Spokane Falls Care
Inspection history, citations, penalties and survey trends for this long-term care facility in Spokane, Washington.
- Location
- 6021 North Lidgerwood, Spokane, Washington 99207
- CMS Provider Number
- 505024
- Inspections on file
- 48
- Latest survey
- April 13, 2026
- Citations (last 12 mo.)
- 14
Citation history
Health deficiencies cited at Spokane Falls Care during CMS and state inspections, most recent first.
The facility failed to follow its abuse prevention and reporting policy and state requirements by not identifying multiple resident-to-resident verbal and physical altercations, as well as a serious accident involving a resident using a motorized WC, as reportable allegations of abuse or potential abuse. Cognitively intact and cognitively impaired residents with conditions such as dementia, bipolar disorder, anxiety, depression, and non-traumatic brain dysfunction were involved in incidents where residents hit each other, made threats of physical harm, or engaged in escalating verbal aggression, sometimes in common areas and in the presence of staff and peers. In one case, a paraplegic resident independently using a motorized WC reported being struck by a car in the community, was thrown from the WC, sustained abrasions, and had WC damage requiring repair, yet this event and its investigation were not reported to the state. Investigation files for these events often lacked detailed witness statements, and in all cited cases there was no documentation that the allegations or investigation results were reported to the State Survey Agency, even though staff and leadership acknowledged in interviews that such altercations were potential abuse and that they were mandatory reporters.
Surveyors found that the facility did not maintain an accident‑hazard‑free environment or complete required post‑fall monitoring for several residents. A paraplegic resident using a motorized WC had no care plan addressing WC safety and was not reassessed for driving safety after being hit by a car, despite staff expectations that therapy evaluate motorized WC users and that use be care planned. Another resident with bilateral leg amputations fell from a shower bench that lacked rubber stoppers, and required neuro checks were missed; other shower benches were also observed missing stoppers. A severely cognitively impaired resident and a resident with dementia and prior stroke experienced multiple falls, but documentation repeatedly lacked required VS and neuro checks and 72‑hour monitoring, even though staff described a fall packet, neuro flowsheet schedule, and alert charting requirements that were not consistently followed.
Surveyors found that the facility failed to follow food safety and sanitation standards in the dietary department, including multiple opened and undated food items in dry storage, the refrigerator, and the freezer, and widespread unclean conditions such as food debris in equipment, dirty counters and floors, broken non-cleanable tiles, and an active water leak with a bucket on the floor. Staff with facial hair wore beard covers that did not fully cover their mustaches and beards while handling and plating food, and a resident reported finding hair in their meal. Meal service was observed to be about an hour late on more than one occasion, and several residents reported that lunch and dinner were frequently late, leaving limited time to eat before activities. Staff acknowledged the importance of proper labeling, kitchen cleanliness, complete beard coverage, and timely meal service, especially for residents with diabetes and those with scheduled outings.
Surveyors found that a resident with an indwelling urinary catheter was repeatedly observed in bed with the urine collection bag hanging on the bedframe, uncovered and visible from the hallway, despite staff acknowledging that dignity covers were expected and that the facility had run out of them, and the resident’s care plan lacking any dignity-related interventions. In a separate case, a severely cognitively impaired resident with multiple psychotropic medication orders, including Seroquel with known serious adverse effects, signed psychotropic consents and admission paperwork involving financial obligations and Medicare/Medicaid denial, even though cognitive testing showed severe impairment, the care plan did not address impaired cognition, and staff later acknowledged the resident likely did not understand what they were signing.
Surveyors found that the facility did not maintain several resident rooms and common care areas in safe, clean, and homelike condition. One cognitively intact resident with multiple chronic conditions lived in a room with damaged closet wood, non-cleanable surfaces, loose caulking, missing drywall, and a missing transition strip with dirt buildup. Another resident with fractures and infection risk reported broken toilet seats in two shower rooms, which staff used daily and which remained broken for an extended period without timely reporting through the electronic maintenance system. A therapy room used by residents had long-standing black and rust stains on the tile floor, and a resident with dementia and frequent falls had a bed placed against a wall with deep gouges exposing drywall that remained unrepaired despite staff awareness that it was a non-cleanable surface.
A resident admitted with documented depression, anxiety, PTSD, and substance use disorder had a Level I PASRR completed that incorrectly indicated no serious mental illness and that a Level II evaluation was not needed. The Social Service Director reported that PASRRs were supposed to be completed in the hospital and reviewed for accuracy, and acknowledged that this resident’s PASRR was incorrect and should have triggered a Level II due to the mental health diagnoses and anticipated stay over 30 days. The DON stated that PASRRs were completed at the hospital and evaluated by Social Services, and that most PASRRs were not completed prior to admission, contributing to the failure to obtain the required Level II PASRR for this resident.
Surveyors found that the facility did not follow care-planned interventions for two residents. One resident with an above-the-knee amputation had a care plan and therapy notes specifying use of bed rails to assist with bed mobility, yet repeated observations showed the bed without rails after a room change, and multiple staff, including an NA, an LPN, the resident care manager, and the DON, acknowledged that bed rails were ordered and should be in place. Another resident with impaired vision had a care plan directing provision of large print reading materials, but the only posted activities calendar was in very small print across the room, which the resident could not read even up close; several staff, including activities and nursing staff, confirmed the font was too small for someone with visual impairment.
Surveyors found that two residents with COPD and other respiratory conditions did not receive safe and sanitary respiratory care. One resident, dependent on continuous oxygen, repeatedly received 3 L instead of the ordered 2 L, and the oxygen concentrator filter was observed on multiple occasions to be covered in thick dust and debris, despite staff stating filters should be cleaned weekly. Another resident who used a BiPAP nightly reported that staff did not clean the mask or tubing, and the record lacked provider orders or documentation for routine BiPAP cleaning, even though staff and leadership stated that daily cleaning and sanitary maintenance of such equipment were expected.
Surveyors observed that a nurse administered incorrect medications and failed to follow timing parameters for a cholesterol medication, resulting in two errors out of 26 medication opportunities and a medication error rate above 5%. A resident received Calcium with Vitamin D instead of the ordered Calcium alone, and Colestipol was not given one hour before or three hours after other meds as ordered. The DON later acknowledged both errors.
Surveyors identified that medications and biologicals were not properly managed in one South Unit medication room and on a medication cart. An LPN’s cart contained expired glucometer quality control solutions, though review of the log showed they had not been used for documented checks. In the South medication room, three bottles of Gericare Aspirin 325 mg were found past their manufacturer expiration dates, and the medication refrigerator was repeatedly below the required 36–46°F range while storing multiple insulin pens, Retacrit vials, Lorazepam vials, and Tubersol. Temperature logs documented several out-of-range readings with no recorded follow-up actions, and staff later acknowledged that expired aspirin had been missed during routine stock checks. The report states these failures placed residents at risk of receiving potentially compromised or expired medications.
A resident with cellulitis on both lower legs and a skin tear on the left lower leg did not receive consistent assessment and documentation of these non-pressure skin conditions as required by facility policy and the care plan. Initial Skin Grid and Total Body forms identified extensive cellulitis and a 3 cm open skin tear, but no subsequent Skin Grid or Total Body forms were found, and a later nursing note described a left lower leg wound without clarifying whether it was the cellulitis or the skin tear. Interviews with the RCM, an LPN, and the DNS confirmed that weekly wound assessments with measurements and documentation were expected for such conditions, yet the resident’s record lacked ongoing, clearly identified weekly monitoring.
Surveyors found that two residents did not receive medications as ordered by their providers. One resident with DM received short-acting insulin doses even when BG readings were below the ordered hold parameter, as documented on consecutive MARs and confirmed by the RCM and Administrator. Another resident with kidney disease and DM, treated for eye symptoms with ordered antibiotic eye drops, missed multiple documented doses both when the drops were ordered for one eye and after the order was changed to both eyes four times daily.
A resident with a history of stroke, encephalopathy, and significant cognitive decline was not properly identified as an elopement risk, despite multiple episodes of confusion, wandering, and leaving the facility unattended. The care plan and elopement risk assessments were not updated in a timely manner, and interventions such as wander guard devices were not effectively implemented, resulting in repeated unsupervised departures.
The facility did not perform required N-95 mask fit testing for all employees, with the last building-wide fit testing occurring in the spring of 2024. The Administrator confirmed the facility was out of compliance, and the Infection Preventionist was unable to provide documentation of completed fit tests, as none had been conducted since the previous round.
Two residents admitted with severe pain following recent surgery did not receive timely pain management, with delays of several hours before prescribed medications were administered. Both residents reported pain at the highest level and were not offered alternative interventions while waiting. Staff interviews confirmed that pain medication should have been provided promptly and that procedures were in place to access needed medications.
The facility did not identify or report multiple allegations of potential abuse and neglect to the State Survey Agency as required. A resident reported a roommate was left in soiled conditions overnight, another reported being left on a bedpan for extended periods, and a third described long delays in call light response and pain medication administration. These grievances were not logged or reported according to regulatory requirements.
Several dependent residents did not receive the required number of baths or showers, with some going up to two weeks or more without proper hygiene care. Additionally, multiple residents, including those with diabetes and physical limitations, did not receive necessary nail care, resulting in long, untrimmed, or jagged toenails. Staff interviews confirmed that inadequate staffing and scheduling issues contributed to missed showers and grooming, and documentation showed a lack of podiatry referrals for residents needing specialized foot care.
A resident with a history of stroke reported being yelled at and argued with by a staff member, an incident witnessed by a CNA who felt it amounted to verbal abuse and reported it to the DON. However, there was no documentation or evidence that the facility investigated the allegation, and the administrator was unaware of the details of the incident.
The facility did not consistently assess, monitor, or document non-pressure related skin conditions for two residents with multiple wounds, including surgical sites, ulcers, and moisture-associated skin damage. Despite policies requiring weekly monitoring and detailed documentation, records lacked wound descriptions, measurements, and evidence of ongoing assessment, and staff interviews confirmed inconsistent practices.
The facility did not consistently obtain timely and accurate weights or implement appropriate monitoring for two residents at nutritional risk, including one with significant weight loss and another on enteral nutrition. Required weekly weights, re-weighs for discrepancies, and proper documentation were not completed as per facility policy, placing residents at risk for unmet nutritional needs.
The facility failed to implement Enhanced Barrier Precautions for two residents, with staff not wearing required protective equipment during care. Hand hygiene was not performed during medication administration, and the Water Management Plan was incomplete, lacking specific interventions to prevent waterborne illnesses.
The facility failed to inform residents and their representatives about rights and responsibilities, including Medicaid rights, upon admission. This deficiency affected 10 residents, with delays in signing admission agreements and lack of documentation of discussions. Staff interviews revealed inconsistencies in completing and reviewing admission paperwork, leading to residents being uninformed of their rights.
The facility failed to provide necessary information on advanced directives to residents or their legal representatives upon admission. This affected several residents, including one who wished to change their DPOA and another who left against medical advice. Staff interviews revealed inconsistencies in the process of reviewing and explaining admission paperwork.
The facility failed to implement an effective admission policy, resulting in incomplete and delayed admission paperwork for several residents. This included not reviewing or signing admission agreements with cognitively intact residents and having cognitively impaired residents sign agreements instead of their legal representatives. Staff interviews revealed confusion and inconsistency in the admission process, leading to residents not being fully informed of their rights and care needs.
The facility failed to provide written information on bed hold policies to residents or their representatives upon admission, affecting eight residents. Documentation and interviews revealed inconsistencies and confusion among staff regarding the responsibility for reviewing and completing admission paperwork, leading to residents being uninformed about their bed hold rights.
