Life Care Center Of Richland
Inspection history, citations, penalties and survey trends for this long-term care facility in Richland, Washington.
- Location
- 44 Goethals Drive, Richland, Washington 99352
- CMS Provider Number
- 505070
- Inspections on file
- 54
- Latest survey
- January 15, 2026
- Citations (last 12 mo.)
- 41
Citation history
Health deficiencies cited at Life Care Center Of Richland during CMS and state inspections, most recent first.
Surveyors found that the facility did not complete required baseline care plans (BCPs) within 48 hours of admission for three new residents. One resident with respiratory failure, hypoparathyroidism, anxiety, insomnia, and continuous O2 had a BCP that omitted focus areas, goals, and interventions for multiple ordered medications, including antipsychotics, anxiolytics, sleep medication, edema treatment, and a specific brand-name Synthroid requirement, as well as missing code status and PASARR Level II information. Another resident admitted after hip replacement with anxiety, depression, and long-term anticoagulant use had a BCP that did not address the anxiety disorder, PASARR, PASARR Level II recommendations, or code status, despite needing substantial assistance with ADLs and having moderately impaired cognition. A third resident with a broken hip, PTSD, and anxiety, requiring substantial to maximal ADL assistance, had a BCP lacking PTSD-related focus areas and PASARR Level II details. Staff, including an LPN/UCC, the Social Services Director, and the DON, confirmed that code status must be entered manually, that PASARR and social services sections should include Level II data and dates, and that these elements were not completed for these residents.
A resident with multiple chronic conditions was admitted with transfer orders specifying that levothyroxine 100 mcg must be given as brand-name Synthroid and that oxycodone-acetaminophen 10-325 mg be available PRN for pain. An LPN responsible for admission order entry did not see or transcribe the brand-name-only instruction, and the EMR and medication card reflected generic levothyroxine instead. The resident reported repeatedly telling staff they required Synthroid, kept their own Synthroid bottle and inhalers in an open bedside drawer, and stated they discarded the facility’s levothyroxine and self-administered their own medication while staff left medications in the room without observing administration. The resident also reported requesting oxycodone for pain during the first day and night without receiving it until the following day, while nursing staff acknowledged that oxycodone was not obtained from the pyxis because they lacked an authorization code and did not follow the stated process of contacting the on-call provider and pharmacy to secure the medication.
The facility did not provide timely PT and OT evaluations and treatments as ordered for two residents admitted with complex medical needs, including respiratory failure and post-hip replacement care. One resident waited five days after admission for initial PT and OT evaluations despite orders written at transfer, and reported receiving little therapy. Another resident, admitted after hip surgery and requiring substantial assistance with ADLs, did not receive PT and OT evaluations until several days after admission and ultimately received only one PT and one OT treatment before discharge. Staff interviews revealed that PT staffing was limited to Monday through Thursday, causing residents admitted on Fridays to wait until Monday for therapy, and leadership believed evaluations only needed to be completed within three days of admission.
A resident with impaired cognition and multiple care needs left the facility and did not return as expected. Staff documented the absence but did not notify the administrator, law enforcement, or the State Agency, resulting in a failure to initiate the required investigation and reporting process.
A resident with diabetes, heart failure, and an indwelling urinary catheter was discharged without documented education on catheter care and without a completed home health referral. Staff interviews confirmed that neither the resident nor their caregiver received necessary training, and the home health agency had no record of a referral, resulting in the resident's rehospitalization.
A resident with impaired cognition and mobility signed out to pay rent but did not return as expected. Nursing staff did not attempt to contact the resident, notify administrative staff, or involve law enforcement when the resident failed to return, despite facility policy requiring these actions. The resident was later found at home unable to transfer independently and required emergency services.
A resident with an indwelling urinary catheter and multiple risk factors for infection experienced several episodes of UTI symptoms and was started on antibiotics, but there was no documentation that the catheter or collection bag was changed as required by facility policy and standing orders. Nursing staff and the DON confirmed that the process for changing the catheter during infection was not followed.
A deficiency was cited due to the facility's failure to keep an area free from accident hazards and to provide adequate supervision to prevent accidents. The environment did not meet safety standards, and there was insufficient oversight of residents in the area.
Multiple residents experienced harm due to staff failing to recognize and respond to changes in condition, including not completing assessments, not notifying providers, and not following physician orders for monitoring and documentation. This included a resident with septic shock after delayed intervention, another with a blocked nephrostomy tube and sepsis, and a resident with neurological symptoms whose ordered imaging and monitoring were not completed. Additional issues included improper administration of PRN pain medication and inadequate response to a resident's unwitnessed fall with a head injury.
Multiple residents dependent on staff for ADLs did not receive timely assistance with showers, oral care, and nail care. Observations and interviews revealed missed or delayed hygiene care, with some residents going days without showers or oral care, and staff citing lack of scheduled shower aides and high workload as contributing factors. Documentation and care plans were inconsistent, leading to unmet resident needs.
The facility did not provide adequate nursing staff daily to meet all residents' needs and failed to have a licensed nurse in charge on every shift, resulting in noncompliance with staffing regulations.
Surveyors found that multiple medication carts and a medication room contained insulin pens and vials without proper labeling, open dates, or resident identification, as well as expired medications and controlled substances belonging to discharged residents or those with changed orders. Staff were unable to identify some medications or confirm adherence to storage protocols, and expired drugs were not consistently removed or destroyed as required.
A resident with significant cognitive and physical impairments had a change in pain management, including discontinuation of a narcotic, initiation of Tylenol as needed, and a new routine order for Robaxin. The resident's representative, who was frequently present, was not informed of the new Robaxin order, and staff confirmed the representative was not notified. This lack of communication prevented the representative from making informed care decisions.
A resident with heart failure, diabetes, dysphagia, and moderately impaired cognition was repeatedly found with a medication cup containing three medications left unattended on the bedside table. The resident could not confirm the medications' origin, and nursing staff were unable to verify or account for the medications left at the bedside. Staff interviews revealed inconsistent medication administration practices and a lack of room checks for unattended medications, contrary to facility policy.
A resident with severe cognitive impairment did not receive required quarterly financial statements for their trust account, as confirmed by both the resident's representative and the business office manager. This failure spanned several months and was identified during interviews and record review.
A resident, assessed as cognitively intact, did not receive multiple packages ordered online despite delivery confirmations. Facility staff, following instructions from the resident's representative due to concerns about spending, withheld and returned the packages without confirming the resident's wishes. The resident had not consented to this action and later requested that their mail and packages be delivered, highlighting a failure to ensure resident rights regarding personal communication and mail.
The facility did not document or resolve grievances raised by two residents regarding missed behavioral health counseling appointments and other concerns discussed in a resident council meeting. Despite being aware of these issues, staff failed to follow the required grievance process, resulting in no investigation or communication of outcomes to the residents.
A resident was administered psychotropic medications without a clear clinical indication or was given medications that restrained their ability to function, resulting in a deficiency related to the inappropriate use of such drugs.
A resident was transferred or discharged without the facility ensuring that their needs and preferences were met, and without adequate preparation for a safe transition.
The facility did not provide or document required bed-hold notifications or transfer notices for two residents during hospital transfers. One resident, who required substantial ADL assistance, and another with multiple hospitalizations for respiratory issues, did not receive or recall receiving information about the bed-hold policy. Staff interviews revealed inconsistent practices and unclear responsibility for notifying residents or their representatives about bed-hold policies.
Two residents with histories of heart complications and stroke were incorrectly documented in their MDS assessments as receiving anticoagulant medications, when in fact they were prescribed clopidogrel, which is not an anticoagulant. The error was acknowledged by the MDS Coordinator, who did not follow the correct process for verifying medication types.
A resident did not receive appropriate care to maintain or improve ROM and mobility, and the facility did not ensure interventions were provided unless a medical reason for decline was documented.
A resident with severe cognitive impairment and multiple health conditions received subcutaneous fluids for dehydration, but staff failed to properly monitor, document, and administer the infusion as ordered by the physician. The infusion bag and dressing lacked required labeling, the infusion rate was set below the prescribed amount, and there was no documentation to confirm when the infusion started or who initiated it. Nursing staff did not follow physician orders or facility policy, resulting in the resident receiving fluids at a slower rate than ordered for two days.
Two residents did not receive physician-ordered OT and PT services as required. One resident with multiple sclerosis and other conditions was admitted for therapy but did not receive any OT or PT, with staff citing insurance issues and lacking documentation. Another resident with peripheral neuropathy and repeated falls had therapy orders discontinued and was placed on a restorative program instead, despite repeated requests for therapy and assistive devices. Staff interviews revealed confusion about therapy orders, miscommunication, and therapy staff shortages, resulting in the failure to provide necessary specialized rehabilitative services.
