South Creek Post Acute
Inspection history, citations, penalties and survey trends for this long-term care facility in Centralia, Washington.
- Location
- 917 South Scheuber Road, Centralia, Washington 98531
- CMS Provider Number
- 505373
- Inspections on file
- 43
- Latest survey
- April 30, 2026
- Citations (last 12 mo.)
- 22
Citation history
Health deficiencies cited at South Creek Post Acute during CMS and state inspections, most recent first.
A resident who was cognitively intact was assessed as high risk for elopement through an elopement risk evaluation and physician documentation, but staff did not initiate an elopement care plan at that time. The resident later eloped and went to a relative’s home, and an elopement care plan was only added to the comprehensive care plan after this event. In interviews, an RN and the Administrator acknowledged that a positive elopement risk assessment should typically trigger an elopement care plan.
A resident who was cognitively intact activated a call light during breakfast to request assistance with toileting and reported waiting approximately 1.5 to 2 hours before staff responded. Facility call light records confirmed the call was activated and not answered for over two hours. Staff interviews indicated that management had communicated expectations that call lights be answered within about 15–20 minutes, but this expectation was not met in this instance, resulting in a prolonged delay in meeting the resident’s expressed need for assistance.
The facility failed to follow its abuse/neglect reporting policy when an allegation involving a resident with COPD and opioid dependence was not promptly reported to the State Survey Agency. The Administrator received a report that the resident had wrist marks related to restraints and had been found unresponsive due to possible overmedication, but did not notify the state hotline as required, believing similar concerns had been previously investigated. The DON was not informed of the allegation during this period, did not initiate an investigation, and had no related documentation. The allegation and investigation were not documented and reported to the state hotline until weeks later, in violation of the facility’s requirement to report such allegations within two hours and applicable state regulations.
A resident with COPD and opioid dependence was the subject of an allegation involving wrist marks related to restraints and an episode of unresponsiveness due to possible overmedication. The Administrator received this allegation but did not initiate a new investigation, believing similar concerns had been addressed previously, and did not inform the DON. As a result, the DON was unaware of the allegation, did not start an investigation, and found no related documentation until much later, when the investigation was finally initiated and documented outside the required timeframe.
A resident did not receive physician-ordered CBC and BMP labs after an initial unsuccessful blood draw, and no further attempts or timely physician notifications were documented. The missed labs led to the resident's condition worsening, requiring hospital admission for profound anemia, hyponatremia, and acute renal failure.
A resident admitted with a wound infection did not receive the prescribed antibiotic Meropenem as ordered by an infectious disease provider. Due to a breakdown in the medication order entry and review process, the order was scanned into the electronic medical record but not entered or activated, resulting in the resident receiving a different antibiotic instead. Staff were unaware of the error until it was brought to their attention by the infectious disease provider.
A resident who required supervision while smoking was left unattended by a NAC, resulting in a fall and head injury. The facility's investigation inaccurately documented the fall as witnessed, despite statements confirming the resident was alone. The DON acknowledged discrepancies in the investigation documentation.
A resident was admitted and given an antihypertensive medication without documented vital signs, including blood pressure or pulse, in the electronic medical record. Staff interviews confirmed that vital signs should have been obtained and recorded both at admission and prior to medication administration, but no such documentation was found.
Two nurse technicians with expired credentials administered scheduled opioid and IV medications, including controlled substances, despite state regulations prohibiting such actions. Staff interviews revealed a lack of education and understanding about the nurse technician scope of practice, with both nursing and administrative staff unaware of the restrictions on medication administration for nurse technicians.
The facility did not ensure that the Dietary Manager had the necessary certification to oversee food and nutrition services, with oversight at times provided by an HR Director also lacking certification. The dietician was only present part-time, resulting in the kitchen being managed by staff without the required qualifications.
The facility did not obtain or maintain proper documentation of Advance Directives for two residents—one with severe cognitive impairment and another who declined an AD but required quarterly review—resulting in missing records and lack of evidence that AD information was provided or reviewed as required.
Two residents were found using bed rails without documented assessment, consent, or physician order, as required by facility policy. Staff confirmed that these steps were necessary, but review of the EHR and care plans showed they were missing for both a severely and a moderately cognitively impaired resident.
The facility did not coordinate required PASARR Level II evaluations for two residents who exhibited mental health symptoms and were prescribed psychotropic medications. Despite Level I screenings indicating the need for further assessment, no Level II referrals were made or documented, and staff interviews confirmed the absence of necessary evaluations in the records.
A resident admitted with schizoaffective disorder and moderate cognitive impairment did not have an accurate PASARR Level I assessment completed, as the screening failed to indicate a serious mental illness and left required sections incomplete. Facility staff later acknowledged the error and the lack of a referral for a Level II PASARR evaluation.
A resident with severe cognitive impairment did not have a documented activities care plan addressing her preferences, goals, or interventions. Despite staff awareness of her enjoyment of singing, morning exercises, and watching TV, the resident was repeatedly observed lying in bed and expressed a desire to participate in activities. Staff confirmed the absence of a care plan and noted limited activity participation.
A resident with dysphagia and moderate cognitive impairment did not receive enteral nutrition and water flushes according to physician orders, as the pump was set incorrectly. Additionally, multiple prescribed medications were not documented as administered in the MAR. Staff confirmed expectations for verifying orders and documentation were not met.
A resident with severe cognitive impairment and dependence on staff for personal hygiene was repeatedly observed with thick facial hair and expressed embarrassment and a desire for more frequent shaving. Staff interviews revealed inconsistent practices regarding the frequency of shaving, and records showed no documentation of care refusals, indicating a failure to provide consistent assistance with this activity of daily living.
