Olympia Transitional Care And Rehabilitation
Inspection history, citations, penalties and survey trends for this long-term care facility in Olympia, Washington.
- Location
- 430 Lilly Road Northeast, Olympia, Washington 98506
- CMS Provider Number
- 505243
- Inspections on file
- 28
- Latest survey
- March 19, 2026
- Citations (last 12 mo.)
- 2
Citation history
Health deficiencies cited at Olympia Transitional Care And Rehabilitation during CMS and state inspections, most recent first.
A resident with dementia, behavioral disturbances, and documented wandering and elopement risk, residing in a secure dementia unit with a wander guard in place, was able to leave the building through a window whose alarm did not sound when opened. The window screen from the resident’s room was later found on the ground outside, and the resident returned by ringing the front entrance doorbell. Facility leadership reported that window alarms were visually checked and that batteries were changed on a periodic basis, but they could not provide documentation of regular functional testing of the window alarms in the secure dementia unit.
A resident with Parkinson’s disease, hyperparathyroidism, and cognitive impairment had an elevated calcium level and provider orders for PTH, vitamin D, and ionized calcium testing. On two separate occasions, ordered PTH and ionized calcium labs were not performed because no specimens were received by the lab, despite facility policy requiring completion and follow-up of ordered tests and tracking of pending or missing results. Later, after additional lab orders including a CMP, the lab reported a critical calcium value, and the resident was transferred to the hospital, where a markedly elevated calcium level and related diagnoses were documented. The Administrator acknowledged that the ordered labs were not obtained and that nursing was responsible for ensuring collection, submission, and receipt of lab results.
The facility did not consistently assess and document non-pressure skin injuries for a resident on antiplatelet therapy, failed to provide bowel care according to physician orders and protocol for three residents, and did not report dental pain for a resident with cognitive impairment. These actions resulted in missed monitoring, delayed interventions, and unaddressed pain.
The facility failed to maintain an effective infection prevention and control program, with incomplete infection surveillance data, lack of action on infection trends, and repeated lapses in staff hand hygiene and use of personal protective equipment during resident care. Laundry processes were also inadequate, leading to cross-contamination, and two residents did not receive COVID vaccinations despite documented consent.
The facility did not ensure complete and accurate documentation or evaluation of antibiotic use for three residents, including missing infection details, lack of timely culture results, and failure to notify providers when prescribed antibiotics were not indicated or when organisms were resistant. The Infection Preventionist confirmed these lapses, which included incomplete logs and missing provider notifications.
A resident's trust account balance was not transferred to the state Office of Financial Recovery within the required timeframe following the resident's discharge due to death. The trust account still held funds several months after discharge, as confirmed by the business office manager.
The facility did not ensure care plans were reviewed and updated to reflect the actual care needs of four residents, including one with a NPO order who was inappropriately directed to receive oral intake, another whose dental and oral care needs were not addressed, a resident with constipation lacking a care plan, and a resident on a diuretic whose care plan failed to document this medication.
The facility did not meet professional standards in several areas, including failure to document and address a resident's skin impairment, inaccurate documentation and provision of oral care for a resident who was NPO, incomplete documentation of treatments for two residents, and failure to administer an influenza vaccine to a resident despite consent and vaccine availability. Staff interviews and record reviews confirmed that required care and documentation were not consistently provided or accurately recorded.
A resident with moderate cognitive impairment, dependent on staff for ADLs, did not receive adequate bathing or oral care. The resident's bathing preferences were not documented, and only one shower was provided over 18 days, with unclear documentation of sponge baths. Oral care was provided only once, despite orders for twice-daily care, and necessary supplies were unavailable. Staff interviews and observations confirmed these deficiencies.
A resident with severe cognitive impairment had a critical lab result that was not reported to the provider for over two days due to a name mismatch in the EHR, resulting in the result being placed in an unmatched category and not seen by staff. The facility's process relied on both lab calls and daily EHR checks, but lacked an alert system for new results, leading to the delay.
A resident with a surgical incision required daily wound care per physician's orders, which was not completed as documented. A nurse admitted to misunderstanding the treatment order, leading to missed dressing changes. The oversight was confirmed by the DON, and the resident was at risk for prolonged wound healing and infection.