A facility failed to monitor a resident's blood values on Coumadin, did not implement a bowel protocol for another resident, and did not adhere to oxygen and blood pressure medication parameters for a third resident. These deficiencies involved not notifying providers of critical lab results, not following bowel movement protocols, and administering medications outside of prescribed parameters.
The facility failed to provide comprehensive dialysis care for four residents, leading to deficiencies in medication administration, fluid intake monitoring, and care plan details. Residents exceeded fluid restrictions, and there was confusion about medication administration at the dialysis center. Staff interviews revealed a lack of clarity and communication regarding care plans and dialysis care management.
The facility did not complete annual evaluations and competency checks for nursing staff, affecting 6 out of 10 sampled employees, including nursing assistants, an LPN, and an RN. Evaluations and skills fairs had not been conducted for about two years, and the HR department confirmed the absence of documentation. The facility was auditing and working to complete these evaluations.
The facility failed to administer significant medications as ordered for four residents undergoing dialysis, leading to missed doses of essential medications. Staff assumed medications would be dialyzed out and omitted doses without consulting providers, potentially impacting residents' health. The Resident Care Manager was unaware of these omissions, and staff failed to communicate issues, resulting in the deficiency.
The facility failed to maintain compliance with Federal regulations, impacting residents' rights and admission documentation. Due to staffing changes and gaps in the Medical Records department, admission agreements and advance directives were incomplete, placing residents at risk of not being informed of their rights and care needs.
A resident with a urinary catheter was observed with their urine collection bag visible from the doorway, as the dignity bag was not in use. The facility's policy lacked guidance on maintaining dignity for catheter use, and staff confirmed the expectation to use dignity bags, which was not followed.
The facility failed to obtain informed consents for psychotropic medications for two residents. One resident received Paroxetine for depression without documented consent, while another received quetiapine for major depression without consent for 23 days. Staff interviews confirmed that consents should have been obtained prior to medication administration, but errors in the process led to these oversights.
A facility failed to assess a resident's ability to safely self-administer medications or store them at the bedside, as required by policy. The resident, with mild cognitive impairment, was observed using an over-the-counter antacid without notifying staff and without a provider's order. Staff acknowledged that the necessary evaluations and care planning were not completed, and the medication should not have been left unattended.
The facility failed to maintain functional sink faucets for two residents, impacting their ability to perform ADLs. One resident had their sink water turned off for weeks due to a leak, while another had a loose faucet. Staff were unaware of these issues, and no maintenance tickets were found, indicating a lack of communication and action.
The facility failed to ensure consistent mail delivery for residents, particularly on weekends, due to staffing issues. This affected residents' rights to receive and send mail promptly, as outlined in the facility's Resident Rights policy. Interviews with residents and staff confirmed that mail was not distributed on weekends, impacting the quality of life for several residents.
The facility failed to conduct timely PASRR evaluations and referrals for three residents with newly evident mental conditions. Two residents diagnosed with depression and started on psychotropic medication did not receive the necessary PASRR level I screening and level II referral. Another resident with a PASRR level II recommendation for behavioral health services experienced a delay in receiving these services. Staff misunderstandings and lack of timely action contributed to these deficiencies.
The facility failed to conduct required PASRR Level II evaluations for two residents with mental health histories prior to admission. One resident with major depressive disorder and another with depression were admitted without the necessary evaluations, as their PASRR Level I screenings did not identify serious mental illness. This oversight risked unmet behavioral health needs.
The facility failed to develop timely baseline care plans for two residents dependent on dialysis, as required within 48 hours of admission. One resident's care plan was delayed by nearly a month, while another had no documented dialysis care interventions during their stay. Staff interviews indicated a multi-step care plan process, but initial plans did not address immediate dialysis needs.
A facility failed to document a discharge summary and AMA form for a resident who left against medical advice due to dissatisfaction with their room. The resident's medical records lacked necessary documentation, including progress notes and notifications to relevant parties. Staff interviews confirmed the absence of required documentation and the failure to notify Adult Protective Services.
The facility failed to properly assess and monitor residents for substance use disorder, safe smoking abilities, and post-fall evaluations. A resident with alcohol abuse was not assessed for SUD risks, another resident with hemiplegia struggled to re-enter the facility after smoking, and a hospice resident did not receive required post-fall assessments. These deficiencies highlight lapses in policy enforcement and resident safety evaluations.
A resident with symptoms of a UTI experienced delays in receiving timely interventions due to the facility's inadequate lab procedures. The resident, who was occasionally incontinent and had a history of amputation, reported urinary frequency and urgency. Despite these symptoms, the care plan lacked relevant interventions, and the urine sample was delayed due to the lab's weekend schedule. The Medical Director expressed concerns about the facility's diagnostic criteria, and the DON acknowledged the delay in processing the sample.
A facility failed to discontinue previous tube feeding orders for a resident with a feeding tube, leading to conflicting documentation in the MAR. The resident, who received more than 51% of their nutrition through the tube, had new orders for Glucerna and water flushes, but the previous orders for Osmolite and water flushes were not discontinued. Staff believed the resident did not receive both formulas due to correct pump programming, but documentation showed both sets of orders were administered.
A facility failed to identify and address trauma in a resident, leading to a deficiency in trauma-informed care. The resident, with a history of hemiplegia and depression, was admitted without a comprehensive trauma assessment, and their care plan lacked interventions for social concerns. Staff interviews revealed a lack of understanding and implementation of trauma-informed practices, putting the resident at risk for re-traumatization.
A resident with a stimulant-induced psychotic disorder did not receive timely behavioral health services as required by their PASRR Level II evaluation. Critical sections of the Social Services Admission Evaluation were left blank, and a behavioral health referral was delayed until several months after admission. The resident expressed concerns about the lack of trauma-informed care, and staff interviews revealed a lack of understanding of the PASRR process.
The facility failed to complete timely medication regimen reviews for three residents, leading to potential risks of unnecessary medication use. A resident with coronary artery disease experienced a delay in discontinuing Clopidogrel, while another resident with diabetes continued receiving insulin without timely physician evaluation. Additionally, a resident with mental health diagnoses had missing MRR documentation for several months. Staff interviews revealed gaps in the MRR process due to management changes.
Expired medications were found in the South Hall medication room and cart, and emergency kits were improperly sealed. An LPN failed to count lorazepam during narcotic reconciliation, and the DON was unaware of expired medications. In the North Hall, liquid Ativan was not logged into the narcotic book, leading to inadequate tracking. The facility's policy for controlled drugs was not followed, resulting in deficiencies.
The facility failed to ensure the Dietary Manager had the necessary certification, despite the part-time status of the Regional Registered Dietician. The Dietary Manager, in their role for nearly three years, lacked the required certification, possessing only a food handler card. The Administrator confirmed the need for certification due to the dietician's part-time presence.
The facility failed to provide two residents with their preferred beverage, coffee, upon request, leading to unmet care needs. One resident, with malnutrition, waited hours for coffee, while another expressed dissatisfaction with its unavailability. Staff interviews revealed inconsistencies in coffee availability, with some indicating it should be available 24/7, but operational limitations and cost concerns led to shortages.
A facility failed to maintain accurate medical records for a resident, who was inaccurately documented as having allergies to Acetaminophen, Baclofen, and Morphine. Despite these documented allergies, the resident was regularly administered Morphine and Tylenol as prescribed. Staff interviews revealed awareness of the inaccuracies, yet corrections were not made, placing the resident at risk of unmet care needs.
A facility failed to explain an arbitration agreement to a resident in their preferred language, Mandarin, despite the resident's severe cognitive impairment and need for an interpreter. The agreement was signed by the resident in English, without involvement from their legal representative. Staff interviews revealed inconsistencies in the process of reviewing arbitration agreements, with uncertainty about the availability of agreements in other languages and the use of interpreter services.
Failure to Identify and Report Resident-to-Resident Altercations and Accident as Abuse
Penalty
Summary
The deficiency involves the facility’s failure to identify multiple resident-to-resident verbal and physical altercations, as well as a resident accident, as reportable abuse or potential abuse, and to notify the State Survey Agency and report investigation results as required by its abuse prevention and reporting policy and state regulation. The facility’s policy required that any allegation meeting the definition of abuse be reported to the State Survey Agency within two hours if serious bodily injury occurred or within 24 hours if it did not, that a thorough investigation be completed and documented, that further abuse be prevented during the investigation, and that investigation results be reported within five working days. The policy defined verbal and mental abuse as oral, written, or gestured language that demeaned or humiliated, and neglect as disregard for resident care, comfort, or safety that resulted in or could have resulted in harm or distress. Despite this, the facility’s incident logs and investigation files for multiple residents showed no documentation that these events or their investigation findings were reported to the state agency. One component of the deficiency concerns a resident accident involving a cognitively intact resident with paraplegia who used a motorized wheelchair independently. The resident’s mobility care plan did not identify use of a motorized wheelchair or include goals and interventions for safe motorized wheelchair mobility. The incident log documented that this resident was struck by a vehicle while out in the community, causing them to fall from the wheelchair and sustain abrasions to the right leg, and resulting in damage to the wheelchair that required a wheel adjustment by a technician. The facility’s incident report recorded that the resident returned to the facility at night and reported that their motorized wheelchair had been hit by a car, causing it to tip and throwing them out, with resulting “road rash” and a dented wheel. There was no documentation that this accident or the investigation findings were reported to the State Survey Agency as required. The remaining components of the deficiency involve multiple resident-to-resident altercations, both physical and verbal, that were not treated as reportable allegations of abuse. For one cognitively intact resident with anxiety, depression, and impulsive behaviors, the incident log showed a physical altercation with another cognitively intact resident in a smoking area after a disagreement, during which both residents hit each other. The former DNS documented that this altercation could be considered abuse but concluded that abuse was not suspected, and there was no documentation of state reporting. The same resident was later reported by a nursing assistant to have told another resident to get out of their way and to have backhanded that resident on the shoulder while passing; both residents were assessed and the aggression documented, but again there was no documentation that the allegation or investigation results were reported to the state. Additional unreported incidents included verbal and physical aggression among various cognitively intact and cognitively impaired residents with diagnoses such as dementia with behavioral disturbance, depression, bipolar disorder, anxiety, and non-traumatic brain dysfunction. In one case, a resident with a history of verbally aggressive outbursts told another resident at the nurses’ station, in front of staff and peers, that they should “beat the s**t out of” them after grabbing and discarding an item. In another, a resident with bipolar disorder initiated verbal aggression toward a roommate over room cleanliness, and in separate incidents, roommates reported threatening statements about physical harm or were struck in the forehead after a verbal altercation escalated to physical aggression. Several investigations lacked resident or staff witness statements or detailed incident descriptions, and summaries often stated that residents remained at baseline and that abuse or neglect was ruled out. Across all of these events, the incident logs and investigation folders contained no documentation that the alleged incidents or investigation results were reported to the State Survey Agency, despite multiple staff, including nursing assistants, LPNs, the Resident Care Manager, Social Services Director, DNS, Regional Director, and Administrator, acknowledging in interviews that resident-to-resident altercations could constitute potential abuse and that staff were mandatory reporters who were expected to identify and report such allegations. The surveyors concluded that these failures to identify and report multiple resident-to-resident altercations and a resident accident/injury as potential abuse or neglect, and to report the allegations and investigation results to the State Survey Agency as required, placed residents at risk for potential continued abuse, possible safety concerns due to inadequate follow-up, and diminished quality of life.