A resident with severe cognitive impairment did not have a care plan addressing activity preferences, despite staff knowledge of her interests in singing, morning exercises, and watching TV. Observations showed the resident spent most of her time in bed without engagement in activities, and staff interviews confirmed limited participation due to lack of support in getting out of bed. The resident expressed interest in doing more activities.
The facility did not follow its bowel management protocol for several residents, resulting in extended periods without bowel movements and no documented interventions. Staff interviews and record reviews confirmed that licensed nurses did not initiate the required bowel protocol, despite clear policy expectations and documentation of missed bowel movements. Both cognitively impaired and alert residents were affected by this lapse in care.
A resident with severe cognitive impairment and a PRN oxygen order was repeatedly observed receiving continuous supplemental oxygen without corresponding documentation of oxygen flow rate or assessment of need in the MAR/TAR. Staff interviews revealed uncertainty about monitoring and documenting the resident's oxygen requirements, and records showed no evidence of SpO2 monitoring on room air as required by the order.
Surveyors found that an LPN stored multiple unlabeled medications in plastic cups marked only with room numbers in a medication cart, contrary to facility policy. The DON confirmed that medications should not be pre-poured or stored in this manner, resulting in a deficiency for improper medication storage and labeling.
Staff did not disinfect shared medical equipment, including Hoyer lifts and vital sign machines, between use with different residents. Disinfecting wipes were not available in key locations, and several staff members confirmed they had not cleaned equipment as required, despite facility expectations.
A resident with severe cognitive impairment was found with a loose, padded bed rail that moved several inches and was not securely attached to the bed frame. Multiple staff, including an LPN, DON, and Maintenance Director, confirmed the bed rail's looseness and lack of routine safety checks, resulting in a deficiency for not ensuring bed rails were properly secured.
A resident with moderate cognitive impairment and at risk for skin breakdown developed a lesion on the genitalia, which was not included in the care plan despite being assessed and communicated to the provider. Staff interviews confirmed the expectation for care plans to be updated with any change in condition, highlighting a deficiency in the facility's care planning process.
A facility failed to readmit a resident after hospitalization due to insurance issues and concerns about potential drug-related substances in his belongings. The resident, who underwent a leg amputation, was not provided with a discharge plan or a written explanation for the denial of readmission. The facility's policy required readmission regardless of payer source, but staff cited a change in ownership affecting insurance agreements as a reason for the denial.
A resident experienced an unwitnessed fall and was not assessed by the nurse on duty, despite being informed by a CNA. The resident had visible bruises, and neurological checks were only initiated the following day. The facility's protocol for falls, requiring immediate assessment and documentation, was not followed.
The facility failed to maintain cleanliness and food safety in its dry storage room and juice dispensing area. Observations revealed liquid and a black substance under a cart, condensation on the ceiling, and a wet, sticky juice dispensing area. Staff acknowledged the poor conditions, which posed a risk for foodborne illness.
The facility failed to maintain a safe and sanitary kitchen environment due to broken linoleum tiles exposing bare concrete near dishwashing and handwashing stations. The Maintenance Director placed mats over the exposed areas, and the Administrator acknowledged the issue, noting it was inherited from a previous owner and would be fixed soon.
The facility failed to maintain cleanliness and proper labeling in its kitchen and storage areas, posing a risk for foodborne illness. Surveyors observed dark residue on the ice machine, unlabeled and undated food items in storage, and lint on kitchen vents. The Dietary Manager and Assistant Director of Nursing acknowledged these lapses, indicating a failure to adhere to food safety protocols.
A facility failed to obtain necessary documentation and approvals for the use of padded quarter bed rails on a severely cognitively impaired resident. Despite the facility's policy requiring an evaluation, consent, physician's order, and care plan for such devices, these were not completed. Staff interviews confirmed the absence of required documentation, placing the resident at risk for injury and unmet needs.
A facility failed to develop a comprehensive care plan for a cognitively impaired resident using padded quarter bed rails, as required by their policy. Despite observations confirming the use of bed rails, staff interviews revealed the absence of documentation, evaluation, or consent for the device, highlighting a lapse in policy adherence.
The facility failed to provide preventative measures for contractures and consistent restorative services for two residents. One resident with a history of CVA and contractures did not receive adequate preventative measures, such as a splint. Another resident, who was supposed to be on a restorative program, received services on only a few occasions due to staff being reassigned, with no follow-up on days the resident refused services.
The facility failed to provide follow-up education for the PCV13 vaccine for a resident who had previously declined it. The resident's electronic health record lacked additional information about the vaccine, and staff were unsure if the resident's desire to receive the vaccine with her granddaughter was followed up. Staff indicated that the vaccine should be reviewed quarterly and offered annually if declined.
A resident with moderate cognitive impairment was sent to the ER and diagnosed with a narcotic overdose after receiving Morphine Sulfate ER. Despite the serious nature of the incident, the LTC facility failed to initiate a formal investigation. Staff interviews revealed that no investigation was documented, and a medication review conducted by a Residential Care Manager was informal and undocumented.
