did not reflect current diagnoses, medications, or denture status
Penalty
Summary
The facility failed to ensure that care plans were revised and accurately reflected residents’ current status and care needs for 2 of 21 sampled residents. Resident 6 was admitted with diagnoses including heart failure, respiratory failure, and PTSD, and was able to make needs known. The EHR showed Resident 6 also had generalized anxiety disorder and was receiving a psychotropic medication, but the current care plan dated 05/05/2026 documented monitoring for side effects of antipsychotic and anticonvulsant medications even though Resident 6 was not prescribed those medications. The care plan also identified PTSD but did not include generalized anxiety disorder or behaviors to monitor and interventions related to PTSD or anxiety disorder. Staff F, LPN/CC, stated the care plan did not accurately reflect the resident’s current status or prescribed medications, and Staff B, DNS, stated it did not meet expectations because it did not address the anxiety disorder or target behaviors and interventions. Resident 71 was admitted with diagnoses including PTSD, high blood pressure, and depression and was able to make needs known. Observation on 05/06/2026 showed a denture cup by the sink with the resident’s name on the lid and new upper and lower dentures dated 01/12/26. The resident stated the lower dentures did not fit well and that denture adhesive had been provided, but the dentures still did not fit right and the resident had not told staff yet. The focused oral/dental care plan, initiated on 06/23/2026, identified the resident as edentulous and having difficulty chewing, but did not show that the resident had dentures or include interventions related to denture use or maintenance. Staff E, CNA, stated they had not seen the resident wear dentures and were unaware of the new dentures, Staff C, LPN/CC, stated the care plan should have been updated when the dentures were obtained, and Staff B, DNS, stated the care plan should have reflected the dentures and interventions.
Failure to Provide Individualized Activities
Penalty
Summary
The facility failed to provide individualized activities for Resident 5, who was admitted with diagnoses including anxiety disorder, depression, and weakness. The admission MDS dated 01/14/2026 showed the resident was cognitively intact. During interviews on 05/03/2026 and 05/06/2026, Resident 5 stated they could not attend in-person activities because of their legs, wanted more activities to occupy them, mostly stayed in bed watching TV, and did not remember the last time activities staff visited to offer activities. The resident also stated activities staff would need to offer something they were able to do because they had difficulty doing some activities. The activities care plan dated 12/26/2026 showed a goal for Resident 5 to participate in activities two to three times per week. Progress notes documented one visit on 12/22/2026 to provide a welcome packet and encourage participation in daily activities, but no further activity documentation was found in the progress notes. Staff H stated room visits should include puzzles, arts and crafts, visiting, and chatting, and that documentation was placed in tasks, but the task record showed no documentation of activities for the past 30 days. Staff J stated paper documentation existed for room visits and that Resident 5 was on a list for room visits every Monday and Wednesday, while the room visit documentation showed only four visits on 01/26/2026, 02/06/2026, 03/10/2026, and 04/08/2026.
Failure to Maintain Heel Offloading for Reopened DFU
Penalty
Summary
The facility failed to consistently implement pressure reducing strategies for a resident with a left heel diabetic foot ulcer that had reopened. The resident was admitted with diagnoses including left hip fracture with surgical repair, a blood clot of the left lower leg, and dementia, and was dependent on staff for mobility and unable to make needs known. The baseline care plan and care plan both included heel offloading interventions, and the wound care provider initially recommended heel floating with pillows or wedge and pressure relieving boots. The wound later resolved, but a weekly skin assessment documented that the left heel wound reopened and was very painful to touch. After the wound reopened, the contracted wound care provider documented that the DFU to the left heel had reopened and recommended the resident wear pressure relieving boots at all times. The current care plan reviewed after the wound reopened did not include new interventions related to the reopened wound. Observations showed the resident seated in a reclined wheelchair with the left foot/heel resting on the footrest strap and no pressure relieving boots in place, and later lying in bed with both heels directly on the mattress without being floated and without boots. Staff interviews indicated the resident had not refused the boots or heel floating, and the LPN/CC and DON stated the resident should have been assessed and the plan of care updated when the wound reopened.