The facility failed to provide timely lab services for two residents, risking delayed treatment. One resident had missing lab results due to equipment issues and lack of follow-up, while another had lab results not documented or forwarded as required. The DON acknowledged these lapses, contributing to the deficiency.
A resident with chronic health conditions and severe pain, dependent on staff for bed mobility, fell and broke their leg when a CNA attempted to reposition them alone, contrary to the care plan requiring two-person assistance. Concerns about the bed size and safety were previously raised but not addressed, leading to the incident.
The facility failed to provide timely toileting and bathing assistance for several residents, leading to prolonged discomfort and potential health risks. A resident with PTSD waited over three hours for incontinence care, while another fell attempting to self-transfer due to long wait times. Additionally, residents dependent on staff for bathing were observed with poor hygiene, indicating missed and undocumented showers.
Failure to Monitor and Maintain Functioning Window Alarms in Secure Dementia Unit
Penalty
Summary
The facility failed to ensure that window alarms in a secure dementia unit were adequately monitored and functioning to prevent elopement. A resident with dementia, behavioral disturbances, wandering behaviors, and impaired safety awareness was assessed as cognitively impaired and at high risk for elopement, with a documented history of attempts to leave a previous facility unattended. The resident’s care plan identified elopement risk and wandering, and a wander guard was implemented as an intervention. The resident had a physician’s order to reside in the secured dementia unit. Despite these identified risks and interventions, the resident was able to exit the facility through a window in the secure dementia unit. A progress note documented that the window screen from the resident’s room was found on the ground outside and that the resident had likely exited through the window, walked around the exterior of the building, and then rang the front entrance doorbell to return. The facility’s investigation determined that the resident left the facility unattended through an alarmed window that did not sound when opened, and that the window alarm had malfunctioned. The Administrator and Plant Operations Manager reported that window alarms were visually checked and reportedly tested or had batteries changed approximately quarterly, but they were unable to provide documentation of functional checks for the window alarms in the secure dementia unit.
Failure to Complete Ordered Laboratory Tests for Resident With Hyperparathyroidism
Penalty
Summary
The facility failed to ensure ordered laboratory tests were completed and followed up for a resident with hyperparathyroidism and elevated calcium levels. Facility policy required that laboratory services ordered by a provider be obtained, that results and pending or missing labs be included in shift report, and that pending or missing labs be followed up in daily clinical meetings. The resident, admitted with Parkinson’s disease and hyperparathyroidism and documented cognitive impairment, had a calcium level of 12.2 (normal 8.6–10.2). A provider ordered PTH, vitamin D, and ionized calcium testing, but laboratory results for that date showed PTH and ionized calcium were not performed because no specimen was received. A subsequent provider note documented that PTH and ionized calcium had not been performed and were reordered. A later physician order again directed that PTH and ionized calcium be obtained, but laboratory results again showed these tests were not performed due to no specimen being received. Another order was written for a CBC and CMP, and on that date the lab called the facility with a critical calcium value, after which the resident was transferred to the hospital. Hospital records documented a calcium level of 17 and admission for acute pulmonary embolism, aspiration pneumonia, and hypercalcemia. During interview, the Administrator acknowledged that the resident had provider orders for PTH and ionized calcium on two separate dates, that the lab indicated specimens were not obtained on those dates, and that nursing was responsible for ensuring labs were collected, sent, and results received as ordered.
Failure to Monitor Skin, Provide Bowel Care, and Report Dental Pain
Penalty
Summary
The facility failed to ensure routine assessment and monitoring of non-pressure skin injuries for a resident with moderate cognitive impairment who was on high-risk antiplatelet therapy. Upon admission, staff documented the presence of bruising on multiple body areas but did not provide specific descriptions, measurements, or detailed locations of the bruises. Subsequent weekly skin evaluations noted the presence of a surgical incision and multiple bruises, but again lacked comprehensive documentation regarding the size, color, and evolution of the bruises. A large bruise extending from the abdomen to the back was observed but not properly documented or monitored, and the care plan instructions for daily skin inspection and monitoring for antiplatelet complications were not followed as there was no direction on the MAR or TAR for staff to monitor the bruising. The facility also failed to provide bowel care in accordance with physician orders and facility protocol for three residents. For one resident, there were multiple periods where the resident went several days without a bowel movement and did not receive the prescribed PRN bowel medications, such as Miralax or Dulcolax suppository, as required by the protocol. Another resident experienced similar lapses, with extended periods without a bowel movement and no administration of bowel medications after the required timeframe. A third resident, who was on hospice care, also went several days without a bowel movement, and the prescribed bowel care was not administered or documented, with confusion over medication discontinuation and lack of notification to the power of attorney. Additionally, the facility failed to report dental pain for a resident with severe cognitive impairment and obvious dental issues. The resident was observed to have a missing front tooth and reported pain in that area on multiple occasions. Oral hygiene records showed frequent refusals of care, and a CNA reported that the resident refused oral care due to pain but did not notify a nurse as required. The DON confirmed that such refusals due to pain should have been reported to nursing staff for further action, but this did not occur.