The facility did not have a program in place to monitor antibiotic use, lacking a system to track or evaluate antibiotic administration among residents.
Two residents with dementia and anxiety were not properly assessed for elopement risk, leading to unsupervised exits from the facility. Despite exhibiting wandering and exit-seeking behaviors, their care plans lacked necessary interventions. Staff interviews revealed lapses in updating care plans and recognizing changes in behavior, contributing to the oversight.
The facility did not complete annual performance reviews for four NACs employed for over a year, potentially affecting care quality. Staff A had no review since 2019, Staff B had none since hiring in 2022, Staff C's last review was in early 2023, and Staff D had none since hiring in 2023. The administrator noted the former DON's failure to conduct these reviews.
A resident with a history of swallowing difficulties was served a meal that did not comply with their prescribed diet, leading to a choking incident. The resident, who had a history of choking, was served a soft roll despite a diet order specifying no side breads. Staff failed to check the dietary card, and the cook overlooked the restriction due to being flustered during meal service.
A resident with impaired cognition experienced two falls, resulting in a fractured hip due to delayed medical intervention. Despite showing signs of pain, staff failed to report and document the incidents properly, leading to a delay in treatment. The resident was eventually diagnosed with a fractured right hip after being transported to the emergency room.
A resident with pressure injuries experienced worsening of their condition due to the facility's failure to perform timely assessments and dressing changes, and to implement wound provider recommendations. The resident's sacral wound deteriorated, requiring hospitalization for surgical debridement.
A resident with impaired cognition and mobility needs experienced a fall that was not reported to the State agency. The RN involved delayed documentation and discouraged reporting. Despite the resident's complaints of pain and immobility, timely medical assessment and intervention were not provided, resulting in a delayed diagnosis of a fractured hip. The facility's focus on the RN's failure to report overshadowed the lack of timely medical care.
A resident with impaired cognition fell and suffered a hip fracture, but the LTC facility failed to investigate thoroughly or provide timely medical care. Despite visible pain and inability to move, the incident was not reported or documented properly, and pain management was inadequate. The facility's investigation policy was not followed, leading to a lack of timely assessment and treatment.
The facility failed to document and incorporate Advanced Directives (ADs) into care plans for two residents, risking their end-of-life care preferences. One resident with a stroke and respiratory failure, and another with COVID-19 and kidney failure, both had intact cognition but lacked AD documentation. The Social Services Director and Administrator acknowledged the lack of process for ensuring ADs were offered and documented.
The facility failed to complete MDS discharge assessments within the required 14-day period for five residents, who had various medical conditions, upon their discharge. The MDS Coordinator admitted to missing these assessments, and the administrator expected them to be completed timely.
The facility failed to develop complete baseline care plans within 48 hours of admission for three residents, missing essential dietary and physician orders. A resident readmitted after hip replacement lacked a documented care plan, while another's plan omitted dialysis and diet details. Staff interviews revealed lapses in documentation and communication.
The facility failed to provide adequate assistance with ADLs for five residents, including showering and oral care, as per their care plans. Residents reported missing scheduled showers due to staff shortages and facility maintenance issues. Interviews revealed systemic issues with staffing and scheduling, leading to unmet hygiene needs.
A long-term care facility failed to maintain effective infection control practices, as staff did not adhere to hand hygiene and PPE protocols during resident care, laundry handling, and self-testing for infectious diseases. Additionally, improper cleaning and disinfecting practices were observed, with staff using non-EPA registered disinfectants for C. Diff isolation rooms, increasing the risk of cross-contamination and disease transmission.
A facility failed to protect residents from abuse and neglect, with multiple allegations involving a specific NA. Residents reported incidents of neglect, rough handling, and inappropriate behavior by the NA, but these were not properly reported or addressed by staff. The DON acknowledged that the correct procedures were not followed, and the alleged perpetrator continued to provide care, placing residents at risk.
The facility failed to report allegations of abuse and neglect for four residents, including incidents of rough handling and negligence by nursing assistants. Despite the facility's policy requiring immediate reporting, these incidents were not documented or reported to the administration or state agency, leaving residents at risk for further harm.
The facility failed to investigate allegations of abuse and neglect and did not protect residents from the alleged perpetrator during the investigation phase. Four residents reported incidents involving a male NA working the night shift, but the facility did not adhere to its policy of removing the AP from contact with residents. Staff interviews revealed that the correct procedures for handling abuse allegations were not followed.
A facility failed to transfer a resident's trust funds within the required 30 days after discharge, resulting in a delay of 37 days. The resident, who was admitted with lung complications and lower back pain, was discharged, but the remaining balance of $165.01 was not sent promptly. The Business Office Manager admitted to missing the transfer deadline, which posed a risk of loss of funds and interest.
The facility failed to provide a homelike environment for a resident due to loud noises from televisions during the night, impacting their sleep. Additionally, maintenance issues such as missing paneling and gouges in walls were observed, posing safety hazards. Staff acknowledged the noise issue but believed it had been resolved.
The facility failed to provide required discharge notifications to two residents, their representatives, and the LTC Ombudsman for hospital transfers. One resident was transferred due to shortness of breath, nausea, and vomiting, while another was sent to the hospital after experiencing dizziness and a low heart rate. Staff interviews revealed a misunderstanding of notification requirements.
The facility failed to provide written bed hold notices to three residents during hospital transfers, as required by policy. Interviews with staff revealed inconsistencies in following the procedure, with no documentation found for the affected residents.
The facility failed to validate and update PASARR screenings for three residents, leading to incorrect assessments and a lack of updates for new diagnoses. Despite having policies in place, the admissions staff did not ensure PASARR Level I screenings were accurate or corrected, resulting in residents not receiving appropriate care.
A facility failed to ensure an effective discharge plan for a resident with multiple diagnoses, including bipolar II disorder and heart disease. Despite the resident's care plan indicating a need to relocate closer to family, no referrals or actions were taken by the facility. Interviews revealed a lack of communication and assistance from the facility, placing the resident at risk for unmet care needs.
A resident with diabetes experienced low blood sugar levels after taking a dietary supplement without proper monitoring or physician orders. An LPN failed to remove the supplement or obtain new orders, and the DON noted the correct process was not followed.
A resident with diabetes and heart failure experienced double vision and reported it to staff, but was incorrectly informed they could not see an eye doctor due to Medicare coverage. Despite a note being passed to the Social Services Director, no appointment was scheduled, indicating a failure in communication and procedure.
A resident with diabetes and post-laminectomy was at risk for pressure ulcers, but the facility failed to complete required skin assessments and obtain treatment orders. Despite staff awareness of the resident's sores, there was no proper documentation or treatment, and the wound care physician did not see the resident as scheduled. The DON acknowledged the failure to follow procedures.
A facility failed to implement a gradual dose reduction (GDR) for a resident on Seroquel, prescribed for bipolar and delusional disorders, despite a pharmacist's recommendation. The resident's medical records showed minimal documented behaviors, and staff acknowledged that the behaviors being monitored were not individualized. The Director of Nursing stated that the team did not feel a GDR was appropriate due to undocumented behaviors, indicating inadequate monitoring and documentation.
Incomplete Baseline Care Plans and Missing PASARR Information for New Admissions
Penalty
Summary
The deficiency involves the facility’s failure to develop and implement complete baseline care plans (BCPs) within 48 hours of admission for three residents, as required by facility policy and regulation. The facility’s Baseline Care Plan policy required that each new resident have a BCP developed within 48 hours of admission, including essential healthcare information, initial goals based on admission orders, physician and dietary orders, therapy services, social services, and PASARR recommendations. Surveyors found that for all three reviewed residents, the BCPs were incomplete and did not include required elements such as specific medication needs, mental health diagnoses, PASARR Level II information, and code status. For one resident admitted with respiratory failure with hypoxia, hypoparathyroidism, anxiety, and insomnia, the comprehensive assessment showed the resident needed set-up to partial assistance for ADLs and supervision/touch assistance for transfers, with intact cognition. However, the BCP dated shortly after admission lacked focus areas, goals, or interventions related to multiple ordered medications, including quetiapine, acetazolamide for edema, Synthroid/levothyroxine (with a specific order requiring brand-name Synthroid), temazepam, hydroxyzine, and continuous oxygen use. The BCP also did not include the resident’s preferences for medical treatment in emergent situations (code status) or any information regarding the resident’s Level II PASARR recommendations, despite transfer orders specifying the brand-name Synthroid requirement. For a second resident admitted following hip replacement surgery with diagnoses including long-term anticoagulant use, anxiety, and depression, the comprehensive assessment showed substantial assistance was needed for showers, lower body dressing, and transfers, and that cognition was moderately impaired. The BCP for this resident contained no focus areas, goals, or interventions addressing the anxiety disorder, PASARR, or PASARR Level II recommendations, and did not document preferences for medical treatment in emergent situations. For a third resident admitted with a broken hip, PTSD, and anxiety, who required substantial to maximal assistance for ADLs and had intact cognition, the BCP lacked any focus areas, goals, or interventions related to PTSD or PASARR Level II recommendations. Staff interviews confirmed that the BCP process relied on a user-defined assessment in the electronic record, that code status did not auto-populate and had to be entered manually, and that PASARR and social services sections, including Level II information and dates, were the responsibility of social services but were not completed for these residents.