Failure to Prevent Hazards and Complete Post‑Fall Monitoring for Multiple Residents
Penalty
Summary
The deficiency involves the facility’s failure to maintain an accident‑hazard‑free environment and to provide adequate supervision and monitoring after accidents for multiple residents. Facility policy required identification and evaluation of environmental hazards, implementation and monitoring of interventions, completion of incident reports, notification of the administrator if a medical device caused or contributed to an injury, and monitoring of residents for a minimum of 72 hours after an incident. A neurological assessment flowsheet specified that after a fall where the head was struck or the fall was unwitnessed, neuro checks and vital signs were to be completed every hour four times, then every four hours six times. Surveyors found that these requirements were not consistently followed for four sampled residents. One cognitively intact resident with paraplegia used a motorized wheelchair independently and had a mobility care plan that did not address any risk assessment, identified hazards, safety interventions, or monitoring related to motorized wheelchair use. The facility’s incident log showed that this resident was struck by a vehicle while out in the community, causing them to fall from the wheelchair and sustain abrasions, and resulting in damage to the wheelchair, including a bent wheel and other needed repairs. Although staff interviews indicated that residents using motorized wheelchairs were supposed to be evaluated by therapy for safety prior to use and that such use should be care planned, there was no motorized wheelchair driving assessment or updated mobility care plan with interventions or preventive measures in place for this resident until more than two months after the accident. Staff, including the physical therapist, resident care manager, and DON, acknowledged that the resident should have been reassessed for motorized wheelchair safety after the accident. Another resident with bilateral below‑knee amputations, poor balance, and deconditioning had a fall care plan that directed staff to monitor for 72 hours post‑fall and complete neurological assessments per protocol. This resident fell from a shower bench when it tipped forward because it was missing rubber caps on the bottom of the legs, resulting in a skin tear to the stump. The facility’s post‑fall investigation documented that the shower chair was missing the rubber caps, and required neurological checks were not completed at several scheduled times following the fall. Subsequent observations showed other shower benches in different halls were also missing one or more rubber stoppers. Staff interviews confirmed that rubber stoppers were important to prevent slipping and falls, that equipment needing repair was to be reported through the maintenance system, and that neuro assessments were required for certain falls, but the maintenance director did not check all benches after being notified of missing parts on one bench. A third resident, severely cognitively impaired, dependent on staff, and at risk for falls, had sustained no falls in the six months prior to admission but experienced seven falls within approximately two months after admission. The care plan instructed staff to remind the resident to use the call light, ensure proper footwear, and involve the resident in activities to minimize falls. Review of fall investigations showed that for multiple falls, there was no documentation that vital signs and neuro checks were completed according to the required flowsheet timeline, and no documentation that the resident was monitored after those incidents. Staff interviews confirmed that a paper fall packet with required actions, including complete body assessment, vital signs, and neuro checks at specified intervals, was to be fully completed, and that residents should be placed on alert charting and monitored for 72 hours after a fall, but the DON acknowledged this resident was not consistently monitored as required. A fourth resident with moderately impaired cognition, hallucinations, disorganized thinking, dementia, prior stroke with weakness, and dependence on staff for mobility and transfers had 12 falls over a six‑month period. Review of fall investigations and the medical record showed that for several of these falls, there was no documentation that vital signs and neuro checks were completed per the neuro flowsheet timeline, and no documentation that the resident was monitored for 72 hours after certain incidents. Staff interviews indicated that after a fall, a nurse was to assess the resident, and vital and neuro checks were to be done according to the schedule on the neuro flowsheet, with the resident placed on alert charting and monitored every shift for at least 72 hours. The DON acknowledged that this resident had not been completely monitored for injury following some falls. These findings collectively demonstrate failures to follow facility policy and required monitoring protocols related to accidents and falls.
Food Storage, Sanitation, Beard Covering, and Meal Timing Deficiencies in Dietary Services
Penalty
Summary
The deficiency involves failure to store, label, and handle food in accordance with professional standards for food safety. During an initial kitchen tour, surveyors observed multiple undated and opened food items in dry storage, including bags of chicken and herb stuffing, vanilla wafers, miniature graham cracker pie crusts, large graham cracker pie crusts, and a muffin in a bag, all without received or expiration dates. In the main refrigerator, a pan containing cheese slices, tomatoes, and lettuce had no date, and a box of zucchini contained cut, wilted pieces. In the freezer, a chocolate cream pie and an opened bag of waffles lacked received or expiration dates. Staff later acknowledged the importance of labeling food to know when it expired and to prevent bacteria. The facility also failed to maintain a sanitary kitchen environment. Surveyors observed food debris on the bottom shelf of a small freezer, an unclean juice machine with dirt debris covering the filter, ovens with food debris and thick dirt on the outside, and a plate warmer with brown splatter on all sides. Additional observations included dirty shelving under the mixer, dirty rags on a stool near the dishwasher, a toaster with crumbs and brown splatter, and unclean counters with food on them. The floor in the back of the kitchen had food debris, gloves, and garbage, and a sheet pan holding vegetable oils and vinegars under the steamer was soiled with spilled oils and dirt. At the kitchen entrance, there was an approximately three-foot area of broken tiles along the wall and floor with thick dirt debris, and a bucket on the floor collecting water from an active leak. The ice machine had dust and dirt buildup on its exterior surfaces, and the March and April cleaning schedules showed multiple omissions. The Dietary Manager and Maintenance Director stated the broken tiles were not a cleanable surface and that it was important to keep equipment and the kitchen clean to prevent bacteria and foodborne illness. Additional deficiencies were observed in staff use of beard coverings and timeliness of meal service. A cook and the Dietary Manager were seen wearing beard covers that did not fully cover their long, thick mustaches and beards while handling and plating food, and one cook stood over food reading meal tickets with facial hair partially uncovered. A resident reported having hair in their food the previous evening. Surveyors also observed that meal trays were sent to the dining room about an hour after the scheduled meal times on multiple days, with plating not started at the listed meal time. Several residents reported that lunch was frequently late, that meals had been over an hour late, and that the delay left them with very little time to finish their meals before scheduled activities. Staff stated it was important to start meal service on time, particularly for residents with diabetes who received insulin and for residents with outings, and that beard coverings were required to cover all facial hair as a physical contaminant control.
Failure to Maintain Catheter Dignity and Obtain Valid Psychotropic Consents
Penalty
Summary
The facility failed to maintain a urinary catheter in a dignified manner for one resident with encephalopathy who was dependent on staff for toileting and had an indwelling urinary catheter. The resident’s care plan addressed catheter care tasks such as changing the catheter per provider orders, emptying the collection bag each shift, keeping the catheter anchored, and maintaining the bag below bladder level, but did not document how the resident’s dignity would be maintained. Over multiple observations on several days, the resident was seen lying in bed with the urine collection bag hanging on the bedframe, without a dignity privacy cover, and yellow urine visible from the hallway. During an interview, the resident did not respond when asked if the exposed urine collection bag bothered them. Staff interviews confirmed that the urine collection bag was not consistently maintained in a dignified manner. A nursing assistant stated that staff typically placed urine collection bags in dignity privacy covers when residents were out of their rooms and noted that the resident only spoke when they wanted to. An LPN stated that dignity covers were used when residents were out of their rooms, not when in their rooms, and acknowledged that because the resident had variable ability to verbalize whether the visibility of the bag bothered them, the bag should be placed in a privacy cover for dignity. The resident care manager and the DON both acknowledged that the urine collection bag should have been in a dignity privacy cover and noted that the facility typically used bags with attached covers, but the facility had run out of dignity covers. The facility also failed to ensure appropriate consent for psychotropic medications and admission paperwork for a resident with severe cognitive impairment. This resident had diagnoses including alcoholic cirrhosis, borderline personality disorder, and diabetes, and was assessed with severe cognitive impairment on the BIMS and a St. Louis University Mental Status score of 1/30. The resident was admitted with orders for multiple psychotropic medications, including Seroquel, which had possible adverse effects such as increased mortality in the elderly. Psychotropic medication consent forms and admission paperwork, including documents related to monetary charges, financial obligations, and denial of Medicare and Medicaid, were signed by the resident despite their severe cognitive impairment. The care plan did not address the resident’s impaired cognition, goals, or interventions. Staff responsible for admission paperwork stated they relied on the face sheet to determine if the resident was their own responsible party and acknowledged the resident was probably unable to understand what they were signing, while the DON stated residents should be cognitively able to understand side effects and what they were signing, based on their ability to answer questions and their BIMS score.
Failure to Maintain Safe, Clean, and Homelike Resident Care Areas
Penalty
Summary
The facility failed to maintain a safe, clean, and homelike environment for multiple residents, including those with significant medical conditions. One cognitively intact resident with heart failure, kidney failure, and diabetes had a room with multiple unrepaired environmental issues observed repeatedly over several days. These included large areas of missing wood in the closet, a non-cleanable wooden shelf above the sink, loose caulking and missing paint around the sink, multiple dents and missing drywall near the bathroom, and a missing transition strip between the room and bathroom with dirt buildup. The resident stated that if this were their home, the walls and holes would not look that way and that it bothered them. The Maintenance Director later acknowledged the shelf was not a cleanable surface, the room was not homelike, and the missing transition strip was a safety hazard, and stated they had been unaware of the condition. Another cognitively intact resident admitted with fractures and at risk for infection due to a healing hip surgical incision reported that a toilet seat in a shower room was broken and expressed concern that a resident could be injured using it. Surveyors observed that in two separate shower rooms, toilet seats had approximately six inches broken completely off the front edge, and these conditions were seen repeatedly over multiple days. Staff interviews revealed that shower rooms were used daily, staff were expected to report broken items via an electronic maintenance notification system, but one housekeeping staff member was unsure of the process and acknowledged the toilet seat had been broken for about a month. The Maintenance Director stated they had only just received notification about the broken toilet seats, despite the ongoing use of these shower rooms. A resident at risk for infection also voiced serious concern about facility cleanliness, specifically describing the South unit therapy gym as unsanitary and in need of professional cleaning. Observations over several days showed the therapy room tile floor had a linear rust stain the length of a file cabinet and significantly large areas of dark black stains in numerous locations. A physical therapist acknowledged that the black and rust stains on the therapy room floor had been present for over a year. In a separate room, a resident with dementia, frequent falls, and moderately impaired cognition had a bed ordered to be placed against the wall for safety; the wall next to the bed had deep gouges and scrapes exposing white drywall plaster, which remained unrepaired over multiple observations. The Maintenance Director stated they were aware the exposed drywall created a non-cleanable surface and that the room was on a list for repair, but the work had not yet been completed.
Failure to Ensure Accurate PASRR Screening for Resident With Mental Health Diagnoses
Penalty
Summary
The facility failed to coordinate with the State-designated PASRR authority to ensure accurate Level I screening and appropriate Level II evaluation for a resident with mental health diagnoses. A significant change assessment dated 02/06/2026 documented that the resident was admitted with diagnoses including depression, anxiety, PTSD, and substance use disorder. An emergency room history and physical also documented a diagnosis of anxiety. However, a Level I PASRR screening completed on 12/03/2025 indicated the resident had no serious mental illness and that a Level II PASRR evaluation was not required. During interviews, the Social Service Director stated that PASRRs were completed in the hospital prior to admission, were to be reviewed for accuracy by Social Services, and that residents with an anxiety diagnosis staying longer than 30 days required a Level II PASRR. The Social Service Director acknowledged that the resident’s PASRR was incorrect given their documented diagnoses and that a Level II should have been completed prior to admission to ensure needed resources were available. The DON stated that PASRRs were completed at the hospital and evaluated by Social Services, and further noted that most PASRRs were not completed prior to admission. This combination of inaccurate Level I screening and lack of appropriate Level II PASRR evaluation for the resident with multiple mental health diagnoses led to the cited deficiency under WAC 388-97-1915(1)(2)(a-c).