Infection Control Program Deficiencies and Lapses in Standard Precautions
Penalty
Summary
The facility failed to fully implement an effective Infection Prevention and Control Program, as evidenced by incomplete and inaccurate infection surveillance data, lack of ongoing monitoring and analysis, and failure to document or act on identified infection trends. Specifically, infection control line listings for January and February did not match the Infection Control Reports, with missing or incomplete documentation of signs, symptoms, diagnostic testing, and microorganism identification. For example, several urinary tract infections and skin infections were either not listed or lacked supporting clinical data, and no action or staff education was documented in response to a trend of yeast infections among female residents. Staff did not consistently follow standard precautions, enhanced barrier precautions (EBP), or perform proper hand hygiene during resident care. Observations revealed that staff entered rooms and provided care to residents on EBP without donning appropriate personal protective equipment or performing hand hygiene before and after glove use. In one instance, a CNA provided oral care to a resident with a gastrostomy without wearing a gown or gloves and failed to perform hand hygiene. In another, a CNA caring for a resident with a suprapubic catheter repeatedly changed gloves without hand hygiene and misunderstood the requirements of EBP. Additionally, a nurse providing wound care to a resident with multiple wounds changed gloves multiple times without hand hygiene, and no hand sanitizer was available at the bedside. Laundry services were also found to be deficient, with soiled linen being improperly handled and cross-contaminated with clean laundry due to the absence of a separating door and lack of hand hygiene by staff. Environmental surfaces in the laundry area were covered in lint and not properly maintained. Furthermore, the facility failed to administer COVID vaccinations to two residents despite having obtained consent, with no documentation or explanation for the missed vaccinations. These failures were confirmed through staff interviews and direct observation.
Failure to Implement Effective Antibiotic Stewardship Program
Penalty
Summary
The facility failed to implement an effective antibiotic stewardship program, as evidenced by incomplete and inaccurate documentation and evaluation of antibiotic use for three residents. For one resident started on Augmentin for a suspected respiratory infection, the infection control log lacked documentation of the infection type, signs and symptoms, diagnostic results, and whether McGeer's Criteria were met. There was no record of the chest x-ray being obtained or results being communicated to the provider, and the required reassessment and documentation were not completed. The Infection Preventionist confirmed these omissions and that the criteria for antibiotic treatment were not met. Another resident was started on doxycycline for a wound infection, but the documentation did not include the presenting signs and symptoms, the specific microorganisms identified, or their sensitivity to the antibiotic. The most recent wound culture was outdated and showed resistance to doxycycline, yet there was no evidence the provider was notified. A third resident was started on Macrobid for a urinary tract infection, but the organism identified was resistant to the prescribed antibiotic, and again, there was no documentation that the provider was informed. These failures were confirmed by the Infection Preventionist during interviews and record reviews.
Delayed Transfer of Resident Trust Funds After Discharge
Penalty
Summary
The facility failed to transfer the trust account balance of a resident who was on Medicaid and discharged due to death on 12/23/2024. Review of the resident's trust account ledger showed a remaining balance of $106.46 on the date of discharge. As of 04/01/2025, staff confirmed that the trust balance had not yet been conveyed to the state Office of Financial Recovery (OFR) as required. This inaction resulted in a delay in the reconciliation of the resident's trust funds, contrary to regulatory requirements.