Failure to Follow Medication Reconciliation and Administration Standards
Penalty
Summary
The deficiency involves the facility’s failure to follow professional standards of practice for medication reconciliation, order transcription, and medication administration for a resident admitted with multiple medical conditions, including respiratory failure with hypoxia, hypoparathyroidism, anxiety, and insomnia. On admission, the facility’s policy required a licensed nurse to reconcile home medications with provider orders and hospital documents, obtain clarifications as needed, and accurately enter orders into the electronic medical record with a second nurse verifying accuracy. For this resident, the Skilled Nursing Facility Transfer Orders included an order for levothyroxine 100 mcg with a specific instruction that it must be the brand name Synthroid, and an order for oxycodone-acetaminophen 10-325 mg every four hours as needed for pain. The LPN/Unit Care Coordinator reported verbally reviewing home medications with the resident on the day of admission and stated there were no concerns or changes needed, and also stated they did not see the additional note specifying brand name Synthroid only when entering the orders. During observation, the resident was found with a clear bag in the bedside table containing a prescription bottle labeled Synthroid 100 mcg and several inhalers, including unopened prescription inhaler boxes. The resident reported keeping their own home Synthroid in the drawer because the generic levothyroxine provided by the facility did not work for them and stated they had informed nursing staff multiple times that they needed the brand name, but staff did not listen. The resident stated that when staff brought levothyroxine to administer, they would throw it on the floor or in the trash and then self-administer their own Synthroid, and that staff left medications in the room without observing administration. A registered nurse confirmed seeing the resident’s Synthroid bottle in the drawer, told the resident they could not take it from them, and instructed the resident to have a loved one take it home, and also stated the order in the system showed levothyroxine, which matched what was in the medication card. The deficiency also includes failure to ensure timely access to ordered pain medication. The resident stated that on the first day and throughout the first night at the facility, they requested their ordered oxycodone for pain but were told the facility did not have the medication and that obtaining it would be a lengthy process, and that they did not receive any oxycodone until the next day. An LPN stated the resident requested pain medication the morning after admission, but the facility did not have oxycodone available because the pharmacy had not sent it and they did not have an authorization code to obtain it from the pyxis; the LPN also stated they did not call the on-call provider. A registered nurse reported being told that the resident’s medications were not available, acknowledged that oxycodone was in the pyxis but could not be accessed without a pharmacy authorization code, and stated that the appropriate process would have been to call the provider so the provider could contact the pharmacy, but they did not call the on-call provider because calls had already been made. The Director of Nursing Services stated that the process should have included contacting the on-call provider to eScribe a prescription to the pharmacy to obtain an authorization code for the pyxis, and that medications should only be kept at the bedside after an assessment, physician order, and care plan update, which had not occurred in this case.
Delayed Therapy Evaluations and Treatments for New Admissions
Penalty
Summary
The facility failed to provide physician-ordered specialized rehabilitative services, specifically PT and OT, in a timely manner for two residents. For one resident admitted with respiratory failure with hypoxia, metabolic encephalopathy, and anxiety, transfer orders dated 01/02/2026 included PT and OT evaluation and treatment. However, the medical record showed that the initial PT and OT evaluations and treatment plan were not completed until 01/06/2026, five days after admission. A comprehensive assessment dated 01/05/2026 documented that this resident required set-up to partial assistance for ADLs and supervision/touch assistance for transfers, with intact cognition. During interview, the resident reported they were not getting much therapy and felt they would be better off at home doing their own therapy. Another resident was admitted following hip replacement surgery with additional diagnoses including long-term use of anticoagulants, anxiety, and depression. The comprehensive assessment showed this resident required substantial assistance for showers, lower body dressing, and transfers, and had moderately impaired cognition. The record showed the initial PT evaluation and treatment plan occurred four days after admission and the OT evaluation and treatment plan occurred five days after admission. The resident was discharged home after receiving only one PT treatment and one OT treatment. In interview, the resident stated they wished therapy had started on the day of admission but were told therapy could not be provided because the Director of Rehabilitation was not present that day. The Director of Rehabilitation reported the facility was short PT staff, with full-time PT staff working Monday through Thursday, resulting in residents admitted on Friday waiting until Monday for therapy evaluations, and stated their understanding that professional standards called for therapy evaluations within three days of admission. The Administrator similarly stated their understanding that therapy evaluations should be completed within the first three days of admission.
Failure to Report Missing Resident to Authorities
Penalty
Summary
The facility failed to report an incident involving a missing resident to the administrator, local law enforcement, and the State Agency as required by regulations. The incident involved a resident who left the facility with a friend to pay rent and did not return as expected. Nursing progress notes documented the resident's absence, but there was no evidence that the administrator or law enforcement were notified at any point during the resident's absence. The administrator later confirmed they were unaware of the situation and stated that the facility would have followed the reporting and investigation process if they had known. The resident involved had a history of hip replacement surgery, bipolar disorder, and anxiety, and required partial to moderate assistance with transfers, bed mobility, dressing, and toileting hygiene. The resident was also noted to have moderately impaired cognition. Despite these vulnerabilities, the absence was not recognized or reported as a missing person incident by staff, and the required notifications and investigation were not initiated.
Failure to Provide Discharge Education and Home Health Referral for Resident with Indwelling Urinary Catheter
Penalty
Summary
The facility failed to develop and implement an effective discharge plan for a resident who was discharged with an indwelling urinary catheter (IUC) and multiple medical conditions, including diabetes, heart failure, and urinary retention. The resident required moderate to maximum assistance with activities of daily living and had moderately impaired cognition. Physician discharge orders specified the need for physical and occupational therapy, skilled nursing for medication management, and post-discharge assessment. However, there was no documentation that the resident or their representative received education on the care and maintenance of the IUC prior to discharge. Additionally, the discharge summary indicated that the resident would be set up with home health services, but there was no evidence that a referral for these services was completed. Interviews with facility staff confirmed that no education or training regarding IUC care was provided to the resident or their representative, and the social services director could not provide documentation of a completed home health referral. The home health agency also had no record of a referral for the resident. As a result, the resident did not receive necessary education or home health services after discharge and subsequently required rehospitalization.
Failure to Supervise and Notify After Resident Elopement
Penalty
Summary
The facility failed to provide adequate supervision and notification procedures for a resident who was reviewed for elopement. According to the facility's policy, if a resident's whereabouts are unknown and they have not signed out or returned as expected, staff are required to review the sign-out log, notify administrative staff, conduct a search, and contact law enforcement if necessary. In this case, a resident with a history of hip replacement, bipolar disorder, anxiety, and moderately impaired cognition signed out to pay rent but did not return as expected, and there was no documented time of return. Staff interviews and record reviews revealed that nursing staff were aware the resident had not returned by the end of the day but did not attempt to contact the resident or notify administrative staff or law enforcement. The resident was later found to be at home, unable to transfer independently, and required emergency services for evaluation due to a decline in functional status. Staff acknowledged that the resident was not safe at home alone and that the expected protocol would have been to attempt contact and, if unsuccessful, initiate the missing person's policy and notify the administrator. Despite the facility's established procedures, staff failed to follow up when the resident did not return at the expected time, did not attempt to contact the resident or their emergency contact, and did not notify law enforcement or administrative staff in a timely manner. This lapse in supervision and notification placed the resident at risk and did not comply with the facility's own policies for managing missing residents or elopement events.
Failure to Change Indwelling Urinary Catheter and Bag During UTIs
Penalty
Summary
The facility failed to provide appropriate care and services to prevent urinary tract infections (UTIs) for a resident with an indwelling urinary catheter (IUC). The resident, who had chronic kidney disease, neuromuscular dysfunction of the bladder, and urinary retention, required maximum assistance for toileting and personal hygiene. Despite having standing orders and facility policy to change the IUC and catheter bag in cases of infection, obstruction, or when the closed system was compromised, there was no documentation that these changes were made when the resident developed symptoms of UTIs and was started on antibiotics on multiple occasions. Nursing progress notes and medication administration records showed that urine specimens were collected and antibiotics initiated for the resident during episodes of UTI symptoms, but the IUC and catheter bag were not changed as required. Interviews with nursing staff and the Director of Nursing confirmed that the process for changing the IUC was not followed, and there was no documentation of catheter or bag changes at the time of infection. This deficiency was identified through interview and record review, and was not in accordance with facility policy or CDC guidelines.