Failure to Initiate Elopement Care Plan for High-Risk Resident
Penalty
Summary
The facility failed to develop and implement a care plan for a resident who had been assessed as a high elopement risk. The resident was admitted on an unspecified date, and a Medicare 5-day MDS dated 03/19/2026 documented that the resident was cognitively intact. An elopement risk evaluation dated 03/13/2026 identified the resident as being at high risk for elopement, and a physician note dated 03/15/2026 documented that the resident was considered an elopement risk. Despite these assessments, no elopement care plan was initiated at that time. On 04/20/2026, the facility’s investigation documented that the resident eloped from the facility and traveled to a relative’s house. The comprehensive care plan showed that an elopement care plan was not initiated until 04/21/2026, which was 39 days after the resident was first assessed as a high elopement risk and one day after the elopement occurred. In interviews, the Residential Care Manager/RN stated that an elopement care plan was usually triggered by a positive elopement risk assessment and acknowledged that it did not appear one was initiated after the 03/13/2026 assessment. The Administrator stated that she would have expected an elopement care plan to be initiated when a resident was assessed to be a high elopement risk.
Failure to Respond Timely to Resident Call Light for Toileting Assistance
Penalty
Summary
Facility staff failed to respond to a cognitively intact resident’s call light within a reasonable time, resulting in a documented delay of over two hours. The resident, who had been admitted earlier in the month, reported that during breakfast he activated his call light to request assistance with toileting and waited approximately 1.5 to 2 hours before staff responded. Facility records from the call light system on the same date showed the call light was activated at 6:22 AM and not answered until 2 hours and 23 minutes later. During interviews, a CNA stated that management had communicated an expectation that call lights be answered in about 15 minutes, and the Administrator stated that staff had been told they should ideally answer call lights within 20 minutes of activation. The facility’s failure to respond to the resident’s call light in a timely manner was cited under WAC 388-97-1060(1) for not honoring resident preferences, choices, values, and beliefs, and placed residents at risk of unmet care needs and diminished quality of life.
Failure to Timely Report Allegation of Abuse/Neglect to State Agency
Penalty
Summary
The facility failed to timely report an allegation of abuse and/or neglect to the State Survey Agency as required by its policy and state regulations. The facility’s abuse, neglect, exploitation, and misappropriation policy, dated September 2022, required that suspected abuse, neglect, exploitation, misappropriation, or injury of unknown source be reported immediately to the administrator and to other officials according to state law, defining “immediately” as within two hours for allegations involving abuse or resulting in serious bodily injury. Resident 1, admitted with diagnoses including COPD and opioid dependence, was the subject of an allegation received by the Administrator (Staff A) on 01/27/2026 at 2:10 PM. The allegation involved reported marks on the resident’s wrists related to restraints and that the resident had been found unresponsive due to being overmedicated. Despite receiving this allegation, Staff A did not report it to the state hotline at the time it was received, stating she believed a prior investigation had addressed similar concerns. The DON (Staff B) reported on 02/13/2026 at 2:00 PM that she had not been informed of the allegation between 01/27/2026 and 02/13/2026, had not initiated an investigation related to the reported restraint-related marks and unresponsiveness, and could not locate documentation of any such investigation. Facility documentation showed the allegation was not reported to the state hotline until 02/13/2026, and the facility investigation document was also dated 02/13/2026. The surveyors concluded that the facility failed to report the allegation within required timeframes, as referenced in WAC 388-97-0640(5)(b).
Failure to Timely Initiate and Document Abuse/Neglect Investigation
Penalty
Summary
The facility failed to initiate and complete a thorough investigation of an allegation of abuse and/or neglect within required timeframes, as required by its policy and WAC 388-97-0640(6). The facility’s abuse, neglect, exploitation, or misappropriation policy dated September 2022 stated that all allegations are to be thoroughly investigated, and that the administrator is responsible for initiating investigations upon receipt of an allegation and ensuring they are documented. Resident 1, admitted with diagnoses including COPD and opioid dependence, was the subject of an allegation reported to the Administrator (Staff A) on 01/27/2026 at 2:10 PM. The allegation involved reported marks on the resident’s wrists related to restraints and that the resident had been found unresponsive due to being overmedicated. Despite receiving this allegation on 01/27/2026, Staff A did not initiate a new investigation at that time, stating she believed a prior investigation had addressed similar concerns. The DON (Staff B) reported on 02/13/2026 at 2:00 PM that she had not been informed of the allegation between 01/27/2026 and 02/13/2026, had not initiated an investigation, and could not locate any documentation of an investigation specific to the reported restraint-related marks and unresponsiveness. Facility documentation showed the investigation was not initiated and documented until 02/13/2026. On 02/20/2026 at 1:10 PM, Staff B confirmed the facility did not initiate or complete the investigation within five working days of the allegation being received on 01/27/2026 because she was not aware of it.
Failure to Obtain Ordered Laboratory Services Resulting in Resident Harm
Penalty
Summary
The facility failed to obtain physician-ordered laboratory services for one resident, resulting in harm. The resident was admitted with orders for a CBC and BMP to be completed due to ongoing nausea. Documentation showed that the weekend RN supervisor attempted to draw the labs once but was unsuccessful, and there was no evidence of further attempts or that the physician was notified of the failed draw. The Medication Administration Record did not show that the labs were collected or completed, and the care plan required labs to be completed per physician orders with results reported to the physician. Interviews with staff confirmed that after the initial unsuccessful attempt, no additional efforts were made to obtain the labs, and the physician was not informed in a timely manner. As a result of the missed laboratory tests, the resident's condition deteriorated, leading to an emergency hospital admission. Hospital records documented that the resident was found to have profound anemia, hyponatremia, acute renal failure, and sepsis, requiring transfer to the intensive care unit. The resident reported feeling neglected and stated that the facility did not perform the necessary blood tests as ordered by the physician. Staff interviews confirmed that the labs were not obtained on the days following the initial order, and the physician was not kept informed of the ongoing failure to complete the ordered tests.