Failure to Maintain Accurate and Updated Care Plans for Multiple Residents
Penalty
Summary
The facility failed to ensure that care plans were reviewed, revised, and accurately reflected the care needs of four residents. For one resident with a NPO order due to dysphagia, multiple care plans inappropriately directed staff to offer or encourage oral food and fluid intake, which conflicted with the resident's dietary restrictions. Another resident with significant dental issues and recommendations for twice-daily oral care did not have these needs or recommendations incorporated into their care plans, despite documented dental consults identifying decayed teeth and specific oral hygiene instructions. A third resident, assessed as constipated on the MDS and reporting ongoing constipation, did not have a care plan developed or implemented to address this issue. Additionally, a fourth resident prescribed a diuretic and identified as severely cognitively impaired had a care plan that incorrectly stated the resident was not on a diuretic and lacked any section addressing diuretic use, despite medication records confirming daily administration. These deficiencies were confirmed by staff interviews and record reviews, indicating that the care plans did not accurately reflect the residents' current needs and conditions.
Failure to Meet Professional Standards in Documentation and Care Delivery
Penalty
Summary
The facility failed to ensure that services provided met professional standards of practice in several areas, as evidenced by inaccurate or missing documentation and failure to follow physician orders. For one resident with severe cognitive impairment, staff did not accurately document a visible skin impairment on the left ankle, despite observations of redness and scabbing under a wander guard. Skin assessments in the electronic health record repeatedly stated no new skin issues, and staff confirmed the impairment was not documented as required. Another resident, who was dependent on staff for oral care and had orders for twice-daily oral care due to being NPO, reported not receiving oral care as ordered. Staff interviews revealed that oral care was not provided on multiple occasions, and a nurse signed the Medication Administration Record (MAR) for oral care that was not actually completed. The Director of Nursing confirmed that documentation was inaccurate, as the nurse had signed for care not provided. Additionally, two residents had incomplete documentation on their MAR and Treatment Administration Record (TAR) for various treatments, including wound care, catheter care, and application of skin products. Staff could not confirm whether these treatments were completed, and there was no documentation of completion or resident refusal. In another case, a resident who had consented to an influenza vaccination did not receive it, despite the vaccine being available, and the MAR was signed off as "Other/See nurse Notes" with a note stating the vaccine was out of supply, which was later contradicted by the infection preventionist.
Failure to Provide Adequate Bathing and Oral Care for Dependent Resident
Penalty
Summary
The facility failed to provide adequate bathing and oral care for a dependent resident who was admitted with moderate cognitive impairment and required staff assistance for activities of daily living. Upon review, it was found that the resident's bathing preferences were not documented upon admission, and the resident received only one shower in an 18-day period, with staff documenting sponge baths on other days. However, the facility did not have a clear policy defining a sponge bath, and the resident reported that the care provided did not meet their expectations for cleanliness. The resident also reported a strong foul odor and unclean appearance, which was confirmed by observation. Additionally, the resident received oral care only once during the same period, despite physician orders for twice-daily oral care due to NPO status from dysphagia. Staff interviews revealed that oral care supplies were unavailable, and neither CNAs nor RNs consistently provided or documented oral care as required. The resident's room lacked any oral care items, and staff acknowledged that oral care was not consistently provided. These failures were confirmed through record review, staff interviews, and direct observation.
Delayed Notification of Critical Lab Result Due to EHR Matching Error
Penalty
Summary
The facility failed to ensure the timely reporting of a critical laboratory result to the provider for one resident. According to the facility's policy, critical laboratory values are to be reported to the attending physician or provider immediately. In this case, a resident who was severely cognitively impaired had a critical lab value collected and resulted, but the provider was not notified until over two and a half days later. The delay was due to a misspelling of the resident's name, which caused the result to be placed in an unmatched category in the electronic health record (EHR) system, preventing it from being seen promptly by staff. Staff interviews confirmed that the process for handling critical lab results relies on both direct calls from the laboratory and diligent daily checks of the EHR results tab by nursing staff. However, there was no notification system in place to alert staff to new results, and if a call from the laboratory was missed, results could go unnoticed. The Director of Nursing Services acknowledged that the delay in notifying the provider did not meet expectations and was directly related to the unmatched lab result in the EHR.