Failure to Maintain Safe Environment and Supervision
Penalty
Summary
A deficiency was identified in the facility's failure to ensure that an area was free from accident hazards and that adequate supervision was provided to prevent accidents. The report notes that the environment did not meet safety standards, which could contribute to accidents occurring. Specific actions or inactions leading to this deficiency include the lack of appropriate measures to identify and remove hazards, as well as insufficient oversight of residents in the affected area.
Failure to Recognize and Respond to Changes in Condition and Adhere to Physician Orders
Penalty
Summary
The facility failed to recognize and respond appropriately to changes in condition for multiple residents, resulting in delayed treatment and unmet care needs. For one resident with a history of urinary tract infection, septic shock, respiratory issues, and heart disease, staff did not complete a change of condition assessment or notify the physician despite significant changes in orientation, oxygen saturation, blood pressure, and pulse. The resident experienced confusion, severe pain, and a drop in oxygen level, ultimately requiring hospitalization for septic shock. Interviews revealed that staff were aware of the resident's deteriorating condition but did not take timely action, and the physician and nurse practitioner were not informed of the critical changes. Another resident with a nephrostomy tube experienced a blocked tube and developed sepsis, leading to hospitalization. Staff failed to monitor and document nephrostomy output as ordered, and did not notify the physician when there was zero output. The resident and their representative reported pain and symptoms consistent with infection, but staff did not follow up or document these concerns, nor did they communicate with the provider as required by facility policy. Documentation gaps and lack of timely intervention contributed to the resident's adverse outcome. A third resident with a history of stroke and brain aneurysms reported new vision changes, dizziness, and head pressure. Although a nurse practitioner ordered a CT scan, there was no documentation of the visit, no alert charting initiated, and no monitoring or assessment of the resident's symptoms by licensed nurses. The order for imaging was not processed in a timely manner, and staff failed to notify the provider about worsening symptoms. Additional deficiencies were identified in the administration of PRN pain medication outside of ordered parameters and without required documentation, as well as in the management of a resident who experienced an unwitnessed fall with a head injury, where neurological checks and family notification were not completed as required.
Failure to Provide Timely Assistance with ADLs Including Showers, Oral Care, and Nail Care
Penalty
Summary
The facility failed to provide timely and adequate assistance with activities of daily living (ADLs), including showers, oral care, and nail care, for multiple residents who were dependent on staff for these needs. Several residents were observed with unkempt hair, soiled clothing, and poor oral hygiene, and interviews with residents and their representatives revealed that scheduled showers and personal care were frequently missed or delayed. Documentation showed that some residents received only a fraction of their scheduled showers over a 30-day period, and in some cases, there was no documentation of bathing or showering for extended periods. Staff interviews confirmed that there were no shower aides scheduled on certain days, particularly Sundays, resulting in missed care for residents scheduled on those days. One resident with severe cognitive impairment and total dependence on staff for hygiene was repeatedly found unkempt, with oily hair, soiled briefs, and visible buildup in their mouth. Their representative reported not witnessing oral care being provided and noted that showers were not given as scheduled. Another resident, who was cognitively intact but physically dependent, was observed with yellowed teeth and buildup, and stated that staff did not offer assistance with oral care. Additional residents reported or were observed to have gone days without showers, with one resident stating they had only received one shower in nearly two weeks, and another with long, dirty fingernails despite orders for weekly diabetic nail care. Staff interviews revealed that high workload, lack of scheduled shower aides, and inconsistent documentation contributed to the missed care. Staff acknowledged that showers scheduled for Sundays were not being provided due to lack of staff, and that care was sometimes deprioritized or not documented. Care plans and schedules reviewed did not always reflect person-centered preferences or provide clear guidance on the frequency of care, further contributing to the deficiencies in meeting residents' ADL needs.
Insufficient Nursing Staff and Licensed Nurse Coverage
Penalty
Summary
The facility failed to provide enough nursing staff each day to meet the needs of every resident and did not ensure that a licensed nurse was in charge on each shift. This deficiency was identified based on observations and findings that indicated staffing levels and licensed nurse coverage were insufficient to comply with regulatory requirements.
Failure to Properly Label, Store, and Discard Medications
Penalty
Summary
Surveyors observed that the facility failed to ensure drugs and biologicals were properly labeled and expired or discontinued medications were discarded as required. On two medication carts and in one medication room, multiple insulin pens and vials lacked labels identifying the resident, dosage, or open dates, making it impossible to verify their intended use or efficacy. Several insulin pens and vials were found past the manufacturer’s recommended storage period at room temperature, and a bottle of potassium tablets was found expired by 60 days. Additionally, the narcotic drawer contained medications belonging to residents who had been discharged or whose orders had changed, including morphine, lorazepam, and oxycodone, which had not been destroyed or returned to the pharmacy. Staff interviews confirmed a lack of awareness regarding the ownership and status of some medications, as well as uncertainty about proper storage and expiration protocols. Staff acknowledged the presence of expired medications and those needing destruction or return, and indicated that medication room maintenance and rotation were the responsibility of night shift nurses. The facility’s own policy required medications to be labeled with expiration dates and to be separated and destroyed or returned if expired, contaminated, or no longer in use, but these procedures were not consistently followed.
Failure to Notify Resident Representative of Medication Change
Penalty
Summary
The facility failed to inform the resident representative (RR) of a change in the pain medication regimen for a resident who was totally dependent on staff for all activities of daily living and had diagnoses including right hip fracture, muscle weakness, seizures, and dementia. The resident's narcotic pain reliever was discontinued and replaced with Tylenol as needed, and subsequently, a new order for Robaxin, a muscle relaxant, was initiated on a routine basis. The RR, who was present in the facility most of the day, was not notified of the new Robaxin order and expressed concern that the medication made the resident drowsier, affecting participation in physical therapy. Interviews with facility staff confirmed that the order for Robaxin was written by an advanced registered nurse practitioner and entered into the medication administration record, but the RR was not informed of this change. The RR's lack of notification prevented them from making an informed decision regarding the resident's care needs, as required by regulation.
Medications Left Unattended at Bedside for Cognitively Impaired Resident
Penalty
Summary
Facility staff failed to ensure the clinical appropriateness and safety of self-administration of medications for a resident with multiple diagnoses, including heart failure, diabetes, and dysphagia. The resident's comprehensive assessment indicated moderately impaired cognition and a need for setup assistance with eating. Despite this, surveyors observed on multiple occasions that a medication cup containing three medications was left unattended on the resident's bedside table while the resident was either asleep or awake, with the resident unable to confirm if the medications were theirs or when they were brought in. Interviews with nursing staff revealed a lack of clarity and consistency in medication administration practices. One RN stated that medications for this resident were typically given with applesauce and could not verify the medications left at the bedside, nor how long they had been there. The RN also admitted to not routinely scanning the room for unattended medications during medication passes. The DON confirmed that leaving medications at the bedside was not the facility's expectation and emphasized adherence to the rights of medication administration. These observations and interviews demonstrated a failure to follow facility policy and regulatory requirements regarding safe medication administration.
Failure to Provide Quarterly Trust Account Statements
Penalty
Summary
The facility failed to provide quarterly financial statements for resident trust accounts in accordance with generally accepted accounting practices for one of three residents reviewed. Specifically, a resident with severe cognitive impairment, including diagnoses of bipolar disorder, dementia, and muscle weakness, had a trust account managed by the facility. The resident's representative reported not receiving any financial statements for the first quarter of the year, and this was confirmed during interviews and record review. The lack of statements covered the months of January, March, October, and November 2024. The business office manager acknowledged that, upon starting in October 2024, they discovered that residents had not been receiving their required financial statements. This lapse in providing timely and accurate financial information prevented the resident and their representative from verifying the status of the resident's personal funds held by the facility.