Failure to Address Resident Hearing and Vision Needs
Penalty
Summary
The facility failed to address one resident’s hearing and vision needs. Resident 112 was admitted with diagnoses including a leg fracture, dementia, and hearing loss in both ears, and was able to make needs known. The record showed the resident lost their glasses and was given readers, but the resident did not wear them because they were concerned that wearing glasses that were not their prescription would further degrade their vision. Observation did not show glasses in the resident’s room, and the resident stated they did not use a hearing aid. The resident was observed to be hard of hearing, requiring an elevated voice and repeated questions to understand. The admission MDS dated [DATE] documented adequate hearing with hearing aid and adequate vision with corrective lenses, while the significant change MDS dated [DATE] documented moderate difficulty hearing without a hearing aid and impaired vision without corrective lenses. The care plan initiated 02/24/2026 addressed impaired vision with interventions to arrange consultation with eye care practitioners as needed and remind the resident to wear glasses, but it did not include a focus area or interventions for hearing loss or use of hearing aids. A resident clothing list showed the resident admitted with one pair of eyeglasses and one Super Ear headset personal sound amplifier, yet observation and interview showed the resident in bed without eyeglasses or a hearing device, with the amplifier stored in the bedside table drawer. Staff interviews confirmed the resident’s hearing was strained, that the hearing device and glasses were not being used, and that the resident’s hearing device use should have been included in the plan of care and the resident should have been referred for eye care assessment.
Respiratory Care Orders and Documentation Not Maintained
Penalty
Summary
The facility failed to provide respiratory care consistent with professional standards of practice for two residents receiving oxygen therapy. One resident with COPD and chronic respiratory failure with hypoxia was observed multiple times lying in bed receiving oxygen at 2 L via nasal cannula. The resident’s oxygen order, dated 02/15/2026, allowed 1 to 4 L per minute continuously via nasal cannula, but it did not include an indication for use or oxygen saturation parameters. The April and May 2026 MARs did not show documentation of oxygen therapy being provided, and the TARs showed only an order to change oxygen tubing if damaged or visibly soiled, not an order for oxygen therapy. Oxygen saturations were not documented consistently daily from 04/01/2026 through 05/04/2026. A second resident with respiratory failure, high blood pressure, and anxiety disorder was observed in the room receiving oxygen at 6 L via nasal cannula on multiple occasions. The resident stated they needed oxygen therapy to breathe, and the care plan identified the resident as dependent on oxygen and to receive oxygen per provider orders. However, provider orders reviewed on 05/04/2026 showed no orders for oxygen therapy or for changing oxygen tubing. Staff stated the oxygen and tubing-change orders had been discontinued when the resident went to the hospital and were not added back to the MAR or TAR when the resident readmitted to the facility.
Failure to Refer Resident With Identified Dental Needs
Penalty
Summary
The facility failed to ensure that Resident 112 received needed dental care. Resident 112 was admitted with diagnoses including a leg fracture, dementia, and hearing loss in both ears. Observation on 05/03/2026 showed the resident had missing lower teeth. The admission MDS, dated [DATE], documented obvious or likely cavities or broken natural teeth, and the care plan dated 02/24/2026 identified oral/dental health problems related to likely cavities or broken teeth with an intervention to coordinate dental care and provide transportation. During interviews, Staff G, Regional Social Services, stated Resident 112's dental needs were captured on the 02/24/2026 MDS and the resident was not referred for dental services. Staff M, Social Services Director, stated residents with dental needs should be referred to social services to be scheduled for assessment by a dental care practitioner, and that Resident 112 should have been referred after the MDS assessment. Staff B, DON, stated residents with identified dental needs should be referred for follow-up with a dentist and that Resident 112 should have been referred to the in-house dental provider; Staff B stated the lack of referral did not meet expectations.
Inaccurate Meal Intake Documentation
Penalty
Summary
The facility failed to accurately document the amount of food eaten for Resident 13, who was admitted with diagnoses including diabetes mellitus, dysphagia, and protein-calorie malnutrition. The quarterly MDS dated 02/12/2026 showed the resident was moderately cognitively impaired. During observation on 05/05/2026 at 12:09 PM, a meal tray was delivered to the resident’s room, set up on a bedside table, and the resident was observed eating slowly, eating less than 25% of the meal, then laying back in bed and closing their eyes while the tray remained in the room. Staff later removed the tray, but the POC documentation for lunch on 05/05/2026 recorded that Resident 13 ate 76-100% of the meal. During interview, the CNA stated the resident typically ate 25-50% of meals and never ate all of the food, and that if they did not pick up a tray they would ask a coworker what the resident ate before documenting it. The CNA stated they were told the resident ate 75-100% of lunch, so that is what was entered. The LPN/RCM stated staff should document meal intake accurately in POC, and the RN/DNS stated it was their expectation that all staff document meal intake accurately.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release June 24, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