Failure to Follow Physician's Orders for Wound Care
Penalty
Summary
The facility failed to complete wound care per physician's orders for a resident, identified as Resident 2, who was admitted with diagnoses including diabetes, orthopedic aftercare following surgical amputation, and peripheral vascular disease. The resident had a 21.5-centimeter surgical incision with staples and required specific wound care as per a physician's order dated 08/12/2024. The order specified that the surgical incision on the left knee should be cleaned with wound cleanser, skin prep applied, and covered with a dry dressing daily, along with an ace wrap as needed. However, the electronic treatment administration record (ETAR) indicated that the treatment was not signed as completed on 08/12/2024 and was incorrectly documented as completed on 08/13/2024 and 08/14/2024. A registered nurse, identified as Staff C, admitted to not performing the dressing changes on 08/13/2024 and 08/14/2024, mistakenly believing the order was for monitoring the dressing rather than changing it. This oversight was acknowledged by the Director of Nursing Services, Staff B, who confirmed that the surgical dressing was not changed daily as ordered on the specified dates. The resident was no longer at the facility at the time of the acknowledgment. The failure to adhere to the physician's orders placed the resident at risk for prolonged wound healing and infection, as noted in a provider's note dated 08/14/2024, which described the management of the wound as unacceptable.
Failure to Provide Timely Laboratory Services
Penalty
Summary
The facility failed to provide timely laboratory services for two residents, leading to a risk of delayed identification and treatment of health conditions. Resident 3, who was admitted with diagnoses including aftercare following hip joint prosthesis and osteomyelitis, had weekly lab tests ordered, including CBC, CMP, ESR, and CRP. However, there were missing lab results for specific dates, and the facility did not have the appropriate equipment to draw blood on one occasion. Additionally, there was no documentation of attempts to complete the missing labs or notify the provider about the issues encountered. Resident 4, admitted with orthopedic aftercare and arthritis due to bacteria in the right hip, also had lab tests ordered, but there was no documentation of the results in the medical record. The Director of Nursing Services acknowledged that the lab results were not forwarded to the Infectious Disease office as ordered, and the results were not available for nurses to review. This lack of documentation and follow-up on lab results contributed to the deficiency identified by the surveyors.
Failure to Follow Care Plan Leads to Resident Injury
Penalty
Summary
The facility failed to ensure that residents were free from avoidable accidents, specifically for one resident who required assistance with Activities of Daily Living (ADLs) and bed mobility. The resident, who had no cognitive issues but suffered from chronic health conditions and severe pain, was dependent on staff for toileting hygiene and bed mobility. The care plan specified that two staff members were needed for bed mobility, but this was not followed. On one occasion, a CNA attempted to reposition the resident alone, resulting in the resident rolling off the bed and sustaining a broken leg. The incident occurred despite previous concerns raised about the resident's bed size and the difficulty staff had in positioning the resident safely. The facility's policy required adherence to individualized care plans, which included using two people for bed mobility. However, the CNA did not follow this directive, leading to the resident's fall and subsequent injury. The resident expressed that the bed was too narrow and lacked siderails, contributing to the fall. The Director of Nursing confirmed that the care plan was not followed during the incident.
Deficiencies in Toileting and Bathing Assistance
Penalty
Summary
The facility failed to provide timely toileting assistance for several residents, leading to prolonged periods of discomfort and potential health risks. Resident 1, who was dependent on staff for toileting due to a broken leg and PTSD, reported waiting over three hours for incontinence care after requesting assistance. This delay resulted in Resident 1 sitting in a soiled brief through breakfast. Similarly, Resident 8, who had memory problems and required assistance for toileting, experienced long wait times for help, leading to a fall while attempting to self-transfer to the commode. Resident 9, who was on diuretics and required substantial assistance for transfers, also reported extended wait times for toileting assistance, sometimes over an hour. The facility also failed to provide adequate bathing services for some residents. Resident 3, who had severe cognitive problems and was dependent on staff for bathing, was observed with dark matter under their nails and a strong urine odor, indicating a lack of proper hygiene care. The facility's records showed inconsistencies in documenting showers and nail care for Resident 3, with no evidence of regular bathing as per the care plan. Resident 4, who had severe cognitive problems and was dependent on staff for bathing, was frequently observed with greasy, uncombed hair and a musty odor, suggesting infrequent bathing. The facility's records showed missed and undocumented showers, with no evidence of attempts to address refusals or preferences for bathing. Additionally, Resident 11 experienced similar issues with bathing services, with records showing missed and undocumented showers. The facility's failure to adhere to care plans and provide timely assistance for activities of daily living, such as toileting and bathing, resulted in inadequate care for the residents, compromising their dignity and quality of life.
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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Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release June 24, 2026) and official state health department websites — never guesswork.
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