Failure to Ensure Resident Access to Personal Mail and Packages
Penalty
Summary
A resident with diagnoses including bipolar disorder and diabetes, who was assessed as cognitively intact and able to make their own decisions, did not receive multiple packages ordered from Amazon despite delivery confirmations. The resident reported missing packages to facility staff, provided proof of delivery, and attempted to resolve the issue by contacting the Activities Director and front desk, but was repeatedly told no packages had been received. Staff interviews revealed that the Activities Assistant, responsible for mail delivery, had been instructed by management to return any packages for the resident from Amazon based on direction from the resident's representative, who expressed concerns about the resident's spending habits. The Activities Director and other staff were not aware if the resident had been informed about the returned packages, and there was no confirmation that the resident had consented to this action. Further interviews confirmed that the administrator and business manager acted on the representative's instructions to withhold or return the resident's packages, assuming the representative had discussed this with the resident, but without direct confirmation. The resident later clarified that while they had given permission for their representative to discuss financial matters with the business office, they had not consented to having their mail or packages withheld. The resident directly communicated to their representative and staff that they wanted their packages and mail to be delivered, indicating a lack of communication and failure to honor the resident's rights regarding their personal mail and packages.
Failure to Document and Resolve Resident Grievances
Penalty
Summary
The facility failed to ensure that grievances voiced by residents, both individually and during resident council meetings, were promptly identified, documented, investigated, and resolved according to facility policy. Specifically, concerns raised during a resident council meeting regarding delayed call light responses, a needed door repair, and complications with behavioral health counseling services were not entered into the grievance log, nor was there evidence of follow-up or communication of resolution to the residents. The facility's grievance policy required that all grievances be documented, investigated, and that residents be updated on the progress and outcome, but this process was not followed for the concerns raised in July 2025. Two residents with diagnoses including anxiety, depression, and other complex mental health disorders, both cognitively intact and able to express their needs, reported not receiving scheduled behavioral health counseling services. Interviews confirmed that these concerns were known to staff, including the Social Service Director, who acknowledged that the grievances were not logged or processed according to policy. The Grievance Officer also stated they were not informed of the grievances from the resident council meeting, resulting in a lack of appropriate documentation and follow-up.
Unnecessary Use of Psychotropic Medications
Penalty
Summary
The facility failed to prevent the use of unnecessary psychotropic medications or the use of medications that may restrain a resident's ability to function. This deficiency indicates that residents were either prescribed psychotropic drugs without a clear clinical indication or were given medications that limited their functional abilities, contrary to regulatory requirements.
Failure to Ensure Safe and Resident-Centered Transfer/Discharge
Penalty
Summary
The facility failed to ensure that the transfer or discharge process met the resident's needs and preferences, and did not adequately prepare the resident for a safe transfer or discharge. The report notes that the necessary steps to assess and address the resident's individual requirements and preferences during the transfer or discharge process were not completed. As a result, the resident was not properly prepared for a safe transition to the next care setting.
Failure to Provide Bed-Hold and Transfer Notifications
Penalty
Summary
The facility failed to provide required written notices regarding bed-hold policies and transfer notifications to residents or their representatives during hospital transfers. Specifically, for two residents reviewed, there was no documentation in the medical records of bed-hold notifications or notices of transfer at the time of their hospitalizations. Staff interviews confirmed that the designated personnel did not notify the residents or their representatives about the bed-hold policy, and the expected documentation was missing from the residents' charts. Staff members provided inconsistent accounts of who was responsible for offering and documenting the bed-hold policy, with some stating that nurses or the business office manager should handle notifications, while others indicated that the admissions director provided initial education at admission only. One resident, who was alert, oriented, and required substantial assistance with activities of daily living, was transferred to the hospital and did not return, with no evidence of bed-hold notification or transfer notice in the record. Another resident, with multiple hospital transfers due to respiratory issues and a history of emphysema, anxiety, and bipolar disorder, reported not being aware of the bed-hold policy and had no documentation of such notifications during several hospitalizations. Staff interviews further revealed a lack of clarity and follow-through regarding the process for offering and documenting bed-hold notifications and transfer notices.
Inaccurate MDS Medication Assessment for Two Residents
Penalty
Summary
The facility failed to ensure that the Minimum Data Set (MDS) assessments accurately reflected the medication status of two residents. For both residents, the comprehensive MDS assessments indicated that they were receiving anticoagulant medications. However, a review of provider orders for the relevant period showed that neither resident was prescribed an anticoagulant. Instead, both residents were taking clopidogrel, which is not classified as an anticoagulant. The MDS Coordinator, a registered nurse, acknowledged during an interview that the assessments were completed incorrectly, as clopidogrel had been mistakenly marked as an anticoagulant. The residents involved had medical histories including heart complications, stroke, and brain aneurysms. The incorrect documentation in the MDS assessments resulted from not following the correct process for verifying medication types against provider orders.
Failure to Maintain or Improve Resident Range of Motion
Penalty
Summary
A deficiency was identified regarding the facility's failure to provide appropriate care to maintain and/or improve a resident's range of motion (ROM), limited ROM, and/or mobility. The facility did not ensure that the resident received necessary interventions to prevent a decline in ROM or mobility, except in cases where such decline was due to a documented medical reason. This lack of appropriate care was observed and cited by surveyors during the review.
Failure to Monitor and Document Hydration Therapy per Physician Orders
Penalty
Summary
The facility failed to ensure that a resident with severe cognitive impairment and multiple medical conditions, including heart and kidney disease, was consistently monitored and received adequate hydration fluids as ordered by the physician. The resident was observed with an infusion bag for subcutaneous fluids that lacked essential labeling, such as start time, infusion rate, and staff initials. The infusion was administered without a pump to indicate the rate, and there was no documentation on the bag or dressing to verify when the infusion began or who initiated it. Staff interviews revealed uncertainty about the infusion's start time and rate, and the dial flow device was set below the ordered rate. The resident continued to receive fluids at a slower rate than prescribed for two days without a physician's order to do so. Review of the resident's medical record confirmed a physician's order for two liters of sodium chloride to be infused subcutaneously at 70 ml/hr for one day. However, staff were unable to confirm compliance with this order due to missing documentation and improper labeling. The Director of Nursing Services acknowledged that nursing staff are expected to document and follow physician orders, but this was not done in this case. The lack of monitoring, documentation, and adherence to physician orders placed the resident at risk for complications related to inadequate hydration.
Failure to Provide Physician-Ordered Therapy Services
Penalty
Summary
The facility failed to ensure that physician-ordered occupational therapy (OT) and physical therapy (PT) services were provided to two residents who required these specialized rehabilitative services. For one resident with multiple sclerosis, neuralgia, and depression, the admission assessment indicated a need for PT, OT, and speech therapy (ST), and transfer orders specified OT three times a week for four weeks and PT three times a week for up to 45 days. However, there were no therapy notes or documentation showing that OT or PT services were provided, and the resident reported not receiving any therapy during their stay. Staff interviews revealed confusion regarding therapy orders, with staff citing insurance coverage issues and a lack of documentation or evaluation by therapy staff. Another resident with a history of repeated falls and peripheral neuropathy was admitted with orders for PT and OT evaluation and treatment. The resident repeatedly requested therapy services and assistive devices to aid in mobility and independence, but was told by staff that a provider referral was needed and that long-term residents did not receive specialized therapy services. Medical records showed that therapy orders were discontinued shortly after admission, and the resident was instead placed on a restorative nursing program focused on upper extremity exercises, with no therapy provided for lower body mobility. Staff interviews indicated that therapy staff shortages and miscommunication contributed to the lack of therapy services, and there was a lack of awareness among staff regarding the resident's developing contracture and therapy needs. Documentation review and staff interviews confirmed that required therapy evaluations and treatments were not completed as ordered for both residents. Orders were either not entered, discontinued without follow-up, or not acted upon due to staff assumptions, insurance misunderstandings, or staffing shortages. The interdisciplinary team did not ensure that therapy needs were addressed, and there was no evidence that the residents received the specialized rehabilitative services necessary to maintain or improve their functional abilities.
Failure to Monitor Antibiotic Use
Penalty
Summary
The facility failed to implement a program that monitors antibiotic use. There is no evidence provided that the facility had a system in place to track, review, or evaluate the use of antibiotics among residents. This lack of monitoring could result in inappropriate or unnecessary antibiotic administration, but the report only states the absence of a monitoring program and does not provide further details about specific residents or incidents.
Failure to Prevent Resident Elopement Due to Inadequate Risk Assessment
Penalty
Summary
The facility failed to identify, assess, and provide adequate supervision to prevent elopement for two residents, placing them at risk. Resident 1, who had diagnoses including dementia and anxiety, was assessed as not at risk for elopement despite having qualifying conditions. After returning from a hospital stay, Resident 1's elopement risk was not reassessed accurately, leading to an incident where the resident left the facility unsupervised. The care plan for Resident 1 lacked focus areas, goals, or interventions for elopement prevention until after the incident occurred. Resident 2, diagnosed with anxiety and Alzheimer's disease, was also not initially identified as an elopement risk despite having qualifying diagnoses. The resident's elopement risk was only recognized after an audit following an elopement incident. The facility's process for identifying elopement risks during admission and updating care plans with changes in condition was not effectively implemented, contributing to the oversight in recognizing Resident 2's risk. Interviews with staff revealed that both residents exhibited behaviors indicative of elopement risk, such as wandering and exit-seeking, which were not adequately addressed in their care plans. The Director of Nursing acknowledged that the process for updating care plans and identifying changes in resident behavior was not followed, leading to the failure in preventing the elopement incidents.
