Sharon Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Centralia, Washington.
- Location
- 1509 Harrison Avenue, Centralia, Washington 98531
- CMS Provider Number
- 505429
- Inspections on file
- 33
- Latest survey
- December 1, 2025
- Citations (last 12 mo.)
- 24
Citation history
Health deficiencies cited at Sharon Care Center during CMS and state inspections, most recent first.
Two residents who required staff assistance for toileting were not checked or changed as scheduled during the night, resulting in one being found with dried BM and another with a saturated brief and bedding. Staff interviews and facility investigations confirmed that the required two-hour check and change protocol was not followed.
Surveyors observed expired and undated food items in both the kitchen and nourishment refrigerators, as well as missing temperature log entries for the nourishment refrigerator on East Hall. Staff interviews confirmed that required procedures for labeling, dating, and monitoring food storage and temperatures were not consistently followed.
A resident with severe cognitive impairment and diagnoses including dementia with agitation and delirium was prescribed Olanzapine, an antipsychotic medication. Facility policy required an AIMS test to be completed upon admission and when starting antipsychotic therapy, but staff interviews and record review confirmed that this assessment was not performed or documented.
A resident's admission MDS assessment was not completed within the required 14-day timeframe. The MDS nurse, responsible for scheduling and completing the assessment, was on vacation and did not finish the assessment on time, leaving it incomplete 16 days after admission. The DON confirmed the expectation for timely completion.
The facility did not complete or submit required PASRR assessments for two residents with mental health diagnoses who remained in the facility beyond the exempted hospital discharge period. Both residents had documentation indicating the need for a Level II evaluation if their stay exceeded 30 days, but no further assessments were conducted or transmitted, as confirmed by the Social Service Director.
A resident with a history of repeated falls did not have their care plan revised to include a new intervention after experiencing a second fall. Although documentation indicated the care plan was updated after the first fall, review showed no new intervention was added following the subsequent incident, and staff interviews confirmed this omission.
The facility did not obtain daily weights as ordered for a resident with heart failure and failed to check for blood return before flushing a PICC line during medication administration for another resident with endocarditis. These actions did not comply with physician orders and were confirmed by staff interviews and record review.
A resident with severe cognitive impairment and chronic pain conditions did not receive required pain assessments every shift, despite care plans and hospice directives mandating regular monitoring. Staff interviews and documentation review confirmed that pain assessments were inconsistently performed, leaving the resident's pain needs unmet.
Sharps containers in two rooms were found filled above the designated line, causing the lids to malfunction and exposing sharps at the opening. Both nursing and environmental services staff stated they would empty the containers if they noticed they were full, but there was no established process or department responsible for monitoring or replacing the containers. This lack of a defined protocol led to the containers being overfilled and observed as a hazard during the survey.
The facility did not include required health recertification and complaint survey results for two years in its publicly accessible survey binder, maintaining only fire and life safety surveys and omitting health-related reports, as confirmed by staff interviews and record review.
The facility failed to assist residents with completing advance directives and maintaining Durable Power of Attorney documentation for four residents. Despite the facility's policy requiring ADs to be reviewed upon admission, the electronic health records for these residents lacked the necessary documentation. Staff acknowledged gaps in documentation and follow-up, which placed residents at risk of not having their healthcare preferences honored.
The facility failed to obtain physician orders for the use of bed rails for two residents, one moderately cognitively impaired and the other alert and oriented. Both residents were observed with quarter length bed rails, but their EHRs lacked the necessary physician orders, as confirmed by staff.
A facility failed to send a Notice Before Transfer to the State Long-Term Care Ombudsman for a resident transferred to a hospital. The resident had diagnoses including congestive heart failure exacerbation. The administrator admitted to not knowing the requirement and sent notices for previous months only after being questioned.
A resident's MDS assessment inaccurately documented their oral/dental status, failing to reflect missing and broken teeth and reported mouth pain. Observations and staff interviews revealed discrepancies between the MDS and the resident's actual condition, highlighting a lack of direct assessment by the MDS Nurse.
A facility failed to develop a comprehensive care plan for a cognitively impaired resident, omitting the placement of the bed against the wall and a mat on the floor. Staff acknowledged the oversight, which was against facility policy, potentially risking the resident's care needs and quality of life.