Failure to Implement Care-Planned Interventions for Mobility and Visual Impairment
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to implement care-planned interventions for two residents, contrary to the facility’s care planning policy requiring measurable objectives and services to maintain residents’ highest practicable well-being. For one resident with a left leg above-the-knee amputation, quarterly assessment documented substantial assistance needs for bed mobility, and the care plan specified extensive assistance by two staff and the use of bed rails to assist with bed mobility. Therapy-to-nursing communication notes further indicated the resident could benefit from bed rails to participate better with cares, repositioning, and bed mobility with reduced assistance. Despite these documented needs and care plan directives, repeated observations over multiple days showed this resident in bed without bed rails or mobility bars attached after a room change, and the resident reported significant trouble with bed mobility and stated they previously had rails, needed them, and wanted them back. A nursing assistant, an LPN, the resident care manager, and the DON each observed the bed without rails and acknowledged that the resident used to have bed rails and that bed rails were care planned and should be in place to assist with bed mobility related to the amputation. These findings demonstrated that the care-planned intervention of bed rails was not implemented as written. For another resident with fractures and impaired vision, the admission assessment documented that the resident could see large print but not regular print in newspapers or books, did not use glasses, and was cognitively intact. The life enrichment evaluation noted the resident read on occasion and did not use glasses or special reading devices. The care plan for impaired vision directed staff to provide large print books or books on tape as desired. However, observations over several days showed an activities calendar with extremely small print on regular-sized paper posted across the room from the resident’s bed, and the resident stated they could not read it even when held close to their face. A nursing assistant, an LPN, the resident care manager, the activities director, and the DON all observed the calendar, acknowledged the print was tiny or extremely small, and agreed that a person with visual impairment could not read it, despite the care plan specifying large print materials for this resident.
Failure to Maintain and Administer Respiratory Equipment and Oxygen as Ordered
Penalty
Summary
Surveyors identified that the facility failed to maintain oxygen equipment in a clean and sanitary manner and failed to administer oxygen as ordered for a resident dependent on continuous oxygen. Resident 74, who had COPD and respiratory failure and was cognitively intact, had a provider order dated 03/21/2026 for continuous oxygen at 2 L and an order dated 08/28/2025 to wash the concentrator filter weekly. The March and April 2026 MARs documented that this resident received 3 L of oxygen on multiple occasions instead of the ordered 2 L. During multiple observations over several days in early April, the resident was repeatedly found receiving 3 L of oxygen via nasal cannula, and the oxygen concentrator filter was consistently noted to be covered in thick dust and debris. Staff interviews confirmed that the oxygen filter was expected to be cleaned weekly by nurses and that it was important to keep filters clean so oxygen flow was not blocked and residents received the proper amount of oxygen. Staff R, an LPN, acknowledged that the resident was prescribed 2 L of oxygen, observed the concentrator set at 3 L, and turned it down to 2 L. When Staff R removed the filter, dust fell off, and they described it as very dusty. The DON also stated it was important to administer oxygen as ordered to maintain residents' oxygen saturations and avoid carbon dioxide retention, and to keep filters clean so residents did not breathe dust into their lungs. For Resident 62, who had COPD, interstitial pulmonary disease, chronic respiratory failure, and obstructive sleep apnea, the facility failed to ensure BiPAP equipment was maintained in a clean and sanitary manner. The resident, cognitively intact and using a BiPAP nightly per a 03/10/2026 provider order, reported that they brought their BiPAP from home and that staff did not clean the mask or tubing. The care plan and provider orders did not contain instructions for BiPAP maintenance or routine cleaning. Multiple staff, including a CNA, an LPN, the Resident Care Manager, and the DON, stated that BiPAP equipment should be cleaned daily with soap and water and documented, and acknowledged that there were no provider orders or documentation for routine cleaning of this resident’s BiPAP equipment. The Administrator stated they expected staff to maintain BiPAP and oxygen equipment in a sanitary manner.
Medication Pass Errors Result in Exceeded Medication Error Rate
Penalty
Summary
The facility failed to maintain a medication error rate below five percent when surveyors identified two medication errors during 26 observed medication administration opportunities, resulting in a 7.69% error rate. During a medication pass on 04/10/2026 at 9:20 AM, a registered nurse (Staff Q) prepared and administered ten medications to Resident 76. Among these medications were Calcium 500 mg with Vitamin D 10 mcg, one tablet by mouth, and Colestipol 1 gm, one tablet by mouth. Review of Resident 76’s physician orders and April 2026 MAR showed the resident was ordered Calcium 500 mg daily by mouth (without Vitamin D) and Colestipol 1 gm to be given one hour before or three hours after other medications. In a subsequent interview, Staff Q confirmed that they had administered Calcium with Vitamin D instead of the ordered Calcium alone and acknowledged this as a medication error after comparing the stock medication with the resident’s orders. Staff Q also reported that the full administration directions for Colestipol, specifically the requirement to give it one hour before or three hours after other medications, were not visible on the initial electronic screen and only appeared after clicking “more,” which they had not done prior to administration. As a result, Colestipol was not administered according to the ordered timing parameters. On 04/13/2026 at 1:39 PM, the DON (Staff B) acknowledged both of these medication errors, which contributed to the facility’s medication error rate exceeding the five percent threshold.
Improper Medication Storage and Expired Drugs in South Unit Medication Room
Penalty
Summary
The deficiency involves failure to ensure medications and biologicals were properly stored and expired medications were removed from inventory in one of two medication rooms on the South Unit. During observation of a medication cart, surveyors found two bottles of Assure Dose glucometer quality control testing solutions with a manufacturer expiration date of 08/17/2025 still present on the cart. The LPN using the cart stated that glucometer quality control checks were performed on night shift and that they were unfamiliar with the process because they did not work nights. The expired solutions were removed from the cart, and review of the glucometer quality control logbook confirmed that the expired solutions had not been used for documented checks. In the South Unit medication room, surveyors observed three bottles of Gericare brand Aspirin 325 mg tablets that were past their manufacturer expiration dates (one bottle expired in June 2025 and two bottles expired in August 2025). The same medication room’s refrigerator was found to be at 34°F, with a freezer compartment containing large amounts of frost, while storing multiple temperature-sensitive medications and biologicals, including various insulin pens (Lantus Solostar, Humalog 50/50, Lispro, Semglee, Novolog, Basaglar), vials of Retacrit, Lorazepam vials, and Tubersol. Manufacturer information and the facility’s temperature log indicated these items should be stored between 36°F and 46°F. Review of the April temperature log for this refrigerator showed multiple readings below the acceptable range on several days, with no documentation in the log’s column indicating what actions were taken when temperatures were outside specifications. Staff interviews confirmed that expired aspirin had been missed during routine checks and that maintenance was contacted when refrigerator temperatures were too cold. The report states that these failures placed residents at risk of receiving potentially compromised or expired medications.
Failure to Consistently Assess and Document Non-Pressure Skin Conditions
Penalty
Summary
The facility failed to assess, monitor, and document non-pressure skin conditions in accordance with its policy and the resident’s care plan for one resident with cellulitis and a skin tear. The facility’s wound policy required weekly monitoring and documentation in the electronic medical record for wounds such as diabetic ulcers, significant skin tears, and other skin conditions, including size, color, odor, healing progression, notifications, and other pertinent information. On admission, the Skin Grid form documented cellulitis on both of the resident’s lower legs, wrapping around the calf and measuring 1.5 feet long, but no subsequent Skin Grid forms were found in the record for ongoing cellulitis monitoring. The resident’s care plan documented cellulitis on both lower legs and directed weekly and as-needed assessment, including measurements and evaluation of the wound perimeter, wound bed, and healing progress, and was later updated to include a left lower calf skin tear with instructions for nursing to monitor and document location, size, and treatment. The Total Body form dated 12/16/2025 showed a 3 cm round open skin tear on the resident’s left lower leg, but there was no further documentation of additional assessments of this skin tear and no additional Total Body forms in the record. The admission assessment documented diagnoses including cellulitis and diabetes, and that the resident was able to make needs known. A nurse progress note dated 01/02/2026 described a wound on the left lower leg as red, without odor or drainage, painful, with scaly surrounding skin, but did not specify whether this referred to the cellulitis or the skin tear, despite both being located on the left lower leg. Interviews with the RCM, an LPN, and the DNS confirmed that facility practice and expectations were for weekly Total Body forms and Skin Grids, with assessment, measurement, and evaluation of non-pressure skin issues, including cellulitis, but the resident’s record lacked consistent weekly documentation and clear identification of the wounds being assessed.
Failure to Administer Insulin and Antibiotic Eye Drops as Ordered
Penalty
Summary
The deficiency involves the facility’s failure to administer medications as ordered by providers for two residents, specifically related to insulin and antibiotic eye drops. One resident with diabetes was admitted on 12/26/2025 and had orders dated 12/12/2025 for long-acting insulin twice daily and short-acting insulin three times daily with meals, plus a sliding scale. On 12/16/2025, the short-acting insulin order was changed from 20 units with meals to 10 units with meals plus sliding scale, with explicit parameters to hold the insulin if the blood sugar was less than 110 mg/dl. Despite this, the December 2025 MAR showed the short-acting insulin was administered nine times when the blood sugar was below 110 mg/dl, and the January 2026 MAR showed it was administered five times under the same condition. The RCM stated that for this resident, staff should have held the insulin when blood sugar readings were under 110 mg/dl, and the Administrator confirmed that insulin had not been held as ordered. Another resident with kidney disease and diabetes had an order for antibiotic eye drops after reporting blurry vision, redness, and tearing in the left eye. On 02/02/2026, the physician ordered antibiotic eye drops to the left eye twice daily for 10 days. The February 2026 MAR documented that the drops were started as ordered, but 3 of 6 possible doses were not administered. On 02/05/2026, after the resident’s left eye vision improved and the right eye developed yellow discharge, the order was changed to antibiotic eye drops in both eyes four times daily for 10 days. Documentation showed that 7 of 40 possible doses under this revised order were missed. The Administrator confirmed that doses of the antibiotic drops had not been given as ordered.
Failure to Supervise Cognitively Impaired Resident Leading to Unattended Departures
Penalty
Summary
A deficiency occurred when the facility failed to provide adequate supervision and ensure a safe environment for a resident with significant cognitive impairment and poor safety awareness. The resident, who had a history of stroke, heart disease, encephalopathy, and demonstrated moderate to severe cognitive decline, was not initially identified as an elopement risk upon admission. Despite multiple documented instances of confusion, disorientation, and wandering behavior, the resident's care plan was not updated to reflect their cognitive decline or risk for elopement. The resident left the facility unattended on more than one occasion, including one instance where they signed themselves out and did not return as expected, prompting staff to contact the family and law enforcement. Another time, the resident left with another resident without signing out and returned after midnight. There were also episodes where the resident returned to the facility exhibiting signs of intoxication, and documentation was lacking regarding their whereabouts and the duration of their absence. Staff and family interviews confirmed the resident's ongoing confusion, lack of safety awareness, and inability to make safe decisions independently. Despite therapy and nursing notes indicating the resident's cognitive impairment and safety concerns, there was no timely update to the elopement risk assessment or care plan. The resident was not consistently identified as an elopement risk until months after the initial incidents, and interventions such as wander guard devices were not effectively implemented or documented. The lack of updated assessments and care planning contributed to the resident's repeated unsupervised departures from the facility.
Failure to Conduct N-95 Fit Testing for All Employees
Penalty
Summary
The facility failed to ensure that N-95 mask fit testing was performed for all 103 employees in accordance with applicable federal regulations. During interviews, the Administrator acknowledged that the facility was out of compliance, stating that the last building-wide N-95 fit testing occurred in the spring of 2024 and that, despite having a plan, the process of fit testing all employees had not yet begun. When asked for documentation of employees who had been fit tested, the Infection Preventionist was unable to provide any records, confirming that such information did not exist. The Infection Preventionist also stated that they had only recently received certification to administer N-95 fit testing and had not yet started the process for facility employees.