Failure to Conduct Annual NAC Performance Reviews
Penalty
Summary
The facility failed to ensure that annual performance reviews for Nurse Aide Certified (NAC) staff were completed for four NACs who had been employed for over a year. Staff A, hired in 1993, had not received a performance review since 2019. Staff B, hired in 2022, had not received any performance review. Staff C, hired in 2021, had their last review in March 2023, and Staff D, hired in 2023, had not received any performance review. This lack of performance evaluations was identified through interviews and record reviews, indicating a lapse in maintaining the competency of the NACs, which could potentially affect the quality of care provided to residents. The administrator acknowledged that the former Director of Nursing had not conducted the required performance reviews.
Failure to Follow Diet Order Leads to Choking Incident
Penalty
Summary
The facility failed to supervise and ensure that the physician's diet order for a resident was followed, which placed the resident at risk for medical complications due to a choking incident. The resident had a history of difficulty swallowing following a stroke and was on a prescribed diet of regular food with an easy-to-chew texture and no side breads. Despite this, the resident was served a soft roll on their meal tray, which was not cut up, leading to a choking incident. This incident was a repeat deficiency, as similar issues had been noted in a previous statement of deficiencies. The resident's medical record indicated a history of choking incidents, including one where the resident choked on a dinner roll and another on a piece of pizza, both requiring the Heimlich maneuver. Staff interviews revealed that the nursing assistant did not check the resident's tray card before serving the meal, and the cook, who was newly hired, did not notice the dietary restriction due to being flustered by multiple requests during meal time. The food service manager was aware of the resident's choking history and the former speech therapist's recommendation against bread items, but the oversight still occurred.
Failure to Address Change in Condition After Resident Falls
Penalty
Summary
The facility failed to identify and take timely action when a change of condition occurred for a resident after a fall. Resident 1, who had moderately impaired cognition and required assistance for mobility and personal care, was found on the floor on two separate occasions. On the first occasion, the resident was found on the floor after attempting to go to the bathroom and was assisted back to bed using a mechanical lift. No injuries were initially observed, and the resident denied pain. However, swelling and pain were later noted in the left hip, and an x-ray was ordered. On the second occasion, the resident was found on the floor again, and despite showing signs of pain, Staff A instructed Staff B not to report the fall to avoid paperwork. Staff B, uncomfortable with this, informed Staff C, who did not take further action, assuming the resident was already on the fall list. The resident continued to show signs of pain and swelling, particularly in the right thigh, which was not addressed until the following day when the resident was transported to the emergency room and diagnosed with a fractured right hip. Throughout the incident, there were multiple failures in communication and documentation among the staff. Staff A delayed documenting the fall, and Staff C did not adequately assess the resident's condition or follow up on the reported pain. The lack of timely medical intervention and proper documentation led to a delay in treatment for the resident's fractured hip, resulting in harm.
Failure to Provide Timely Pressure Ulcer Care
Penalty
Summary
The facility failed to consistently assess and perform dressing changes as ordered for Resident 2, who was admitted with pressure injuries (PIs) and other medical conditions including cellulitis, heart problems, and Parkinson's disease. Upon admission, Resident 2 had an unstageable PI to the sacrum, which worsened over time due to inadequate monitoring and care. The facility did not implement the wound provider's recommendations timely, including the application of a wound vac, which was delayed by five days after being ordered. The facility's documentation showed lapses in daily wound care for Resident 2, with missing records on specific dates in August and September 2024. The consulting wound provider noted the deterioration of the sacral wound, which eventually required surgical debridement at the hospital. The wound had developed a large amount of foul-smelling purulent drainage, and the necrotic tissue was identified as the likely source of the drainage. Despite recommendations for a wound vac, it was not applied until several days later, contributing to the worsening condition. Interviews with staff revealed issues with wound assessments and communication. Staff K, an LPN/Resident Care Manager, admitted to not documenting wound measurements properly and acknowledged the delay in applying the wound vac. The consulting wound provider was unable to see Resident 2 due to credentialing issues, and the consulting physician noted the unacceptable state of the wound upon their return. The facility's failure to provide timely and adequate wound care resulted in Resident 2 being hospitalized for further evaluation and treatment.
Failure to Report Fall and Delay in Medical Intervention
Penalty
Summary
The facility failed to report an incident of neglect involving a fall with significant injury to the State agency as required. This incident involved a resident who was admitted with heart problems and had moderately impaired cognition. The resident required assistance from two staff members for turning, repositioning, toileting, and transfers, and one staff member for dressing and personal hygiene. On the evening of the incident, the resident was found out of bed by a registered nurse (RN), who, along with a nursing assistant (NA), assisted the resident back to bed. The RN did not document the fall until three days later and instructed the NA to keep the incident a secret. The resident later complained of pain and was unable to move their right leg, but no immediate medical intervention was sought. Despite being informed of the fall and the resident's pain, the RN on duty did not conduct a thorough assessment or administer pain medication. The resident's condition was only addressed the following morning when another nurse documented the resident's pain and inability to move their right leg, leading to the resident being transported to the emergency room. The hospital records confirmed a fractured right hip, requiring surgery. The facility's administrator did not report the incident to the State agency, focusing instead on the RN's failure to report or document the fall, rather than the delay in medical assessment and intervention. This deficiency was a repeat issue from previous statements of deficiencies.
Failure to Investigate Resident Fall and Provide Timely Care
Penalty
Summary
The facility failed to thoroughly investigate an incident of neglect involving a resident who suffered a hip fracture after a fall. The resident, who had moderately impaired cognition and required assistance for mobility and personal care, was found on the floor by a registered nurse (RN) and a nursing assistant (NA). Despite the resident's complaints of pain and inability to move their right leg, the investigation did not include statements from all relevant staff members, and there was a lack of timely medical assessment and care. The incident was not reported to the family, and the fall was not documented as instructed by the RN. The resident was eventually transported to the emergency room the following day, where a fractured right hip was diagnosed, necessitating surgery. Staff interviews revealed that the resident was in visible pain, yet pain management was inadequate, with only one dose of Tylenol administered and no documentation of refusal. The facility's policy on conducting investigations was not followed, as the investigation lacked thoroughness and failed to address the significant changes in the resident's condition and the delay in obtaining necessary medical evaluation and treatment.
Failure to Document and Incorporate Advanced Directives
Penalty
Summary
The facility failed to properly document and incorporate Advanced Directives (ADs) into the care planning process for two residents, placing them at risk of not having their end-of-life care preferences honored. Resident 22, who was admitted with a stroke and acute respiratory failure, had intact cognition but did not have an AD documented in their medical record. Despite the resident expressing a desire for their son to be their legal representative, the facility did not assist them in formulating an AD or document any such assistance. The Social Services Director acknowledged that while residents were asked about ADs upon admission, there was no process for ensuring documentation or follow-up. Similarly, Resident 35, admitted with COVID-19 and end-stage kidney failure, also had intact cognition and required assistance with daily activities but did not have an AD documented. The resident reported not being offered assistance in formulating an AD upon admission. The facility's Administrator confirmed that the Social Services department was responsible for handling ADs and expected that residents would be offered assistance in creating one if needed. However, there was no evidence of such actions being taken or documented in the care plans for these residents.
Failure to Complete Timely MDS Discharge Assessments
Penalty
Summary
The facility failed to complete the Minimum Data Set (MDS) discharge assessments within the required 14-day period for five residents, placing them at risk for unmet needs upon discharge. The residents involved had various medical conditions, including diabetes, pneumonia, stroke, anxiety, kidney disease, urine infection, knee replacement, and end-stage kidney and heart failure. Despite being discharged from the facility, comprehensive discharge assessments were not completed for these residents, which is a requirement to ensure their needs are adequately addressed post-discharge. Interviews with facility staff revealed that the MDS Coordinator, a registered nurse, acknowledged the oversight, stating that they remembered to complete end-of-therapy assessments but missed the discharge assessments for the affected residents. The facility administrator also expressed an expectation that the MDS discharge assessments should have been completed in a timely manner, indicating a lapse in the facility's adherence to regulatory requirements.