A facility failed to provide nail care for a resident who was dependent on staff for ADLs. Despite the facility's policy requiring nail care during baths, the resident's nails were not trimmed for about a month. Staff interviews confirmed that nail care was overlooked, and the DON observed that the resident's nails had not been trimmed for about two weeks.
A resident signed an arbitration agreement without a clear understanding due to confusion and lack of proper explanation by facility staff. The staff, including the Admissions Coordinator and Administrator, were unaware of the 30-day rescission period, leading to potential risks for residents signing legal documents without full knowledge.
The facility failed to ensure proper infection prevention practices, including the use of PPE and hand hygiene, for two residents. A CNA did not perform hand hygiene between changing gloves, and two CNAs did not wear isolation gowns when required. Additionally, a CNA used contaminated gloves outside a resident's room. The DON confirmed that staff were expected to follow isolation precaution signs and perform hand hygiene.
Failure to Provide Timely Toileting Assistance for Dependent Residents
Penalty
Summary
The facility failed to provide timely toileting assistance to two residents who required staff support for activities of daily living. One resident, who was moderately cognitively impaired and dependent on staff for toileting, was found in the morning with dried bowel movement on her sheets and body, and her brief was stuck to her, indicating she had not been checked or changed during the night as required by her care plan. Staff interviews confirmed that the resident was on a two-hour check and change schedule, but this protocol was not followed during the night shift. Another resident, also moderately cognitively impaired and requiring maximum assistance with toileting, reported that her brief was not changed during the night. She was found in the morning with a saturated brief, incontinent pad, and blanket, necessitating a complete bed change. Staff confirmed that this resident was to be checked and changed every two hours, and documentation and interviews indicated that the required care was not provided during the night shift. Both incidents were corroborated by staff and resident interviews, as well as facility investigations.
Failure to Label, Date, and Monitor Food Storage and Temperatures
Penalty
Summary
The facility failed to ensure proper labeling and dating of food items in both the kitchen and nourishment refrigerators. During observations, surveyors found expired and undated food items, including a container of Parmesan cheese and a container of jam in the kitchen refrigerator, as well as a fruit cup past its use-by date and six undated fruit cups in the nourishment refrigerator on East Hall. These items were not removed in accordance with the facility's stated policy of discarding food after three days or by the use-by date. Additionally, the facility did not maintain accurate temperature logs for the nourishment refrigerator on East Hall. The temperature log was missing entries for several consecutive days, indicating a lack of consistent monitoring. Staff interviews confirmed that kitchen staff were responsible for labeling, dating, and monitoring food storage and temperatures, but these procedures were not consistently followed, resulting in the deficiencies observed.
Failure to Complete Required AIMS Test for Resident on Antipsychotic Medication
Penalty
Summary
The facility failed to complete an Abnormal Involuntary Movement Scale (AIMS) test for a resident who was prescribed an antipsychotic medication, Olanzapine, upon admission. According to the facility's policy, an AIMS test should be performed when a resident is admitted on antipsychotic medications, every six months, and as needed. Record review showed that the resident, who had diagnoses including dementia with agitation and delirium and was severely cognitively impaired, was receiving Olanzapine as ordered by the physician. However, there was no documentation of an AIMS test being completed for this resident. Interviews with facility staff, including the Resident Care Manager/RN and the Director of Nursing/RN, confirmed that an AIMS test should have been completed upon admission and when the antipsychotic medication was started. Both staff members acknowledged that the AIMS test was missed for this resident, and it was not found in the resident's electronic health record. This omission was identified during the review of records and staff interviews.
Late Completion of Admission MDS Assessment
Penalty
Summary
The facility failed to complete the admission Minimum Data Set (MDS) assessment within the required timeframe for one resident. According to the Resident Assessment Instrument (RAI) User's Manual, the admission MDS must be completed no later than the 14th calendar day after admission. Record review showed that the resident's admission MDS was still in progress 16 days after admission. During interviews, the MDS nurse stated that she typically scheduled the MDS assessment for seven days after admission and aimed to complete it one week after the assessment reference date (ARD). She acknowledged that the assessment was not completed on time because she was on vacation, and it should have been finished two days prior. The Director of Nursing confirmed the expectation that the admission MDS be completed by the 14th day of admission.