Failure to Administer Prescribed Antibiotic Due to Medication Order Entry Error
Penalty
Summary
The facility failed to ensure that a resident's prescribed medication, Meropenem, was administered as ordered by the infectious disease provider. The resident, who was admitted with a wound infection and was cognitively intact, had a care plan and provider orders specifying a four-week course of Meropenem 1g IV every 8 hours. However, a review of the resident's physician orders and medication administration records showed that Meropenem was never ordered or administered. Instead, the resident received a different antibiotic, Zosyn, during their stay. Interviews with facility staff revealed that the process for entering admission medication orders involved the medical records department inputting orders into the electronic medical record system (PCC), followed by review and activation by two nurses. The infectious disease clinic's orders for Meropenem were faxed and scanned into the resident's record before admission, but were not entered into the system for review and activation. This communication error resulted in the omission of the Meropenem order, and staff were unaware of the issue until notified by the infectious disease provider.
Failure to Thoroughly Investigate Unsupervised Fall During Smoking
Penalty
Summary
The facility failed to thoroughly investigate a fall involving a resident who was cognitively intact and required supervision while smoking. The resident's care plan and smoking assessment both indicated that staff supervision was necessary during smoking due to cognitive impairment and inability to safely smoke or access the smoking area independently. On the day of the incident, a nursing assistant (NAC) assisted the resident outside to smoke but left the resident unattended to use the restroom. During this time, the resident dropped a lit cigarette, leaned forward from the wheelchair to retrieve it, and subsequently fell, hitting her head on the concrete. The facility's fall investigation inaccurately documented the incident as a witnessed fall, despite statements from the resident and staff indicating the resident was left alone at the time. Interviews with the resident, a collateral contact, and staff confirmed the resident was unsupervised when the fall occurred. The Director of Nursing acknowledged discrepancies in the investigation documentation and agreed that the witness statement could have been more detailed. The failure to accurately investigate and document the circumstances of the fall resulted in a deficiency under WAC 388-97-0640 (6)(a)(b).
Failure to Document Vital Signs on Admission and Before Antihypertensive Administration
Penalty
Summary
The facility failed to obtain and document vital signs upon admission and prior to administering a blood pressure medication for one resident. According to the facility's policy, vital signs should be recorded in the resident's medical record upon admission. The resident, who was cognitively intact, was admitted and subsequently discharged on the same day. Physician orders required blood pressure monitoring prior to administering antihypertensive medication, specifically Metoprolol, and directed staff to notify the physician if systolic blood pressure was less than 100. However, review of the electronic medical record and medication administration record showed that the resident received Metoprolol without any documentation of vital signs, including blood pressure or pulse, at admission or before medication administration. Interviews with nursing staff, including a registered nurse, an LPN, a residential care manager, and the DON, confirmed that the facility's practice is to obtain and document vital signs for new admissions and before administering blood pressure medications. Staff described a process where vital signs are initially recorded on a sheet and then entered into the electronic medical record. Despite this, all interviewed staff were unable to locate any documentation of the resident's vital signs in the electronic medical record for the relevant period, confirming the deficiency.
Nurse Technicians Administered Prohibited Medications Without Proper Credentials
Penalty
Summary
The facility failed to comply with state and local regulations by allowing two nurse technicians, Staff D and Staff E, to administer scheduled and intravenous (IV) medications, including controlled substances, to residents. According to the state's administrative code, nurse technicians are not authorized to administer chemotherapy, blood or blood products, IV medications, scheduled drugs, or perform procedures on central lines. Despite this, records showed that Staff D administered scheduled opioid medications 11 times and IV medications three times in one month, while Staff E administered scheduled opioid medications 20 times and IV medications once during the same period. Both staff members' nurse technician credentials had expired at the time of these actions. Interviews with staff revealed a lack of understanding and education regarding the scope of practice for nurse technicians. Staff D reported that she was still in nursing school and believed she could perform medication administration tasks as long as an RN was present, but had not received specific education on which medications or routes were permitted. Staff C, an LPN, confirmed that nurse technicians dispensed controlled medications and had not received education on their roles. The Director of Nursing also stated that nurse technicians administered narcotic and IV medications, indicating a systemic lack of awareness and training regarding regulatory limitations.
Dietary Manager Lacked Required Certification
Penalty
Summary
The facility failed to ensure that the Dietary Manager had the required qualifications or certification to perform their duties in the kitchen. According to interviews and record review, the Dietary Manager began working in the position without having obtained the necessary dietary management certification and was still waiting for a proctor to administer the final test. During the Dietary Manager's absence, oversight of the kitchen was provided by the Human Resources Director, who also did not yet have the required certification but was in the process of obtaining it. The facility's dietician was only present on a part-time basis. This resulted in the kitchen being managed by staff who did not possess the required competencies and skills as mandated by regulation.
Failure to Obtain and Maintain Advance Directives Documentation
Penalty
Summary
The facility failed to obtain and/or maintain Advance Directives (AD) for two of twenty sampled residents. For one resident who was severely cognitively impaired, there was no documentation in the care plan or electronic health record (EHR) regarding the existence of an AD, nor evidence that information or assistance was provided to develop one. The social history assessment also did not indicate the presence of a responsible party or legal guardian, and staff confirmed that no outreach was made to the resident's family regarding guardianship or ADs. For another resident who was alert and oriented, the care plan documented that the resident did not wish to execute an AD at the time and that AD information should be offered quarterly and as needed. However, there was no documentation in the EHR that AD information was reviewed or offered on a quarterly basis or as needed. Staff interviews confirmed the lack of documentation and acknowledged that the facility's expectation was to review and offer AD information upon admission and quarterly.