Failure to Provide Timely Pain Management on Admission
Penalty
Summary
The facility failed to provide timely and appropriate pain management for two residents who required such services upon admission. One resident, admitted after a below-the-knee amputation, reported severe pain rated at 10 out of 10, described as throbbing, stabbing, and burning, both at rest and with movement. Despite the resident's ability to communicate their needs and a clear pain assessment indicating severe pain, pain medication was not administered until approximately six hours after admission. The resident stated they requested pain medication upon arrival but experienced a significant delay before receiving it, resulting in prolonged, uncontrolled pain. Another resident, admitted following spine surgery with two surgical wounds, also reported pain at a level of 10 out of 10 in their lower back and right leg. This resident did not receive prescribed pain medications until over three hours after admission. The resident expressed dissatisfaction, stating they were told the facility had run out of their pain medication and that no alternative pain management interventions, including non-pharmacological options, were offered. Interviews with staff confirmed that pain medication should have been provided promptly and that procedures existed to obtain medications from the facility's dispensing system if not immediately available from the pharmacy.
Failure to Report Allegations of Abuse and Neglect
Penalty
Summary
The facility failed to identify and report potential allegations of abuse and/or neglect to the State Survey Agency as required for three residents. Resident 1, who had a lower leg amputation and was able to communicate needs, filed a grievance stating that their roommate was left in feces all night without being changed, and reported other incidents where it took up to two hours for staff to respond. This allegation of potential neglect was not logged or reported to the State Survey Agency. Resident 2, with diabetes and depression, also filed a grievance indicating they were left on a bedpan from morning until the evening shift and not checked on again until the following morning, despite needing regular changes due to risk of skin breakdown. This concern was similarly not reported as required. Resident 3, admitted after spine surgery and able to communicate needs, reported excessive delays in call light response and a significant delay in receiving pain medication upon admission, stating their pain was severe and the facility had run out of their medication. This grievance was also not logged or reported to the State Survey Agency. Interviews with facility staff confirmed that these allegations of potential abuse and/or neglect were not properly documented or reported, as required by regulation.
Failure to Provide Required Bathing and Nail Care for Dependent Residents
Penalty
Summary
The facility failed to provide the required number of baths or showers per week for five out of six dependent residents reviewed for Activities of Daily Living (ADLs). Multiple residents, including those with significant medical conditions such as cancer, multiple fractures, diabetes, malnutrition, and post-surgical needs, did not receive regular showers or bed baths as documented in their records. In several cases, the intervals between baths or showers extended from seven to fourteen days, and in one instance, a resident received only one shower nearly four weeks after admission. Staff interviews confirmed that due to staffing shortages and high resident acuity, it was not always possible to complete all scheduled showers, and some residents had not received a shower since admission. In addition to bathing deficiencies, the facility did not provide adequate grooming, specifically nail care, for four out of six dependent residents reviewed. Residents with conditions such as diabetes and physical limitations were observed with long, yellow, or jagged toenails, and in some cases, residents or their family members reported that nail care had not been provided since admission. Documentation showed no record of nail care being completed for these residents during the review period. For diabetic residents, care plans indicated the need for podiatry referrals, but there was no evidence that such referrals or appointments had been made. Staff interviews revealed that nail care was expected to be performed during showers unless the resident was diabetic, in which case nurses or a podiatrist would be responsible. However, staff acknowledged that nail care was often not completed due to time constraints and lack of resources. There was also confusion among staff regarding the scheduling of showers and the process for documenting refusals or missed care. The lack of consistent hygiene and grooming placed residents at risk for poor hygiene and diminished quality of life, as directly observed and reported by residents and staff.
Failure to Investigate Alleged Verbal Abuse
Penalty
Summary
The facility failed to investigate an allegation of potential verbal abuse involving a resident with a history of stroke and left-sided weakness, who was able to communicate their needs. The resident reported that a staff member entered their room, yelled, and argued with them, leading the resident to ask the staff member to leave. Another staff member present during the incident confirmed that the situation escalated into an argument and felt it reached the level of verbal abuse. This staff member reported the incident to the Director of Nursing immediately after it occurred. Despite the report, there was no documentation in the facility's incident log indicating that an investigation into the alleged verbal abuse took place. The administrator stated they were only aware that the resident no longer wanted the staff member in their room and was not informed about the alleged yelling. The Director of Nursing at the time was no longer employed at the facility, and no further information about an investigation was available.
Failure to Assess and Document Non-Pressure Skin Conditions
Penalty
Summary
The facility failed to properly assess, monitor, and document non-pressure related skin conditions for two residents. For one resident admitted with multiple skin impairments, including wounds on the abdomen, groin, lower legs, and a G-tube site with moisture-associated skin damage, there was no documentation of wound type, measurements, or appearance upon admission. The care plan identified a risk for pressure ulcers and directed staff to document changes in skin status, but there was no record of the resident's current wounds or treatments. The Treatment Administration Record initially lacked wound care orders, and subsequent documentation was inconsistent, with some skin evaluation forms omitting details about the wounds. Interviews revealed delays in dressing changes and concerns about proper wound care practices. Another resident, admitted after surgery for a fractured leg and with a history of diabetes, had multiple wounds documented in hospital transfer orders, including a venous ulcer, fragile skin, and surgical incisions. The facility's admission assessment noted several wounds but did not provide details on type, measurements, or appearance. The care plan addressed pressure ulcer risk and general skin care but did not specify the resident's current wounds. Skin evaluation forms recorded the presence of wounds but lacked further description or evidence of ongoing monitoring and assessment. Staff interviews indicated that weekly skin checks and documentation of wounds with descriptions and measurements were expected practices. However, the records reviewed did not consistently reflect these practices, as there was a lack of detailed documentation regarding the residents' wounds, their progression, and the care provided. This failure to follow facility policy and document wound assessments and care placed the residents at risk for worsening skin conditions.
Failure to Ensure Timely and Accurate Weight Monitoring for Residents at Nutritional Risk
Penalty
Summary
The facility failed to ensure timely and accurate weight monitoring and appropriate interventions for residents at nutritional risk. For one resident with liver disease and diabetes, there was a significant discrepancy in admission weights, with an initial weight recorded at 130 lbs and another at 286 lbs on the same day. The inaccurate weight was later struck out, but subsequent weights showed a substantial loss over several months, totaling an 18% decrease. Despite this significant weight loss, the only interventions noted were related to anticipated fluctuations due to edema and diuretic therapy, and no new nutritional concerns or interventions were documented. The resident's intake was generally fair to good, and the weight loss was attributed to a combination of fluid loss and previous high-calorie intake from alcohol, but no re-weighs or further assessments were documented in response to the ongoing weight loss. Another resident, admitted with cancer and multiple pathological fractures and receiving enteral nutrition via G-tube, did not have an admission weight documented. The resident's weights were only recorded twice over a month, with a significant increase noted, but weekly weights as required for residents on tube feedings were not obtained. The care plan required weekly weight monitoring, but this was not consistently followed. Staff interviews confirmed that weights should be taken weekly and then monthly unless otherwise indicated, and that re-weighs were requested but not always completed. Facility policy required accurate and timely weight measurements, with re-weighs for significant changes and daily review of weight alerts by nutritional services. However, the facility did not consistently follow these protocols, as evidenced by missed or inaccurate weights, lack of timely re-weighs, and insufficient monitoring for residents at nutritional risk or on enteral nutrition. These failures placed residents at risk for significant weight loss and unmet nutritional needs.
Infection Control and Water Management Deficiencies
Penalty
Summary
The facility failed to implement Enhanced Barrier Precautions for two residents, Resident 35 and Resident 61, who were on these precautions due to their medical conditions. Resident 35, who had a history of Clostridium difficile infection and an indwelling medical device, was observed with a sign indicating the need for gown and gloves upon room entry. However, a nursing assistant, Staff EE, entered the room without wearing the required protective equipment, straightened the resident's linens, and touched the resident's hair. Staff EE admitted to not being aware of the current precaution requirements due to a lack of recent education and frequent assignment changes. Resident 61, who had prostate cancer with brain metastasis and an indwelling urinary catheter, was also on Enhanced Barrier Precautions. During a dressing change, Staff G, an LPN, did not wear a gown as required by the precautions, although gloves were used. The Infection Preventionist, Staff T, acknowledged a gap in monitoring compliance with the precaution policies, which was crucial to preventing infections among staff and residents. Additionally, the facility failed to ensure proper hand hygiene during medication administration. Staff H, an LPN, did not perform hand hygiene before dispensing medications to a resident, only washing hands after completing the task. Furthermore, the facility's Water Management Plan was found to be incomplete and not comprehensive, lacking a filled-in CDC Legionella assessment form and a specific plan for interventions to prevent waterborne illnesses. The Maintenance Director, Staff N, confirmed the plan's deficiencies and was unsure about the Water Management Team's composition and review frequency.
Failure to Inform Residents of Rights and Responsibilities
Penalty
Summary
The facility failed to routinely inform both cognitively intact residents and the legal representatives of cognitively impaired residents about the facility rules, resident rights, and responsibilities, including Medicaid rights. This deficiency was identified for 10 out of 14 sampled residents. The lack of proper documentation and timely review of admission agreements placed residents at risk of not being fully informed of their rights, unmet care needs, and diminished quality of life. For Resident 27, who was cognitively intact, there was no documentation of an admission agreement being reviewed or discussed upon their admission. Similarly, Resident 28, who had severe cognitive impairment, signed the admission agreement 43 days after admission, without any documentation that it was reviewed with their representative. Other residents, such as Resident 30 and Resident 44, also experienced delays in signing their admission agreements, with no evidence of prior discussion or review upon admission. Interviews with staff members, including the Medical Records staff, Resident Care Manager, and Director of Nursing, revealed inconsistencies in the completion and review of admission paperwork. Staff acknowledged that some residents did not have their admission paperwork completed upon admission, and some even discharged before completion. The Administrator expected admission paperwork to be completed within 24-72 hours of admission, but this expectation was not consistently met, leading to the deficiency.
Failure to Provide Advanced Directive Information
Penalty
Summary
The facility failed to routinely provide written information, including the facility policy on advanced directives, to residents or their legal representatives upon admission. This deficiency was identified for six of the twelve sampled residents. The facility's policy required staff to provide residents and/or their representatives with information on their rights to formulate advanced directives, both in writing and orally, prior to or upon admission. However, this was not consistently done, as evidenced by the lack of documentation and signed agreements in the residents' records. Resident 20, who was admitted with paralysis and malnutrition, was found to have no documentation of their Durable Power of Attorney (DPOA) in their record, despite being competent and expressing a desire to change their DPOA. The resident's sibling, who was listed as the DPOA, had not provided the necessary documentation, and the facility had not followed up adequately. Similarly, Resident 218, who was cognitively intact, had no admission agreement or documentation that advanced directives were offered, and they left the facility against medical advice without this being addressed. Other residents, such as Resident 68 and Resident 44, also did not receive the required information on advanced directives upon admission. In some cases, forms were signed without the necessary attachments or explanations, and in others, cognitively impaired residents signed documents without their legal representatives being involved. Interviews with staff revealed a lack of clarity and consistency in the process of reviewing and explaining admission paperwork, including advanced directives, to residents and their representatives.