Failure to Complete Required PASRR Assessments for Residents with Mental Health Diagnoses
Penalty
Summary
The facility failed to ensure that the Pre-admission Screening and Resident Review (PASRR) assessments were properly reviewed, completed, and submitted for two residents with mental health diagnoses. For one resident admitted with anxiety and depression and identified as moderately cognitively impaired, the PASRR indicated a Mood Disorder and noted an exempted hospital discharge, stating that a Level II evaluation was required if the resident remained beyond 30 days. However, no further PASRR was completed or transmitted after the resident stayed past the 30-day period. The Social Service Director acknowledged during interview that the review was missed and should have been completed. Similarly, another resident admitted with major depressive disorder was documented as alert and oriented, and their PASRR Level 1 assessment also indicated an Exempted Hospital Discharge with the requirement for a Level II evaluation if the stay exceeded 30 days. Record review showed no evidence that a new PASRR Level 1 or Level II was completed after the resident remained in the facility beyond the anticipated discharge period. The Social Service Director confirmed responsibility for PASRR referrals and admitted not submitting the required referral for a Level II evaluation, having not realized the resident's stay had exceeded 30 days.
Failure to Revise Care Plan After Multiple Falls
Penalty
Summary
The facility failed to ensure that a resident's care plan was revised to accurately reflect care needs following multiple falls. A resident with a history of repeated falls was admitted with multiple diagnoses and was assessed as cognitively intact. The facility's records showed that the resident experienced falls on two separate occasions in August, and documentation from fall investigations indicated that the care plan was updated to cue and encourage the resident to use the call light and wait for help. However, review of the resident's fall care plan revealed that after the second fall, no new revision or intervention was documented to address the most recent incident. Interviews with facility staff confirmed that the expected process after a fall was to update the care plan with a new intervention. The Resident Care Manager/LPN acknowledged that a new intervention should have been added after the second fall but stated it was missed. The Director of Nursing/RN also confirmed the expectation that the care plan be updated after each fall. This deficiency was identified through interview and record review, as the care plan did not reflect the resident's most current care needs following the second fall.
Failure to Follow Physician Orders for Weights and PICC Line Care
Penalty
Summary
The facility failed to follow physician's orders for daily weights for a resident with multiple diagnoses, including congestive heart failure. The resident was admitted with severe cognitive impairment, and the physician's orders specified daily weights for one week, then weekly weights unless otherwise ordered. Review of the electronic health record showed missing documentation of weights on several specified dates, indicating that the ordered monitoring was not completed as required. During an interview, the Resident Care Manager/Registered Nurse acknowledged that some weights were missed. Additionally, the facility did not adhere to physician's orders regarding medication administration for another resident with endocarditis and a peripherally inserted central catheter (PICC) line. The orders required flushing the PICC line and checking for blood return before each medication administration. During an observed medication pass, a registered nurse flushed the PICC line and started IV antibiotics without checking for blood return as ordered. When questioned, the nurse stated that blood return had been checked the previous day during a blood draw, but not at the time of the medication administration.
Failure to Complete Shift Pain Assessments for Cognitively Impaired Resident
Penalty
Summary
The facility failed to complete pain assessments every shift for a resident with multiple chronic pain-related diagnoses, including vascular dementia, fibromyalgia, and chronic pain syndrome. The resident was severely cognitively impaired and unable to consistently verbalize pain, requiring staff to use both verbal and non-verbal pain assessment tools. Documentation showed that the care plan and hospice plan of care required regular pain monitoring and assessment using appropriate scales. However, record review revealed that pain assessments were not consistently completed every shift as required. Observations and interviews indicated that the resident experienced ongoing pain, including pain related to a right heel deep tissue injury and generalized discomfort. Staff interviews confirmed that pain assessments were supposed to occur every shift, but this was not consistently documented or ordered. The lack of regular pain assessments placed the resident at risk for unmet care needs and diminished quality of life, as noted in the report.