Failure to Obtain Assessment, Consent, and Physician Order for Bed Rail Use
Penalty
Summary
The facility failed to obtain required assessments, consents, and physician orders for the use of bed rails for two residents. One resident, who was severely cognitively impaired, was observed multiple times with a padded bed rail in use, but there was no documentation in the electronic health record (EHR) of an assessment, consent, or physician order for the bed rail. Staff interviews confirmed that facility policy requires these steps before bed rails are used, and staff were unable to locate the necessary documentation for this resident. Another resident, who was moderately cognitively impaired, was observed with quarter bed rails and the bed positioned against the wall on several occasions. There were no physician orders or care plan entries addressing the use of bed rails or the bed's placement against the wall in the EHR. Staff confirmed that an assessment, consent, physician order, and care plan should have been in place for these interventions, but none were found for this resident.
Failure to Coordinate PASARR Level II Evaluations for Residents with Mental Health Needs
Penalty
Summary
The facility failed to coordinate the Preadmission Screen and Resident Review (PASARR) Level II services for two residents who required further evaluation for mental health needs. For one resident with moderate cognitive impairment, the Level I PASARR indicated a Level II evaluation was required, but no assessment was ever requested or obtained. This resident later developed new delusions and hallucinations and was started on new psychotropic medications, yet the PASARR was not updated to reflect these changes or to initiate a Level II referral. Another resident, admitted with a diagnosis of Post-Traumatic Stress Disorder and exhibiting symptoms such as mood instability, agitation, and refusals of care, also had a Level I PASARR indicating the need for a Level II evaluation. However, the assessment was never requested or obtained, despite the resident being treated with multiple psychotropic medications. Interviews with facility staff confirmed that the required referrals and documentation for Level II PASARR evaluations were not found in the electronic health record for either resident.
Failure to Complete Accurate PASARR Assessment for Mental Health Diagnosis
Penalty
Summary
The facility failed to ensure that a Pre-Admission Screening and Resident Review (PASARR) assessment was accurately completed for a resident with a documented mental health diagnosis. The resident was admitted with schizoaffective disorder and was noted to be moderately cognitively impaired, receiving both antipsychotic and antidepressant medications. However, the Level I PASARR completed prior to admission did not indicate the presence of a serious mental illness, such as schizophrenia or a mood disorder, and the section regarding service needs and assessor data was left incomplete. Upon review, facility staff acknowledged that the PASARR was inaccurate and that the necessary sections were not filled out, which should have prompted a referral for a Level II PASARR evaluation. The deficiency was identified through interviews and record reviews, which confirmed that the required screening process was not properly followed according to facility policy and regulatory requirements.
Failure to Develop Person-Centered Activities Care Plan for Cognitively Impaired Resident
Penalty
Summary
The facility failed to develop a person-centered activities care plan for a resident who was severely cognitively impaired. The resident was admitted to the facility and, according to the Admission Medicare - 5 Day Minimum Data Set assessment, was documented as severely cognitively impaired. A review of the resident's electronic health record (EHR) revealed there was no care plan addressing activity preferences, goals, or interventions. Multiple observations over several days showed the resident lying in bed, either sleeping or awake, with no evidence of engagement in activities. Interviews with staff indicated that the resident enjoyed singing, morning exercises, and watching TV in her room, but there was no care plan in place to support these preferences. Staff members acknowledged the absence of an activities care plan and noted that the resident did not participate in many activities, often remaining in bed. The resident herself expressed a desire to participate in activities but stated she only got out of bed sometimes. Staff also indicated that the resident might participate if encouraged to get out of bed, but no structured plan was documented to facilitate this.
Failure to Follow Professional Standards in Enteral Nutrition and Medication Documentation
Penalty
Summary
The facility failed to ensure that services provided met professional standards of practice for a resident receiving enteral nutrition. Specifically, a review of the resident's electronic health record revealed a physician order for enteral feeding with Jevity 1.2 at 70ml/hr over 18 hours, with water to run concurrently at 60ml/hr and tube flushes of 50ml pre and post feeding. However, during observation, the tube feeding pump was set to deliver water flushes at 50ml/hr instead of the ordered 60ml/hr. Staff confirmed that the pump settings did not match the physician's order, indicating a failure to verify and implement the correct settings at the beginning of the shift. Additionally, the facility did not document the administration of several medications for the same resident, as evidenced by blank entries in the Medication Administration Record (MAR) for multiple prescribed medications, including Pro-Stat Liquid, Amoxicillin-Pot Clavulanate, Guaifenesin ER, and Gabapentin Oral Solution. Staff interviews confirmed that it was the expectation for nurses to review physician orders, verify pump settings, and document medication administration, but these actions were not completed as required.
Failure to Provide Consistent Shaving Assistance for Dependent Resident
Penalty
Summary
The facility failed to provide necessary assistance with shaving for a resident who was severely cognitively impaired and dependent on staff for personal hygiene. Over several days, the resident was repeatedly observed with thick facial hair on her upper lip and chin, measuring about one quarter inch long. The resident expressed discomfort and embarrassment about the facial hair and stated that she would like to be shaved more often. She reported that shaving was only offered on shower days and not in between, despite her desire for more frequent care. Review of the resident's personal hygiene records showed no documentation of refusal of care for shaving during the observed period. Interviews with staff revealed inconsistent practices regarding the frequency of shaving, with some staff indicating it was offered daily and others stating it was only provided during showers. The Director of Nursing confirmed that shaving should be offered daily or as needed, and refusals should be documented, but this was not reflected in the resident's records. These findings demonstrate a failure to ensure consistent and adequate assistance with activities of daily living for a dependent resident.