Deficiencies in Admission Process and Documentation
Penalty
Summary
The facility failed to establish and implement an effective admission policy, which resulted in several deficiencies related to the admission process for residents. Specifically, the facility did not ensure that admission paperwork, including the admission agreement and other essential documents, was completed and reviewed with residents or their legal representatives upon admission. This failure was observed in 10 out of 14 sampled residents, including those who were cognitively intact and those with cognitive impairments. The lack of proper documentation and review of admission agreements placed residents at risk of not being fully informed of their rights and care needs. For cognitively intact residents, such as Resident 27 and Resident 30, the admission agreements were not reviewed or signed until several days after their admission. In some cases, like Resident 68, there was no documentation of an admission agreement being completed at all. For residents with cognitive impairments, such as Resident 28 and Resident 42, the agreements were signed by the residents themselves rather than their legal representatives, which is not in compliance with the required procedures. This oversight indicates a systemic issue in the facility's admission process, where the necessary paperwork was not completed in a timely manner, and residents or their representatives were not adequately informed of their rights and responsibilities. Interviews with staff members, including the Medical Records staff, Resident Care Manager, and Director of Nursing, revealed a lack of clarity and consistency in the admission process. Staff members were unsure of their responsibilities regarding the completion and review of the 29-page electronic admission paperwork. The Administrator expected the paperwork to be completed within 24-72 hours of admission, but this expectation was not consistently met. The failure to complete and review admission paperwork upon admission was acknowledged by staff, highlighting a significant gap in the facility's procedures and communication regarding resident admissions.
Failure to Provide Bed Hold Policy Information Upon Admission
Penalty
Summary
The facility failed to provide written information regarding bed hold policies to residents or their representatives upon admission, as required by their policy. This deficiency was identified for eight out of fourteen sampled residents, including both cognitively intact and severely cognitively impaired individuals. The facility's policy, implemented in September 2022, mandates that residents or their representatives receive written notice of the bed hold policy at the time of admission. However, documentation and interviews revealed that this was not consistently done. For several residents, including those who were cognitively intact, there was no documentation that the admission agreement, which includes information on bed hold, was reviewed or discussed upon admission. In some cases, the agreement was signed days or even weeks after admission, and in one instance, it was signed by a cognitively impaired resident instead of their representative. Interviews with staff indicated confusion and uncertainty about who was responsible for reviewing and completing the admission paperwork, which includes the bed hold policy. Staff interviews further highlighted a lack of clarity and consistency in the process of reviewing and explaining the admission paperwork. Staff members, including a Licensed Practical Nurse, Medical Records personnel, and the Director of Nursing, provided varying accounts of who should be responsible for this task. The Administrator expected the paperwork to be reviewed and completed within 24-72 hours of admission, but this expectation was not met, leading to residents and their representatives being uninformed about their bed hold rights.
Deficiencies in Monitoring and Protocol Implementation
Penalty
Summary
The facility failed to appropriately monitor and address subtherapeutic blood values for a resident on Coumadin, a blood thinner. Resident 268, who was admitted with conditions including heart failure and aortic valve stenosis, was supposed to have daily PT/INR tests to ensure their blood clotting levels were within the therapeutic range of 2-3. However, after an initial test on 11/26/2024 showed a subtherapeutic level of 1.89, no further PT/INR results were documented, and the provider was not notified of the low result. This oversight placed the resident at risk for blood clots and other serious complications. The facility also failed to implement a bowel protocol for Resident 27, who had a history of constipation. Despite having orders for a bowel protocol that included administering a liquid oral laxative on the third day without a bowel movement, the resident went several days without documented bowel movements, and the protocol was not followed. The resident's medical records showed significant gaps between bowel movements, with no interventions documented, and the provider was not informed of the constipation issues. Additionally, the facility did not adhere to oxygen and blood pressure medication parameters for Resident 29, who had COPD and hypertension. The resident's oxygen saturation levels frequently exceeded the prescribed range, and the staff failed to consult the physician. Furthermore, the resident was administered Lisinopril despite blood pressure readings that were below the ordered parameters, without rechecking or documenting a second reading. These failures to follow medical orders and protocols could have led to adverse health effects for the residents involved.
Deficiencies in Dialysis Care and Fluid Management
Penalty
Summary
The facility failed to provide comprehensive dialysis care for four residents, leading to several deficiencies. For Resident 30, the care plan lacked specific instructions regarding the dialysis access site, and there were omissions in medication administration on dialysis days. Additionally, a non-functioning fistula was used for a blood draw, potentially causing a large hematoma. The resident was aware of the restrictions on using the arm with the fistula but was unsure how to proceed when the lab staff could not draw blood from the other arm. Resident 32's care plan did not include critical information from the dialysis center, such as restrictions on blood pressure measurements and blood draws in the access arm. The resident exceeded their fluid restriction on multiple occasions, and there was confusion about whether the resident took their medication at the dialysis center. The dialysis center confirmed that they did not administer medications brought by residents, and the resident reported only receiving a vitamin after meals. Residents 35 and 63 also experienced issues with fluid intake monitoring, exceeding their prescribed fluid restrictions on several days. The care plans for these residents did not adequately address the management of dialysis access sites or fluid intake monitoring. Staff interviews revealed a lack of clarity and communication regarding care plans, fluid restrictions, and medication administration, contributing to the deficiencies in dialysis care.
Failure to Conduct Annual Staff Evaluations and Competency Checks
Penalty
Summary
The facility failed to ensure that nursing assistants and licensed nurses had their competencies, skill sets, or performance evaluations completed yearly as required. This deficiency was identified for 6 out of 10 sampled employees, including a Resident Care Manager, nursing assistants, an LPN, and an RN. Interviews revealed that evaluations and skills fairs had not been conducted for about two years. The Director of Nursing acknowledged that these evaluations should be done annually, and the Human Resources department confirmed that no documentation of evaluations or competencies was found for the requested employees. The facility was in the process of auditing and completing these evaluations.
Failure to Administer Medications During Dialysis Sessions
Penalty
Summary
The facility failed to ensure that significant medications were administered as ordered for four residents who were undergoing dialysis. These residents, who had various medical conditions including end-stage renal disease, diabetes, and malnutrition, did not receive their prescribed medications on multiple occasions when they were absent from the facility for dialysis sessions. The medications omitted included gabapentin, acetaminophen, sevelamer, cholecalciferol, escitalopram, ferrous gluconate, levetiracetam, vitamin C, carvedilol, lactobacillus, torsemide, creon, apixaban, lantus insulin, lisinopril, metoclopramide, aspirin, atorvastatin, and midodrine. The medication administration records (MAR) for these residents showed codes indicating that the medications were not given because the residents were absent from the facility without medications. Staff interviews revealed that it was a common practice to skip doses of medications under the assumption that they would be dialyzed out of the residents' systems. However, this practice was not based on provider consultation, and the staff acknowledged that missed doses could negatively impact the residents' health. The Resident Care Manager was unaware that medications were being omitted during dialysis sessions and stated that the physician should be consulted to determine which doses could be omitted and to adjust medication administration times. The staff were expected to communicate any issues with medication administration so that alternative plans could be made, but this communication did not occur, leading to the deficiency.
Deficiencies in Admission Documentation and Resident Rights
Penalty
Summary
The facility administration failed to effectively use its resources to maintain compliance with Federal regulatory requirements, impacting several residents in areas such as Advance Directives, Admission and resident rights, and bed hold notification. Specifically, the facility did not ensure that the Admission Agreement, which includes information on advance directives, resident rights, and the facility's bed hold notification/policy, was completed upon admission. This failure placed residents at risk of not being informed of their rights, unmet care needs, and diminished quality of life. The survey identified deficiencies in informing residents and/or their representatives about facility rules and their rights, providing written information regarding the right to form an Advance Directive, and ensuring the facility's admission policy was effectively implemented. Interviews with facility staff revealed gaps in the management of admission paperwork and resident records. The business office manager, who was responsible for completing admission packets, had left the facility, and the responsibility was transferred to medical records. However, due to staffing changes and a gap in the Medical Records department, some documents were not scanned into resident records. The Administrator acknowledged being aware of the backlog in document scanning but was not fully aware of the extent of missing documents until the survey team raised concerns. The absence of a dedicated Medical Records staff member for several months contributed to incomplete resident records, including missing admission documentation and advance directives.
Failure to Maintain Dignity for Resident with Urinary Catheter
Penalty
Summary
The facility failed to maintain the dignity of a resident requiring a urinary catheter by not using a privacy cover for the urine collection bag. Resident 61, who had diagnoses including prostate cancer that had spread to the brain and urinary retention, was observed multiple times with their urinary catheter tubing and urine collection bag hanging on the bed frame, with the urine visible from the doorway. A blue privacy bag, intended to cover the urine collection bag, was not in use, compromising the resident's dignity. The facility's Bowel and Bladder Program policy did not address dignity concerns related to urinary catheters. Observations over several days showed the urine collection bag and dignity bag in the same positions, with the catheter tubing and clamp resting on the floor, which was also a cleanliness issue. Staff I, a Nursing Assistant, confirmed that urine collection bags were supposed to be kept in dignity bags, and Staff B, the Director of Nursing, stated that the staff was expected to ensure this practice was followed.
Failure to Obtain Informed Consent for Psychotropic Medications
Penalty
Summary
The facility failed to ensure informed consents were obtained prior to administering psychotropic medications to two residents. Resident 60, diagnosed with depression, was prescribed Paroxetine, a psychotropic medication, on 10/18/2024. Despite receiving the medication daily as documented in the November and December 2024 Medication Administration Records, there was no documentation of an informed consent explaining the risks and benefits of the medication being completed with the resident or their representative. Interviews with staff confirmed that informed consents should have been obtained before the medication was administered, but this was not done for Resident 60. Similarly, Resident 20, who had diagnoses including stroke, failure to thrive, and depression, was prescribed quetiapine, an antipsychotic medication, on 10/30/2024. The consent for this medication, which included the risks and benefits, was not signed until 11/22/2024, 23 days after the resident began receiving the medication. Staff interviews revealed that the consent process was supposed to be initiated during admission or when a new medication was ordered. However, due to an error during the admission assessment, the consent was not obtained in a timely manner for Resident 20.
Failure to Assess Resident for Safe Self-Administration of Medications
Penalty
Summary
The facility failed to ensure that the interdisciplinary team (IDT) assessed and determined a resident's ability to safely self-administer medications or store medications at the bedside. This deficiency was identified for one resident, who was part of a sample of 14 residents reviewed for resident rights. The facility's policy required that residents requesting to self-administer medications be evaluated for their ability to do so safely, with the evaluation analyzed by the IDT. However, there was no documentation in the resident's care plan or progress notes indicating that such an evaluation had been conducted. The resident in question, who had diagnoses including failure to thrive and mild cognitive impairment, was observed with an over-the-counter antacid on their bedside table, which they used without notifying staff. The resident did not have a provider's order for the antacid, and staff members, including a Licensed Practical Nurse and the Resident Care Manager, acknowledged that the proper procedures for self-administration and bedside storage of medications had not been followed. The Director of Nursing and the Administrator confirmed that the necessary evaluations and care planning had not been completed, and the medication should not have been left unattended.
Facility Fails to Maintain Functional Sink Faucets for Residents
Penalty
Summary
The facility failed to ensure that sink faucets were safe and functional in resident rooms, affecting two residents. Resident 38, who was independent in completing activities of daily living (ADLs) with some assistance, had their sink water turned off for several weeks due to a leak that caused water to flow into an adjacent room. This issue was not reported in the facility's maintenance app, and staff were unaware of the problem until it was brought to their attention during the survey. Staff had to use alternative methods to provide care, such as filling basins with water from other rooms. Resident 23, who was on hospice care and had a loose faucet in their room, experienced a similar lack of communication and action. Although the faucet was functional, it was not secured to the sink, and staff were unaware of the issue until it was reported during the survey. Despite claims that work orders had been submitted, no maintenance tickets were found in the system. The lack of awareness and communication among staff contributed to the delay in addressing these maintenance issues.