Incomplete Baseline Care Plans for New Admissions
Penalty
Summary
The facility failed to develop a baseline care plan within 48 hours of admission for three residents, which included necessary dietary orders, physician orders, and treatment plans. Resident 19, who was readmitted following a hip replacement, did not have a documented 48-hour care plan upon return from the hospital. The Social Services Director acknowledged that the care plan was missed, indicating a lapse in the responsibility of the Resident Care Managers or the Admission Nurse. Resident 35's baseline care plan was incomplete, lacking physician orders, dialysis schedule, and diet orders. Staff interviews revealed that the baseline care plan was not always documented correctly, and the Director of Nursing Services was unaware of these omissions. Similarly, Resident 50's care plan did not include physician orders, diet orders, or the resident's dependency on staff for eating, despite the dietician entering tube feeding orders prior to the resident's arrival. These deficiencies highlight a pattern of incomplete documentation and communication failures within the facility.
Deficiencies in ADL Assistance and Hygiene Care
Penalty
Summary
The facility failed to provide adequate assistance with activities of daily living (ADLs) for five residents, specifically in the areas of showering, grooming, and oral care, as per their care plans. Resident 5, who had a stroke resulting in right-sided weakness, required substantial assistance with personal hygiene, including brushing teeth. However, the resident reported not receiving the necessary help, leading to unmet hygiene needs. Similarly, Resident 14, who required total assistance for showers twice a week, reported only receiving one shower per week and none for over two weeks after returning from the hospital. Resident 6, who needed assistance with bathing and other ADLs, went nine days without a shower, despite not refusing care. Resident 13, with a myoneural disorder and other conditions, experienced significant gaps in receiving showers, with periods of up to twenty-four days without one. Staff interviews revealed that there were issues with shower aide availability and scheduling, contributing to these deficiencies. Resident 22, who required assistance due to a stroke, frequently missed scheduled showers due to staff shortages and facility maintenance issues, such as a non-functioning shower room. The report highlights systemic issues in the facility's ability to meet residents' ADL needs, particularly in providing regular showers and personal hygiene assistance. Staff interviews indicated that the facility struggled with staffing shortages, particularly with shower aides, and had challenges in maintaining functional shower facilities. These deficiencies resulted in residents not receiving the care outlined in their care plans, leading to unmet hygiene needs and dissatisfaction among the residents.
Inadequate Infection Control Practices in LTC Facility
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by multiple observations of staff not adhering to hand hygiene and personal protective equipment (PPE) protocols. Six staff members were observed not performing hand hygiene or changing gloves during resident care, which included activities such as repositioning residents, providing incontinent care, and handling soiled linens. Additionally, staff entered isolation rooms without donning the required PPE, increasing the risk of cross-contamination and transmission of infectious diseases. The improper use of PPE was further highlighted in the handling of resident laundry and self-testing for infectious diseases. Staff were observed sorting laundry without the appropriate PPE, such as gowns and face shields, and were unable to identify linens from COVID-19 or C. Diff positive rooms. This lack of proper identification and handling of potentially contaminated laundry posed a significant risk of spreading infections within the facility. Furthermore, a staff member was observed conducting a COVID-19 self-test without PPE, contrary to the facility's guidelines. Environmental cleaning and disinfecting practices were also found to be inadequate. Staff used a neutral all-purpose cleaner that was not EPA-registered for killing C. Diff spores, and there was no specific order for cleaning isolation rooms. Staff were unaware of the need for an EPA-registered disinfectant and failed to perform hand hygiene after cleaning isolation rooms. These lapses in infection control practices placed residents at an increased risk of exposure to infectious diseases.
Failure to Protect Residents from Abuse and Neglect
Penalty
Summary
The facility failed to protect residents from abuse and neglect, as evidenced by multiple allegations involving a specific nursing assistant (NA) identified as Staff R. Resident 22 reported an incident where they became entangled in a call light cord, and the NA initially refused to assist, only returning after the resident threatened to call the police. Despite reporting the incident, Resident 22 continued to receive care from the same NA. Similarly, Resident 52 alleged neglect by the same NA, who failed to empty their urine drainage bag, causing discomfort, and refused to assist with retrieving a dropped item. These allegations were reportedly communicated to a nurse manager, but no administrative follow-up occurred, and the NA continued to be assigned to Resident 52. Resident 45 experienced rough handling by Staff R during care, which was reported to Staff M, an LPN, who failed to follow the proper protocol of reporting the incident to administration or the state agency. Instead, Staff M attempted to resolve the issue by having Staff R apologize to the resident. Resident 54 also reported an incident involving Staff R, where a package of wipes was thrown at them, but Staff M did not report this allegation either. The Director of Nursing Services (DON) acknowledged that the correct procedures were not followed, and the alleged perpetrator should have been removed immediately. Interviews with staff revealed a lack of communication and understanding of the severity of the allegations. Staff A, the Administrator, was unaware of the resident involvement in the incidents and failed to recognize the allegations as reportable events. The failure to report and address these allegations promptly placed residents at risk for further abuse and neglect, as the alleged perpetrator continued to provide care to the affected residents. The facility's inaction and lack of proper investigation into these allegations highlight significant deficiencies in their abuse prevention and reporting protocols.
Failure to Report Allegations of Abuse and Neglect
Penalty
Summary
The facility failed to report allegations of abuse and neglect for four residents, placing them at risk for further harm. The facility's policy required immediate reporting of such allegations to the Administrator and the state agency, but this was not adhered to. Resident 22 reported an incident where a nursing assistant refused to help when their call light became tangled around their neck, and the assistant left the room without assisting. Resident 52 reported consistent negligence by a night shift nursing assistant, but no follow-up was conducted by the administration. Resident 45 alleged rough handling by a nursing assistant, which they felt was retaliatory. This incident was reported to a night nurse, but the nurse did not escalate the report, believing the resident misunderstood the care provided. Resident 54 reported an incident where a nursing assistant threw a bag of wipes at them, but this was not reported to the administration as the staff member believed the complaint was about delayed response to a call light. Interviews with the facility's Administrator and Director of Nursing revealed they were unaware of these allegations, as they had not been reported by the staff. A review of the facility's incident log showed no records of these allegations, indicating a systemic failure to document and report incidents of abuse and neglect as required by policy.
Failure to Investigate and Protect Residents from Alleged Abuse
Penalty
Summary
The facility failed to conduct a complete and thorough investigation into allegations of abuse and neglect, and did not ensure the protection of residents from the alleged perpetrator (AP) during the investigation phase. This deficiency affected four residents who reported incidents involving a male Nursing Assistant (NA) working the night shift. The facility's policy required the removal of the AP from contact with residents during investigations, but this was not adhered to. Resident 22, who had a stroke affecting their left side, reported an allegation of abuse/neglect involving an African American male NA. Resident 52, with a diagnosis of diabetes, also reported negligent care by a similar NA. Both residents' allegations were not communicated to the facility's administrator, and no investigations were initiated. Resident 45, who required substantial assistance with mobility, reported rough handling by Staff R, NA, but the staff member was not removed from resident care, and no investigation was started. Similarly, Resident 54, with a fracture in their lower left arm, reported an incident involving a hurried NA throwing wipes at them, but this was not investigated. Staff interviews revealed that the facility's staff did not follow the correct procedures for handling abuse allegations. Staff M, who received reports from Residents 45 and 54, did not remove the involved staff or initiate investigations. The Director of Nursing Services, Staff B, stated that the expected protocol was not followed, which included removing the staff member, notifying supervisors, and reporting to the State agency.
Delayed Transfer of Resident Trust Funds
Penalty
Summary
The facility failed to ensure the timely transfer of funds from a resident trust account within 30 days following the discharge of a resident, identified as Resident 316. The resident was admitted with lung complications and lower back pain and was subsequently discharged. However, the facility delayed sending the remaining balance of $165.01 from the resident's trust account, issuing the check 37 days after discharge. During an interview, the Business Office Manager, Staff DD, acknowledged the oversight in transferring the funds within the required timeframe, as stipulated by the facility's policy and WAC 388-97-0340 (4)(5). This delay placed the resident and/or their representatives at risk for loss of funds and accumulated interest.
Failure to Maintain a Homelike Environment
Penalty
Summary
The facility failed to maintain a quiet, comfortable, and homelike environment for Resident 218, as observed during a night shift when loud noises from televisions and music were present in the 100-hallway while residents were trying to sleep. Resident 218 specifically requested assistance from Staff Y, a Nursing Assistant, to ask their neighbor to lower the volume of their television, which had been loud throughout the night. Although the neighbor complied, the television remained audible from the hallway. In an interview, Resident 218 expressed difficulty sleeping due to the persistent loud noise from neighboring televisions, leading them to nap during the day instead. Additionally, the facility's physical environment was found lacking in maintenance and repair. Observations revealed missing paneling with sharp edges at the Team 1 Nursing station desk, gouges in the drywall behind Resident 55, and detached panel boards in a resident's room, posing potential safety hazards. Staff Z, the Maintenance Director, acknowledged these issues and explained the process for assessing and documenting needed repairs, which included reviewing maintenance logs daily. However, the Administrator and Director of Nursing Services admitted to being aware of the unacceptable noise levels during the night shift, mistakenly believing the issue had been resolved.