Failure to Provide Resident-Centered Activities Based on Preferences
Penalty
Summary
The facility failed to provide resident-centered activities that incorporated the preferences, goals, or interventions for a resident who was severely cognitively impaired. The resident's electronic health record did not contain a care plan addressing activity preferences, and repeated observations over several days showed the resident lying in bed, either sleeping or awake, with no evidence of engagement in activities. Interviews with staff revealed that although the resident enjoyed singing, morning exercises, and watching TV, there was no care plan in place to support these interests. Staff also noted that the resident did not participate in group activities and spent most of her time in bed, with participation limited by lack of encouragement or assistance to get out of bed. The resident herself expressed a desire to participate in activities but indicated she did not do so regularly.
Failure to Initiate Bowel Management Protocol for Multiple Residents
Penalty
Summary
The facility failed to initiate bowel management interventions as outlined in its bowel protocol for six of seven sampled residents. According to the facility's policy, licensed nurses are required to identify residents who have not had a bowel movement for three days, review their medication administration records, and initiate a stepwise bowel protocol involving medications and assessments. However, documentation revealed that multiple residents went between five and seven days without a bowel movement, and there was no evidence that the bowel protocol was initiated as required. Certified Nurse Assistants were responsible for charting bowel movements every shift, but the lack of follow-through by licensed nurses resulted in prolonged periods without intervention. Interviews with staff confirmed that the expected protocol was not followed. An LPN was unable to provide documentation that interventions were started for several residents, and a Resident Care Manager acknowledged that the protocol was not initiated for at least two residents after reviewing their records. The Director of Nursing Services also stated that it was the expectation for nurses to assess and initiate the protocol, but this did not occur. The residents affected included those who were moderately cognitively impaired as well as those who were alert and oriented, and the failure to provide timely bowel management interventions was confirmed through both record review and staff interviews.
Failure to Document and Assess Supplemental Oxygen Use
Penalty
Summary
The facility failed to ensure continuous supplemental oxygen was provided as needed for a resident with a physician's order for oxygen at 1-5 liters per minute via nasal cannula, to be administered when oxygen saturation (SpO2) was less than 88%. Review of the resident's medical record showed no documentation of oxygen flow rate in the Medication Administration Record (MAR) or Treatment Administration Record (TAR), despite multiple observations of the resident using 4L of oxygen via nasal cannula on several occasions. The resident's SpO2 levels for the month were consistently within normal range (92% to 98%), and daily skilled charting summaries documented normal breath sounds and respiratory rates with no respiratory distress. Interviews with facility staff revealed a lack of clarity regarding the assessment and documentation of the resident's need for continuous versus PRN oxygen. The Resident Care Manager and LPN acknowledged that nurses should monitor the resident's SpO2 on room air to determine the need for supplemental oxygen, but there was no evidence this was being done or documented. The Director of Nursing Services stated that nurses were expected to assess and document the need for continuous oxygen and record PRN oxygen use in the MAR/TAR, which was not observed in the records reviewed.
Improper Storage and Labeling of Medications in Medication Cart
Penalty
Summary
Surveyors observed that medications in the Middle South medication cart were not properly stored or labeled according to facility policy and professional standards. Specifically, the top drawer of the cart contained six or seven loose plastic medication cups, each with multiple unlabeled medications. The only identifying information on the cups was a room number written on them. When questioned, the LPN present quickly disposed of the cups before the surveyor could count or further inspect the medications. The LPN explained that the medications were for residents scheduled to go out to appointments and that one resident had refused their medications. The Director of Nursing (DON) later confirmed that it was her expectation that medications should not be pre-poured and that there should not be cups with unlabeled medications for multiple residents stored in the medication cart. The facility's policy requires medications to be stored in an orderly manner, with each resident's medications assigned to an individual area to prevent mixing. The observed practice did not comply with these requirements, resulting in a deficiency related to medication storage and labeling.
Failure to Disinfect Shared Medical Equipment Between Resident Use
Penalty
Summary
Staff failed to clean and disinfect shared medical equipment, such as Hoyer lifts and vital sign machines, between resident use on both North and South hallways. On multiple occasions, staff were observed moving a Hoyer lift from one resident's room to the hallway and then to another room without disinfecting it. Similarly, a nurse assistant used a vital sign machine on one resident and then used the same machine on another resident without cleaning it in between. Disinfecting wipes were not available in isolation carts or in certain rooms, and staff were unable to locate or had not used disinfecting wipes on shared equipment during their shifts. Interviews with staff, including a LPN, CNAs, and the Infection Prevention Nurse, confirmed that the expectation was to disinfect shared equipment between uses, but this was not being followed. The lack of adherence to infection prevention and control guidelines was observed and confirmed through staff interviews and record review, resulting in noncompliance with regulatory requirements.
Failure to Maintain Secure Bed Rail Attachment
Penalty
Summary
A deficiency was identified when a resident with severe cognitive impairment was found to have a bed rail that was not securely fastened to the bed frame. The bed rail, located on the upper right side of the bed and covered with padding, was observed to be loose, with approximately six to seven inches of movement back and forth and leaning away from the mattress by the same distance. The bracket attaching the bed rail to the bed frame was also observed to be loose during multiple observations on consecutive days. Staff interviews revealed that there was no routine schedule for checking bed rails for safety, and maintenance was only notified when staff identified an issue. The Resident Care Manager and LPN were unsure if the bed rail should be tighter, and the DON confirmed that the bed rail was too loose. The Maintenance Director also confirmed the need for tightening after inspecting the bed rail. These observations and interviews demonstrated a failure to ensure that bed rails were securely fastened and free of gaps, as required.