Inconsistent Mail Delivery Affects Resident Rights
Penalty
Summary
The facility failed to ensure consistent mail delivery, including on Saturdays, for four of the eight sampled residents, which compromised their rights to receive and send communication through the mail. The facility's Resident Rights policy, dated August 2022, stated that residents have the right to privacy in written communication, including the right to send and promptly receive mail. However, interviews with residents and staff revealed that mail was not distributed on weekends due to staffing issues. Resident 13 reported that mail was not delivered on weekends because there was no staff available to distribute it. This was confirmed during a group interview with the Resident Council, where other residents agreed that the lack of weekend mail delivery was problematic. Staff interviews further corroborated this issue, with the Director of Nursing and Staff O, the Life Enrichment Assistant, acknowledging that Staff O was the only person responsible for mail distribution and was not available on weekends. This situation resulted in residents not receiving their mail promptly, as required by their rights.
Failure to Conduct Timely PASRR Evaluations and Referrals
Penalty
Summary
The facility failed to ensure that residents with newly evident mental conditions were referred for a Preadmission Screening and Resident Review (PASRR) and for behavioral health services as needed. Specifically, three residents were affected by this deficiency. Residents 35 and 60 were diagnosed with depression and started on psychotropic medication therapy, but a PASRR level I screening and referral for level II was not completed. Resident 54 had PASRR level II recommendations for behavioral health services, but these recommendations were not implemented in a timely manner. Resident 60 was admitted to the facility without any mental health diagnoses, and a level I PASRR was completed prior to admission. However, a quarterly assessment later documented a diagnosis of depression and the prescription of a psychotropic medication, Paroxetine. Despite this change in mental health status, the facility did not complete a new level I PASRR or refer the resident for a level II assessment. Staff E, the Social Services Director, believed that a depression diagnosis did not require a new PASRR or referral, which led to the oversight. Resident 35 was initially admitted with no serious mental illness and did not require a level II evaluation. However, after a hospitalization, the resident was prescribed escitalopram for depression, and a significant change assessment documented symptoms of depression. Despite this, no second PASRR evaluation was completed. Resident 54, who had a PASRR level II completed prior to admission, required behavioral health services, but these services were delayed. Staff E admitted to being unsure of the PASRR process, which may have contributed to the delay, and Staff B, the Director of Nursing, acknowledged the untimely referral for behavioral health services.
Failure to Conduct Required PASRR Level II Evaluations
Penalty
Summary
The facility failed to ensure that residents with histories of mental disorders were appropriately screened for the need for specialized behavioral health services prior to admission, as required by the Pre-Admission Screening and Resident Review (PASRR) process. Specifically, two residents, identified as Resident 20 and Resident 61, were admitted without the necessary PASRR Level II evaluations. Resident 20, who had diagnoses including depression and adult failure to thrive, was taking antipsychotic medication daily. Despite this, the PASRR Level I screening completed at the hospital did not identify a serious mental illness, and no Level II evaluation was conducted prior to admission. Similarly, Resident 61, diagnosed with prostate cancer that had spread to the brain and depression, was receiving antidepressant medication daily. The PASRR Level I screening also failed to identify a serious mental illness, and no Level II evaluation was conducted. During an interview, the Social Services Director, Staff E, acknowledged that there was a list of diagnoses that required a Level II evaluation, maintained by the Director of Nursing, Staff B. Staff E admitted that Resident 20 should have had a Level II evaluation due to the diagnosis of major depressive disorder. Additionally, Staff E initially believed that Resident 61's depression did not warrant a Level II evaluation but later agreed that the Level II evaluator should determine the seriousness of the depression. This oversight placed the residents at risk for unmet behavioral health needs and potential decline in their psycho-social well-being.
Failure to Develop Timely Dialysis Care Plans
Penalty
Summary
The facility failed to develop baseline care plan goals and interventions related to dialysis needs within the required 48-hour timeframe for two residents, both of whom were dependent on dialysis due to end-stage renal disease (ESRD). Resident 63 was admitted with diagnoses including ESRD and was dependent on dialysis, yet the comprehensive care plan addressing dialysis needs was not initiated until nearly a month after admission. The initial nursing admission evaluation did not document the type of dialysis access or its location, and there was no baseline care plan developed within the required timeframe. Similarly, Resident 220, who was admitted with diagnoses including cardiac arrest and ESRD, did not have any goals or interventions related to dialysis needs documented in the comprehensive care plan during their stay. The nursing admission evaluation left questions regarding dialysis blank, and the resident had previously experienced a cardiac arrest likely due to missed dialysis sessions. Interviews with facility staff revealed that the care plan development process was multi-step, but the initial basic care plan failed to address the immediate dialysis care needs of the residents.
Failure to Document Discharge Summary and AMA Form
Penalty
Summary
The facility failed to complete a discharge summary with all the required components for Resident 66, who was reviewed for discharge. The necessary documentation, including a recapitulation of the resident's stay, the resident's status at the time of discharge, a medication reconciliation, and a discharge plan of care, was not completed. This deficiency was identified during a review of Resident 66's medical records, which showed no progress notes or AMA form, despite the resident leaving the facility against medical advice (AMA) due to dissatisfaction with their room. Interviews with facility staff revealed that there was an expectation for documentation of a discharge summary, AMA form, and progress notes when a resident chose to discharge AMA. Staff members, including the Resident Care Manager, Medical Records staff, and the Director of Nursing Services, acknowledged the absence of such documentation. Additionally, the Social Service Director stated that the facility's protocol was to notify Adult Protective Services when a resident discharged AMA, but no documentation was found to confirm this notification was made.
Deficiencies in Resident Assessment and Monitoring
Penalty
Summary
The facility failed to adequately assess and monitor residents for substance use disorder (SUD), safe smoking abilities, and post-fall evaluations, leading to potential safety hazards and unmet care needs. Resident 68, who had a history of alcohol abuse and tobacco use, was not properly assessed for SUD risks upon admission. Despite having a diagnosis of alcohol cirrhosis and alcohol abuse, the resident's care plan lacked specific goals or interventions for SUD. Additionally, Resident 68 was found to possess marijuana cigarettes, which were not allowed in the facility, indicating a lapse in monitoring and enforcement of facility policies. Resident 20, who had hemiplegia and cognitive impairments, was assessed as being able to smoke independently. However, observations showed that the resident struggled to navigate their wheelchair over a door jamb to re-enter the facility after smoking, posing a safety risk. Despite being observed in distress and needing assistance to return inside, the facility's smoking evaluation did not account for these challenges, and staff were unaware of the resident's difficulties, highlighting a gap in the assessment process. Resident 23, who was on hospice care with diagnoses including cancer and dementia, experienced an unwitnessed fall. The facility's documentation did not include neuro checks or thorough assessments for latent injuries following the fall, as required by their policy. Staff interviews revealed a lack of awareness regarding the need for alert charting and neuro checks after unwitnessed falls, resulting in inadequate post-fall monitoring and documentation for Resident 23.
Delayed UTI Intervention for Resident
Penalty
Summary
The facility failed to implement timely interventions for a resident, identified as Resident 218, who exhibited symptoms of a urinary tract infection (UTI). The resident, who had a history of left below the knee amputation and was occasionally incontinent of urine, reported symptoms of urinary frequency and urgency. Despite these symptoms, the care plan did not include goals or interventions related to the resident's elimination patterns. A urine sample was ordered on 12/01/2024, but there was a delay in sending the sample to the lab due to the facility's lab service not performing routine labs on weekends. The sample was collected and sent late on 12/01/2024, and the results indicating a UTI were not received until after the resident had left the facility against medical advice. Interviews with staff revealed that the facility's process for handling potential UTIs was inadequate. Staff CC, an LPN, noted that the lab did not perform STAT labs on weekends, which contributed to the delay. The Medical Director, Staff V, expressed concerns about the facility's criteria for diagnosing UTIs and advocated for a more immediate testing method, such as a urine dipstick. The Director of Nursing, Staff B, acknowledged that the delay in sending the urine sample was not timely and that preliminary results were not received for Resident 218. These procedural shortcomings placed the resident at risk of worsening infection and deterioration of health.
Failure to Discontinue Previous Tube Feeding Orders
Penalty
Summary
The facility failed to ensure that physician orders for nutrition were transcribed completely for a resident who was receiving nutrition through a feeding tube. The resident, who had a history of stroke and received more than 51% of their calories and water through a feeding tube, was observed with a tube feeding formula bag and a water bag hanging on an IV pole. The tube feeding pump was set to deliver the formula at 250 ml per hour and water at 130 ml per hour. However, the facility did not discontinue previous physician orders for a different tube feeding formula and water flushes when new orders were obtained, leading to conflicting documentation in the Medication Administration Record (MAR). The MAR showed that the resident was receiving both the new and previous tube feeding formulas and water flushes simultaneously until the previous orders were discontinued. Interviews with staff revealed that the previous orders should have been discontinued when the new orders were received. Staff members believed that the resident did not receive both formulas and water flushes due to the correct programming of the tube feeding pump, which was a two-pump system. However, the documentation indicated that the amounts specified in both sets of orders were administered, suggesting a failure in accurately transcribing and following physician orders.
Failure to Implement Trauma-Informed Care System
Penalty
Summary
The facility failed to implement a system to identify residents who are survivors of trauma, which led to a deficiency in providing trauma-informed care for Resident 20. Resident 20, who had a history of hemiplegia, depression, and failure to thrive, was admitted without a comprehensive assessment of their social concerns or trauma history. The admission evaluation did not include an assessment by a social worker, and the care plan lacked goals or interventions addressing the resident's social concerns or factors impacting their psycho-social well-being. This oversight put Resident 20 at risk for re-traumatization and a decline in their psycho-social health. Interviews with facility staff revealed a lack of understanding and implementation of trauma-informed care practices. The Social Services Director admitted to not completing a social work evaluation for Resident 20 and was unsure of the procedure for identifying trauma in residents. A Nursing Assistant was unaware of trauma-informed care and stated that potential triggers for residents were not documented. The Director of Nursing acknowledged that all residents should be screened for trauma to implement appropriate services and prevent re-traumatization, but this was not done for Resident 20.
Failure to Provide Timely Behavioral Health Services
Penalty
Summary
The facility failed to provide timely and appropriate behavioral health services to a resident diagnosed with a stimulant-induced psychotic disorder. The resident was admitted with a PASRR Level II evaluation indicating the need for behavioral health services. However, the Social Services Admission Evaluation left critical sections regarding mood, behavior, and psychiatric services blank. The care plan noted the resident's verbally abusive behaviors and poor impulse control, yet there was no immediate follow-up to address these issues. The resident filed a grievance in June, expressing concerns about the lack of trauma-informed care and the absence of a trauma-related care plan. Despite the resident's documented needs, a behavioral health referral was not made until August, and the resident was not evaluated by a Behavioral Health Nurse Practitioner until September. Interviews with facility staff revealed a lack of understanding of the PASRR process and an acknowledgment that the referral process was not timely. This delay in providing necessary behavioral health services put the resident at risk of unmet behavioral health needs and deterioration of their psychosocial well-being.