Sharps Containers Overfilled Due to Lack of Monitoring Process
Penalty
Summary
Sharps containers in two resident rooms were observed to be filled above the designated fill line, as indicated by the warning label on the containers. During observations, the overfilled containers caused the lids to malfunction, with sharps instruments catching on the lid and protruding toward the opening, creating a potential hazard. The containers were not dated consistently, and the issue was noted during multiple observations by surveyors. Staff interviews revealed that there was no clear assignment of responsibility for monitoring or emptying sharps containers, with both nursing and environmental services staff stating they would empty the containers if they noticed they were full. However, there was no established process or department designated to regularly check and replace the containers when full. Staff members, including a registered nurse and the Environmental Services Supervisor, acknowledged that the containers should be emptied at the fill line but confirmed that no specific protocol or department was responsible for this task. The Director of Nursing also stated the expectation that staff would change the containers when they reached the full line. The lack of a defined process led to the containers being overfilled, as observed by surveyors, and placed residents, visitors, and staff at risk for injury and exposure.
Failure to Provide Required Survey Results in Public Binder
Penalty
Summary
The facility failed to ensure that its survey result binder included the required health recertification and complaint survey results for two of the three years reviewed, specifically for 2024 and 2025. During an observation, the survey binder was found in a wall-mounted receptacle near the skilled nursing entrance and was labeled as containing the three most current years of survey reports. However, upon review, the binder only contained a Federal Fire and Life Safety recertification survey and its re-inspection from 2024, with no health recertification or health complaint investigation survey results for 2024 or 2025. Interviews with the DON and the Administrator revealed that only one survey binder was maintained, and the Administrator admitted to not including complaint investigation surveys in the binder, typically only placing annual survey results. The Administrator also stated that the survey results were not available last year and could not be found online.
Failure to Document Advance Directives
Penalty
Summary
The facility failed to have procedures in place to assist residents with completing advance directives (AD) and obtaining and maintaining Durable Power of Attorney (DPOA) documentation for four of nine sampled residents. This deficiency was identified through interviews and record reviews. The facility's policy on advance directives, dated August 1, 2018, requires determining whether a resident has an AD upon admission and providing information about the right to refuse treatment and formulate an AD. However, the electronic health records (EHR) for Residents 1, 24, 26, and 30 did not show any AD or documentation that an AD was reviewed since their admission. Resident 1 was severely cognitively impaired, Resident 24 was moderately cognitively impaired, and Residents 26 and 30 were alert and oriented. Despite these varying cognitive statuses, none of their EHRs contained the necessary AD documentation. Staff K, the Social Services Director, acknowledged gaps in documentation and follow-up, while Staff A, the Administrator, confirmed that ADs should be reviewed and addressed at the initial care conference. The lack of proper documentation and follow-up placed residents at risk of not having their healthcare preferences and decisions honored.
Failure to Obtain Physician Orders for Bed Rails
Penalty
Summary
The facility failed to obtain a physician's order for the use of physical restraints for two residents, which is a requirement according to their policy. Resident 3, who was moderately cognitively impaired, was observed multiple times with quarter length bed rails on both sides of their bed. Despite these observations, a review of Resident 3's Electronic Health Record (EHR) revealed no physician's order for the bed rails. Staff members, including the Resident Care Manager and the Director of Nursing Services, acknowledged that a physician's order was necessary for such enablers, but none was found for Resident 3. Similarly, Resident 288, who was alert and oriented, was observed with quarter length bed rails on both sides of her bed on several occasions. A review of her EHR also showed no physician's order for the use of these bed rails. The absence of physician orders for these enablers was confirmed by staff, indicating a failure to adhere to the facility's policy and procedure regarding the use of devices/enablers.
Failure to Notify Ombudsman of Resident Transfer
Penalty
Summary
The facility failed to ensure that a copy of the Notice Before Transfer was sent to a representative of the Office of the State Long-Term Care Ombudsman for a resident reviewed for transfer notice requirements. This deficiency was identified during an interview and record review. The resident, who was admitted to the facility with diagnoses including congestive heart failure exacerbation and physical deconditioning, was transferred to a local hospital. The facility administrator, Staff A, acknowledged that he was unaware of the requirement to send a copy of the Notice of Transfer to the Ombudsman and only sent out the notices for the months of June, July, and August after being questioned about it.