Failure to Update Care Plan After Change in Condition
Penalty
Summary
The facility failed to update the care plan of Resident 1 after a change in condition, specifically the development of a lesion on the resident's genitalia. Resident 1, who was moderately cognitively impaired and at risk for skin breakdown due to various health conditions, was admitted to the facility and had a skin care plan in place. However, this care plan did not include the newly identified lesion on the resident's genitalia, which was first noted on 01/31/2025. Despite the lesion being assessed by staff and communicated to the provider, the care plan was not updated to reflect this change in condition. Staff interviews revealed that the facility's protocol required care plans to be updated with any change in a resident's condition. Staff D, an RN, and Staff C, the Residential Care Manager and LPN, both acknowledged the absence of an updated care plan for the penile lesion. Staff B, the Director of Nursing Services, also confirmed the expectation for care plans to be revised with any change in condition. The failure to update the care plan placed residents at risk for unmet care needs and a decreased quality of life.
Failure to Readmit Resident After Hospitalization
Penalty
Summary
The facility failed to ensure the readmission of a resident after a planned hospitalization, which was a violation of their own policy on bed-holds and returns. The policy required that residents be permitted to return to the facility following hospitalization or therapeutic leave, regardless of payer source. However, after the resident underwent surgery for a leg amputation, the facility did not readmit him, citing issues with his insurance coverage due to a change in ownership affecting agreements with insurers. The resident reported that nothing was discussed with him regarding his discharge plan, and the facility staff confirmed that no discharge plan was implemented. Additionally, the Admission Director expressed concerns about potential drug-related substances found in the resident's belongings, which influenced the decision not to readmit him. The Administrator was unaware of the reasons for the resident's non-return and stated that insurance status should not have been a factor. Furthermore, the facility did not provide the resident with a written explanation for the denial of readmission or information on his appeal rights, as confirmed by the Administrator. The Director of Nursing Services also confirmed the absence of a discharge plan in the resident's electronic medical record.
Failure to Assess Resident After Unwitnessed Fall
Penalty
Summary
The facility failed to ensure a resident was properly assessed after an unwitnessed fall, which was a deficiency in providing quality care related to falls. The incident involved a resident who was cognitively intact and required some assistance with Activities of Daily Living. The resident experienced a fall on New Year's Eve, which was not documented in the progress notes, and the initial neurological evaluations were only conducted the following day. The resident had visible bruises on the right side of her forehead and around her right eye, indicating a lack of immediate assessment and care. The facility's investigation revealed that the nurse on duty, Staff D, was informed of the fall by a CNA, Staff E, but did not assess the resident. Staff E reported the fall to Staff D, who allegedly did not take action to assess the resident despite being informed twice. The resident's roommate also confirmed that no nurse came to assess the resident after the fall, and the resident herself did not recall the fall or being assessed until the morning when neurological checks began. Interviews with facility staff, including the Director of Nursing Services and the Infection Preventionist, highlighted that the facility's protocol for falls was not followed. The protocol required immediate nursing assessment, neurological checks, and documentation, none of which were completed in a timely manner. The facility's expectation was for nurses to investigate falls promptly, consider potential abuse or neglect, and implement interventions to prevent further incidents, which did not occur in this case.
Deficiency in Food Storage and Cleanliness
Penalty
Summary
The facility failed to maintain cleanliness and food safety standards in its dry storage room and juice dispensing area. During an inspection, a pink wheeled cart in the dry storage room was found with clear and brown liquid underneath, and a black, spotted substance was observed on the floor and baseboards. Additionally, there was liquid dripping from a ceiling vent, and condensation patches were forming on the ceiling above shelving that held dry foods. Staff C, the Dietary Manager, acknowledged the poor condition of the storeroom, noting it was the worst she had encountered in four years. Staff D, the Maintenance Director, confirmed the water dripping from the ceiling vent was not normal, and Staff E, the Infection Preventionist, found the black substance's appearance unacceptable. In the juice dispensing area, the floor and compressor were wet, sticky, and had a black, spotted substance. Staff C stated that the area was cleaned by a contractor responsible for refilling the juices, but admitted the cleanliness was below her standards. Staff A, the Administrator, confirmed the juice dispensing area was dirty and acknowledged the need for management oversight in cleaning. The facility's failure to maintain these areas in a clean and sanitary manner placed residents at risk for foodborne illness and cross-contamination.
Deficiency in Kitchen Floor Maintenance
Penalty
Summary
The facility failed to maintain a safe and sanitary environment in the kitchen area, as observed by surveyors. The kitchen floor had broken linoleum tiles near the dishwashing and handwashing stations, exposing approximately 5 square feet of bare concrete at the dishwashing station and 2 square feet at the handwashing station. This condition was acknowledged by the Maintenance Director, who had placed mats over the exposed areas as a temporary measure. The Administrator was also aware of the issue, noting that the building was acquired in this condition from a previous corporation and that the broken tiles were slated for repair as soon as possible.