Failure to Notify Residents and Ombudsman of Hospital Transfers
Penalty
Summary
The facility failed to provide a written notice of discharge to two residents and their representatives, as well as to the Office of the State Long-Term Care (LTC) Ombudsman, for hospitalizations. This deficiency was identified during a review of the facility's policy on transfers and discharges, which did not include the requirement to notify the LTC Ombudsman. Resident 14, who was cognitively intact and required substantial assistance with activities of daily living, was transferred to the hospital with symptoms of shortness of breath, nausea, and vomiting, but no notice of transfer/discharge was issued to the resident, their representative, or the LTC Ombudsman. Similarly, Resident 51, who had intact cognition and was admitted with heart failure, end-stage kidney failure, and respiratory failure, was sent to the hospital after experiencing dizziness, nausea, and a dangerously low heart rate. Despite the facility-initiated transfer, no notification was provided to the resident, their representative, or the LTC Ombudsman. Interviews with facility staff revealed a misunderstanding of the requirement to report hospital transfers to the LTC Ombudsman, contributing to the oversight.
Failure to Provide Bed Hold Notices During Hospital Transfers
Penalty
Summary
The facility failed to issue a written notice of bed hold to residents or their representatives at the time of hospital transfer, as required by their policy. This deficiency was identified for three residents who were transferred to the hospital. Resident 14, who had diagnoses including cardiac disease, diabetes, and depression, was transferred to the hospital without documentation of a bed hold notice on 05/21/2024. Similarly, Resident 19, with a right hip replacement, diabetes, and cardiac disease, was transferred on 02/28/2024 without a bed hold notice. Resident 51, diagnosed with end-stage kidney failure and respiratory failure, was also transferred to the hospital without a documented bed hold notice. Interviews with facility staff revealed that the responsibility to offer the bed hold policy to residents prior to hospital discharge was not consistently followed. Staff C, a Licensed Practical Nurse/Unit Coordinator, indicated that the policy should be offered unless the transfer was emergent, in which case it should be provided the next day. However, Staff C could not locate a bed hold policy for Resident 51. Additionally, Staff B, the Director of Nursing Services, confirmed that the nursing staff did not follow the correct process, as they could not locate bed hold policies for Residents 14, 19, and 51.
Failure to Validate and Update PASARR Screenings
Penalty
Summary
The facility failed to review and validate the Preadmission Screening and Resident Reviews (PASARR) for three residents, leading to incorrect assessments on admission and a lack of updates for new diagnoses. Resident 19 was admitted with a diagnosis of depression, but the PASARR Level I screening did not include this diagnosis, and it was not corrected or updated. Similarly, Resident 30 was admitted with multiple diagnoses, including bipolar disorder and depression, but the PASARR Level I screening failed to include an anxiety disorder diagnosis. This screening was also not corrected or updated. Resident 46's PASARR Level I screening did not include an anxiety disorder diagnosis, and like the others, it was not corrected or updated. Interviews with facility staff revealed that the admissions staff were responsible for reviewing PASARRs, and if further screening was required, they were to notify Social Services. However, the process failed as the PASARRs were not reviewed for accuracy, and necessary corrections were not made. The facility's policy required PASARR Level I screenings to be completed before admission, but this was not adhered to, resulting in the residents not receiving appropriate care and services for their needs.
Failure in Resident-Centered Discharge Planning
Penalty
Summary
The facility failed to ensure an effective, resident-centered discharge plan for a resident, identified as Resident 46, who was reviewed for discharge planning. The resident was admitted with multiple diagnoses, including a history of falls, bipolar II disorder, depression, muscle weakness, heart disease, and anxiety. The comprehensive assessment indicated that the resident had moderately impaired cognition but was independent in bed mobility, transfers, and walking. The care plan initially indicated that the resident would remain in the facility for long-term care until a bed could be secured closer to the family. However, the progress notes from May to July 2024 did not reflect any ongoing conversations or actions taken by the facility to facilitate the discharge plan. Interviews with the resident's representative and facility staff revealed a lack of communication and action regarding the discharge plan. The resident's representative expressed that they had requested assistance in relocating the resident closer to family but had not received any updates or referrals from the facility. Staff members, including the Social Services Assistant and Director, acknowledged that no referrals had been sent out and that the family was expected to look for facilities due to the staff's unfamiliarity with the desired discharge location. This inaction placed the resident at risk for unmet care needs and a diminished quality of life.
Failure to Monitor and Manage Resident's Blood Sugar Levels
Penalty
Summary
The facility failed to ensure that a resident received medications or supplements as prescribed and monitored according to physician orders. Resident 21, who was admitted with diagnoses including diabetes and morbid obesity, experienced low blood sugar levels after taking a dietary supplement called Sugar Defender. The resident's blood sugar levels were documented to have fallen below 100 mg/dL on multiple occasions after starting the supplement, with some readings as low as 56 mg/dL. Despite these low readings, there was no documented follow-up from the provider after being notified by Staff L, an LPN, about the resident's condition and supplement use. Staff L did not remove the supplement from the resident's room or obtain new orders from the provider, assuming the provider had addressed the issue during rounds. The Director of Nursing Services, Staff B, indicated that Staff L did not follow the correct process, as they should have retrieved the supplement until it was reviewed and deemed safe by the provider. The lack of appropriate action and documentation regarding the resident's use of the supplement and the resulting low blood sugar levels led to the deficiency.
Failure to Provide Vision Services for Resident
Penalty
Summary
The facility failed to provide necessary vision services for a resident who experienced changes in their vision. The resident, who had a medical history of diabetes and heart failure, reported experiencing double vision for over a month. Despite having intact cognition and being independent in transfers, the resident was told they could not see an eye doctor until they were no longer on Medicare. This misinformation led to a delay in addressing the resident's vision concerns. Interviews with staff revealed a breakdown in communication and procedure. A Licensed Practical Nurse/Unit Coordinator acknowledged receiving a report from the resident about their vision issues and passed a reminder note to the Social Services Director, who was responsible for arranging appointments. However, the Social Services Director stated they did not receive the note, and no appointment was scheduled. The Director of Nursing Services confirmed that the correct process was not followed, and an appointment should have been scheduled regardless of the resident's payer source.
Failure to Manage and Treat Pressure Ulcers
Penalty
Summary
The facility failed to complete necessary skin assessments and obtain treatment orders for a resident with pressure ulcers, leading to the risk of development and worsening of these ulcers. The resident, who was admitted with conditions including diabetes and post-laminectomy, was at risk for pressure ulcers due to functional impairments in their lower legs. Despite having an order for weekly skin assessments, the resident's assessments were not completed as required, with the last documented assessment occurring over a month prior to the survey. Additionally, the resident reported having sores that were not properly assessed or treated, and the wound care physician did not see the resident as scheduled. Observations revealed multiple open areas on the resident's buttocks and a sore believed to be caused by a urinary catheter, none of which were being monitored or treated according to the Treatment Administration Records. Interviews with staff confirmed awareness of the resident's skin issues, but there was a lack of follow-through in reporting and documenting these issues, as well as in initiating treatment orders. The Director of Nursing Services acknowledged the failure to follow the process for skin assessments and treatment initiation.
Failure to Implement Gradual Dose Reduction for Psychotropic Medication
Penalty
Summary
The facility failed to ensure that a resident was free from unnecessary psychotropic medications, as evidenced by the lack of a gradual dose reduction (GDR) for Seroquel, which was prescribed for bipolar disorder and delusional disorder. Despite a pharmacist's recommendation for a GDR, the facility continued the medication without attempting a dose reduction since the resident's admission. The resident's medical records showed no documented behaviors that would justify the continued use of the medication, with only one instance of delusional behavior recorded over several months. Additionally, there were multiple instances of missing documentation regarding the resident's behaviors, which further hindered the assessment of the medication's necessity. Observations and interviews revealed that the resident exhibited behaviors such as talking to themselves and yelling, which were not directed at others but could startle other residents. Staff acknowledged that the behaviors being monitored were not individualized to the resident, and there was a lack of specific documentation to support the need for the medication. The Director of Nursing Services stated that the team did not feel the resident was appropriate for a GDR due to undocumented behaviors, indicating a failure to adequately monitor and document the resident's condition to determine the necessity of the psychotropic medication.
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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