Inaccurate MDS Assessment of Resident's Oral/Dental Status
Penalty
Summary
The facility failed to ensure the Minimum Data Set (MDS) assessment accurately reflected a resident's oral/dental status, specifically for a resident identified as severely cognitively impaired. The MDS assessment documented that the resident did not have tooth fragments or broken natural teeth, had no mouth pain, and was able to be examined. However, a Nutrition Assessment and a Nutrition/Dietary progress note both documented that the resident's natural teeth were in poor shape. Observations on multiple occasions revealed that the resident had missing upper teeth, lower teeth with sharp edges, and dark tan coloration, and the resident reported experiencing mouth pain. Staff interviews revealed that the MDS Nurse, responsible for gathering information for the MDS, did not personally assess the resident's oral/dental status and relied on medical records and staff input. The Director of Nursing Services acknowledged the inaccuracy of the MDS oral/dental status and indicated the need for a correction. The failure to conduct a visual assessment of the resident's oral/dental status led to the inaccurate documentation in the MDS, placing the resident at risk for unidentified and unmet care needs.
Failure to Develop Comprehensive Care Plan
Penalty
Summary
The facility failed to develop a comprehensive care plan for a resident who was severely cognitively impaired. The resident's care plan did not address the placement of the bed against the wall and the use of a mat on the floor, which were observed multiple times during the survey. The facility's policy required that such devices or enablers be appropriately care planned and added to the resident's Kardex, but this was not done for the resident in question. Staff members, including a Certified Nursing Assistant and the Resident Care Manager, acknowledged that the care plan should have included the bed and mat arrangements. The Director of Nursing Services also confirmed that it was expected for care plans to be in place for residents with their bed against the wall and mats on the floor. This oversight placed the resident at risk for unmet care needs and a diminished quality of life.
Failure to Provide Adequate Nail Care for Dependent Resident
Penalty
Summary
The facility failed to provide adequate nail care for a resident who was dependent on staff for assistance with activities of daily living (ADLs). The facility's policy stated that nail care is part of personal hygiene and should be provided by a certified nursing assistant unless the resident is diabetic, in which case a licensed nurse should perform the task. Resident 5, who was severely cognitively impaired and required substantial assistance with personal hygiene, had not received nail care for about a month, despite expressing a desire for assistance. The resident's last documented bath or shower was on August 31, 2024, and by September 10, 2024, their fingernails were approximately 1/3 inch long. Staff interviews revealed that nail care was supposed to be performed during baths or showers, but this was not done for Resident 5. The Nursing Assistant confirmed that they checked nails during baths, and the Director of Nursing Services stated that nail care should be done by the shower aid unless the resident was diabetic. Upon observation, the Director of Nursing Services noted that Resident 5's nails appeared to have not been trimmed for about two weeks, indicating a lapse in the facility's adherence to its own nail care policy.
Failure to Explain Arbitration Agreement Properly
Penalty
Summary
The facility failed to adequately explain the arbitration agreement to a resident, identified as Resident 25, who was part of a sample reviewed for arbitration agreements. The resident was admitted and readmitted to the facility, with assessments indicating she was alert and oriented. However, nursing notes documented instances of confusion and forgetfulness. Despite this, the arbitration agreement was signed by the resident and the Admissions Coordinator, Staff J, on a specified date. During an interview, Resident 25 could not recall signing the agreement or having it explained to her, citing pain from a broken hip and uncertainty about the document's meaning. Staff J, responsible for determining a resident's capability to sign such agreements, admitted to not informing residents or their representatives about the 30-day period to rescind the agreement. Staff J believed residents could change their minds at any time, a misunderstanding shared by the facility's Administrator, Staff A, who also did not know the correct rescission period. This lack of awareness and communication placed residents at risk of signing legal documents without full understanding or knowledge of their rights.
Infection Control Deficiency in PPE and Hand Hygiene
Penalty
Summary
The facility failed to maintain proper infection prevention practices, specifically in the use of personal protective equipment (PPE) and hand hygiene, for two residents. In one instance, a Certified Nurse Assistant (CNA) was observed providing care to a resident, removing her gloves, and then retrieving new gloves from an isolation cart without performing hand hygiene in between. This CNA acknowledged that she should have washed her hands between changing gloves. In another instance, two CNAs entered a resident's room, which had an enhanced barrier precautions sign, without wearing isolation gowns. One of the CNAs was observed taking trash out of the room and entering a code on a door with contaminated gloves, then returning to the resident's room and sanitizing her hands only after removing the gloves. The CNA was unsure of the resident's isolation status and admitted to using contaminated gloves outside the resident's room. The Director of Nursing Services confirmed that infection control training was provided and that staff were expected to follow isolation precaution signs and perform hand hygiene before leaving a resident's room.
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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