Food Safety and Cleanliness Deficiencies
Penalty
Summary
The facility failed to maintain cleanliness and proper labeling in its kitchen and storage areas, which posed a risk for foodborne illness among residents. During an initial tour, surveyors observed a dark residue on the ice machine dispenser snout, indicating a lack of cleanliness. Additionally, an opened Ben & Jerry's ice cream container in the walk-in freezer and an opened container of egg shade food coloring in dry storage were not labeled or dated, violating food safety standards. Lint was also observed hanging from overhead vents in the kitchen prep area and tray line side, further indicating inadequate maintenance of cleanliness. During a follow-up visit, the issues persisted, with seven items found opened and unlabeled in the dry storage room. The ice machine still had dark residue, which the Dietary Manager identified as black dirt. Lint continued to hang from vent covers over the hot-hold food service/prep area and behind the tray line. In the north nourishment refrigerator/freezer, several opened items, including a milk jug, rainbow sherbet ice cream, and a box of Kentucky Fried Chicken, were not labeled or dated. The Assistant Director of Nursing confirmed that staff were responsible for labeling items with the date opened, highlighting a lapse in adherence to food safety protocols.
Failure to Obtain Required Documentation for Bed Rails
Penalty
Summary
The facility failed to obtain necessary documentation and approvals for the use of physical restraints on a resident, specifically padded quarter bed rails. The facility's policy requires a Bed Rail/Bed Enabler/Device Evaluation to be completed prior to the use of such devices, along with obtaining consent from the resident or their representative, a physician's order, and incorporating the device into the resident's care plan. However, for Resident 17, who was severely cognitively impaired, these steps were not followed. Observations on multiple occasions confirmed the presence of bed rails, yet the resident's electronic health record lacked any evaluation assessment, consent, or physician's order related to the bed rails. Interviews with facility staff, including registered nurses and resident care managers, revealed a lack of compliance with the facility's policy. Staff members acknowledged the absence of the required documentation and care planning for Resident 17's bed rails. The Assistant Director of Nursing also confirmed that it was expected for residents to have assessments, consents, orders, and care plans for such devices, indicating a lapse in adherence to established procedures. This oversight placed the resident at risk for injury, unmet needs, and a diminished quality of life.
Failure to Document Care Plan for Bed Rails
Penalty
Summary
The facility failed to develop a comprehensive care plan for a resident who was severely cognitively impaired and required the use of padded quarter bed rails on both sides of the bed. Despite the facility's policy requiring that the use of such devices be included in the care plan with the goal of using the least restrictive measures, the care plan for this resident did not document the use of the bed rails. This oversight was identified during a review of the resident's electronic health record and was confirmed through multiple observations of the resident in bed with the padded quarter bed rails in place. Interviews with facility staff, including a Registered Nurse, a Resident Care Manager, and the Assistant Director of Nursing, revealed that it was the facility's expectation to have care plans for residents using bed rails or mobility bars. However, staff were unable to locate any evaluation, consent, order, or care plan for the resident's use of the quarter bed rails. The lack of documentation and care planning for the bed rails was acknowledged by the staff, indicating a lapse in following the facility's policy and procedures.
Failure to Provide Preventative Measures and Consistent Restorative Services
Penalty
Summary
The facility failed to ensure preventative measures for contractures and consistent restorative services for two residents, leading to a deficiency in maintaining activities of daily living (ADLs). Resident 30, who was moderately cognitively impaired and had a history of a cerebral vascular accident (CVA) with contractures to the left hand, reported being unable to open her left hand. Despite this, staff did not provide adequate preventative measures, such as a splint, to address the contractures. Staff F, a Resident Care Manager and LPN, did not believe the resident's nails were causing harm, and Staff C, an Assistant Director of Nursing and RN, suggested offering a splint only after the issue was raised. Resident 17, who was severely cognitively impaired, was supposed to be on a restorative program as per their care plan. However, the Restorative Task form indicated that the resident received services on only a few occasions, with over 85% of the month lacking services. The form noted that the resident refused services on some days, and on other days, services were not available because restorative aids were pulled to the floor. There was no documentation of follow-up for the days the resident refused services, and Staff C confirmed that the lack of documentation was due to the restorative aids being reassigned.
Failure to Provide Follow-Up Education on Pneumococcal Vaccine
Penalty
Summary
The facility failed to provide follow-up education for the Pneumococcal Conjugate Vaccine (PCV13) for one of the five sampled residents reviewed for immunizations. Resident 45 had previously declined the PCV13, as documented in a consent form dated August 11, 2020, without any reason provided for the declination. No additional information about the pneumococcal vaccine was found in the resident's electronic health record. On May 23, 2024, Staff J, an Infection Preventionist and LPN, stated that the PCV13 should be reviewed quarterly at care conferences, but was unsure if this was followed up for Resident 45, who had expressed a desire to receive the vaccine with her granddaughter. Staff C, the Assistant Director of Nursing and RN, mentioned that if the pneumococcal vaccine was declined, it should be offered to long-term care residents every year.
Failure to Investigate Narcotic Overdose Incident
Penalty
Summary
The facility failed to initiate an investigation after a resident was sent to the emergency room and later admitted with a diagnosis of narcotic overdose. The resident, who was moderately cognitively impaired, had a physician order for Morphine Sulfate ER to be administered twice daily for pain. On a particular day, a licensed nurse noted a sudden change in the resident's mental status, including unresponsiveness and inability to follow directions, prompting a transfer to the emergency room. The emergency department documented signs of opioid withdrawal and administered Narcan multiple times, leading to a diagnosis of narcotic overdose and hypoxia. Despite these events, the facility's accident and incident investigation log did not reflect any investigation into the medication overdose. Interviews with facility staff revealed that no formal investigation was conducted. The Director of Nursing Services acknowledged the lack of an investigation, and the Administrator admitted uncertainty about whether an investigation had been initiated. The Residential Care Manager conducted a medication review but found no evidence of an overdose and did not document the review, indicating a failure to formally investigate the incident.
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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