Failure to Complete Timely Medication Regimen Reviews
Penalty
Summary
The facility failed to consistently complete monthly medication regimen reviews (MRR) and follow up on recommendations in a timely manner for three residents, leading to potential risks of unnecessary medication use. Resident 27, who was admitted with coronary artery disease and high blood pressure, was on both aspirin and Clopidogrel. The pharmacist recommended discontinuing Clopidogrel to reduce bleeding risks, but the medication was not discontinued until 52 days later, and the October MRR was missing. Staff interviews revealed a lack of understanding of the MRR process, and the Director of Nursing acknowledged a gap due to management changes. Resident 60, with a history of stroke and diabetes, continued to receive sliding scale insulin and a blood-thinning medication without timely physician evaluation or clarification, despite repeated requests from the pharmacist. The facility's documentation did not show a timely response to the pharmacist's recommendations, and staff interviews confirmed the delay in addressing these recommendations. Resident 29, diagnosed with anxiety, bipolar disorder, and dementia, had missing MRR documentation for several months. The facility provided records for only three months, with no information for July, August, and September. Staff interviews indicated that frequent changes in the Director of Nursing position contributed to lapses in the usual process for handling MRR reports. The administrator acknowledged the missing documentation but was unable to provide further records.
Expired Medications and Inadequate Narcotic Tracking in Medication Rooms
Penalty
Summary
The facility failed to ensure expired medications were removed from inventory in the South Hall medication storage room and medication cart. During an observation, expired medications, including Zinc Sulfate and Ocular Vitamin tablets, were found in the medication room, and expired lorazepam and Cath-flo activase were found in emergency kits within a locked refrigerator. Staff G, an LPN, acknowledged that the lorazepam was not counted during narcotic reconciliation, and the pharmacy was responsible for monitoring expiration dates in the emergency kits. Additionally, the emergency kits were not properly sealed with the required zip ties, and Staff B, the Director of Nursing, was unaware of the expired medications in the refrigerator. In the North Hall medication room, a bottle of liquid Ativan was found in the medication refrigerator without being logged into the narcotic tracking-controlled substance book, which is necessary for shift counts. Staff C, the Resident Care Manager, confirmed that the Ativan had not been logged until the day of the observation. The facility's policy required controlled drugs to be logged and counted at each shift change, but this was not adhered to, leading to a lack of accurate medication reconciliation. The Administrator expected staff to store and track controlled medications properly, but this expectation was not met, resulting in deficiencies in medication management.
Dietary Manager Lacks Required Certification
Penalty
Summary
The facility failed to ensure that the dietary staff had the proper qualifications, specifically concerning the Dietary Manager's certification. During an interview, the Regional Registered Dietician stated they were only part-time at the facility, typically two days per week. The Dietary Manager, who had been in their position for almost three years, admitted during a phone interview that they did not have the required dietary manager certification, although they had been approved to take the class. A review of dietary staff records confirmed that the Dietary Manager only possessed a current food handler card and no other qualifications. The facility's Administrator acknowledged that due to the dietician not being full-time, the Dietary Manager was required to have the certification, which they did not possess.
Failure to Provide Preferred Beverages to Residents
Penalty
Summary
The facility failed to provide residents with their preferred beverages, specifically coffee, upon request, which affected two residents, Resident 27 and Resident 68. Resident 27, who was cognitively intact and had a diagnosis of malnutrition, expressed frustration over not receiving coffee in the morning, despite it being their beverage of choice. The resident reported waiting for hours only to be informed that the facility was out of coffee. The resident council also noted that coffee service was cut off at certain times, which contributed to the issue. Similarly, Resident 68, who also had a diagnosis of malnutrition, expressed dissatisfaction with the unavailability of coffee, which was confirmed by staff who stated that the facility often ran out of coffee and limited its availability due to cost concerns. Interviews with staff revealed inconsistencies in the availability of coffee, with some staff indicating that coffee was supposed to be available 24/7, while others acknowledged that the kitchen's operating hours limited access. The facility's policy required gathering residents' food and beverage preferences upon admission, but records showed no documentation of coffee preferences for the affected residents. The lack of a consistent supply and the facility's operational limitations led to unmet care needs and diminished quality of life for the residents involved.
Inaccurate Allergy Documentation in Resident's Medical Record
Penalty
Summary
The facility failed to maintain accurate medical records for Resident 23, who was reviewed for unnecessary medications. Resident 23 had been inaccurately documented as having allergies to Acetaminophen (Tylenol/APAP), Baclofen, and Morphine in their electronic medical record (EMR). Despite these documented allergies, the resident was regularly administered Morphine and Tylenol as prescribed by the physician. The inaccuracies in the medical record were not corrected even after staff determined that the allergies were not true. Interviews and record reviews revealed that the inaccuracies persisted despite multiple staff members being aware of the issue. Staff U, an LPN, confirmed that Resident 23 was not allergic to Morphine and that Tylenol was avoided due to liver damage, not an allergy. The Pharmacist Director also noted that the allergies had been listed since June 2022 and that the facility staff, not pharmacists, entered the information into the system. The facility's Administrator acknowledged the inaccurate documentation, which placed the resident at risk of unmet care needs.
Failure to Explain Arbitration Agreement in Resident's Language
Penalty
Summary
The facility failed to properly explain the arbitration agreement to Resident 272, who was admitted on June 13, 2024. Resident 272's preferred language was Mandarin, and they had severe cognitive impairment, requiring an interpreter for communication. Despite this, the arbitration agreement was presented in English and signed by the resident, not their legal representative, on June 11, 2024. The communication care plan indicated the need for gestures, family, and an interpreter line to communicate with the resident, yet there was no documentation showing the arbitration agreement was explained in a language or manner understood by the resident or their representative. Interviews with facility staff revealed a lack of clarity and consistency in the process of reviewing arbitration agreements. Staff A, the Administrator, stated that the business office manager was responsible for this task, but due to the absence of a BOM, Staff F from Medical Records had taken over the responsibility. Staff F was unsure if the facility had arbitration agreements in languages other than English and could not confirm how non-English speaking residents or their representatives understood the agreements. Staff B, the Director of Nursing, mentioned that agreements were available in other languages and that interpreter services should be used, but there was no evidence of this practice being followed for Resident 272.
Latest citations in Washington
Inaccurate PASARR screening affected two residents. One resident with vascular dementia, depression, and adjustment disorder had a PASARR level one that did not reflect mental health diagnoses, and staff stated it was inaccurate. Another resident with PTSD had a PASARR level one that did not include the PTSD diagnosis, with no additional PASARR level one or level two found in the EHR; staff stated the screening was not accurate and should have been repeated.
Undated open meds were found on 2 medication carts, including an open insulin vial and multiple open eye drop bottles with no dates. An LPN and an RN both stated the items should have been dated when opened, and the DON stated open multidose vials or bottles found without a date should be discarded immediately.
A resident with respiratory failure, HTN, and anxiety became SOB and diaphoretic, received a breathing tx, and was sent by EMS to the hospital. The facility could not locate the required SNF/NF to Hospital Transfer form or other transfer records showing what information was communicated to the receiving provider.
Care plans for two residents were not updated to match their current status and care needs. One resident had PTSD and generalized anxiety disorder and was receiving a psychotropic medication, but the care plan listed monitoring for antipsychotic and anticonvulsant meds that were not prescribed and did not include the anxiety diagnosis or related behaviors and interventions. Another resident had new upper and lower dentures, but the oral/dental care plan only noted edentulous status and difficulty chewing, with no mention of dentures or denture-related interventions.
Failure to Provide Individualized Activities: A resident with anxiety, depression, and weakness was cognitively intact but said they could not attend group activities because of leg problems and wanted more in-room activities. The resident mostly stayed in bed watching TV, and staff documentation showed only limited room visits with no consistent activity documentation despite a care plan goal for participation two to three times per week.
Failure to maintain heel offloading for a resident with a reopened DFU. A resident with dementia and dependence for mobility had a left heel wound that had healed and then reopened; the wound care provider recommended heel floating and pressure relieving boots at all times, but observations showed the resident in bed with heels on the mattress and later reclined in a wheelchair with the heel resting on the footrest strap and no boots in place. Staff stated the resident had not refused the boots or heel floating, and the care plan was not updated after the wound reopened.
Failure to Address Hearing and Vision Services for a Resident: A resident with dementia, bilateral hearing loss, and impaired vision was observed without eyeglasses or a hearing device, despite records showing admission with eyeglasses and a personal sound amplifier. The care plan addressed vision only and did not include hearing-related interventions, while staff interviews confirmed the resident’s hearing was strained and that the resident’s device use and vision needs were not fully reflected in the plan of care.
Respiratory care was not provided consistently for two residents receiving O2. One resident with COPD and chronic respiratory failure had an O2 order missing the indication for use and Sats parameters, no MAR documentation of O2 therapy, and inconsistent Sats charting. Another resident with respiratory failure was observed on continuous O2 via NC, but provider orders for O2 therapy and tubing changes were not present after readmission, despite the care plan stating the resident was dependent on O2.
A resident with dementia, hearing loss, and missing lower teeth had an MDS showing obvious or likely cavities or broken natural teeth, and the care plan identified oral/dental health problems with an intervention to coordinate dental care and transportation. Staff stated the resident’s dental needs were captured on the MDS, but no referral was made for dental services or follow-up with the dentist, and the DON said the lack of referral did not meet expectations.
Inaccurate Meal Intake Documentation: A resident with DM, dysphagia, and protein-calorie malnutrition was observed eating less than 25% of a meal, but the POC documented 76-100% intake. The CNA said the resident usually ate only 25-50% of meals and that intake was sometimes documented based on what a coworker reported. The LPN/RCM and DON stated meal intake should be documented accurately.
Inaccurate PASARR Screening for Two Residents
Penalty
Summary
The facility failed to ensure that two residents were screened for additional mental health supports through the PASARR process. Resident 97 was admitted with diagnoses including vascular dementia, depression, and adjustment disorder, and was able to make needs known. Review of the PASARR level one dated 04/10/2026 showed no mental health diagnoses and no need for a PASARR level two, even though the resident’s record included mental health diagnoses. During interview, the Regional Social Services staff and the Administrator stated the PASARR was inaccurate, needed modifications, and did not meet expectations. Resident 6 was admitted with diagnoses including heart failure, respiratory failure, and PTSD, and was able to make needs known. Review of the PASARR level one dated 03/30/2026 showed no serious mental illness indicators marked and no PASARR level two indicated, and the EHR contained no other documented PASARR level one or level two. The Social Services Director stated the hospital-provided PASARR was reviewed for accuracy and, if inaccurate, another level one would be completed, and stated this resident’s PASARR did not include PTSD and should have had another level one completed. The Administrator also stated the PASARR was not accurate and another level one needed to be conducted, but none could be located in the EHR.
Undated Open Medications on Medication Carts
Penalty
Summary
The facility failed to ensure proper storage and labeling of medications for 2 of 3 sampled medication carts reviewed for medication storage and labeling, including carts on the 400 and 500 halls. On the 500 hall medication cart, an open vial of insulin and an open bottle of eye drops were observed with no dates. During interview, an LPN stated that when an insulin vial or bottle of eye drops is opened, it should be dated immediately and said both items should have been dated upon opening; the LPN stated they would dispose of the undated vial and bottle. On the 400 hall medication cart, two open bottles of eye drops were observed with no dates. During interview, an RN stated both bottles should have been dated as soon as they were opened and said they would get new eye drops and dispose of the undated bottles. The DNS/RN stated that if an eye drop was opened it should have been dated immediately and that any open multidose vial or bottle found without a date should be discarded immediately.
Missing Hospital Transfer Documentation
Penalty
Summary
The facility failed to ensure hospital transfer documentation was completed for one resident who was transferred to the hospital after complaining of not being able to breathe and appearing diaphoretic. The resident had diagnoses of respiratory failure, high blood pressure, and anxiety disorder, and was able to make needs known. A breathing treatment was provided, and the provider agreed to send the resident out for further evaluation, after which emergency transportation took the resident to the hospital. Record review found no documentation showing what information was provided or communicated to the receiving facility for the transfer. Staff stated that transfer documentation should have included a SNF/NF to Hospital Transfer form, the resident's face sheet, and the medication and treatment administration records, but they were unable to locate documentation showing these items were completed or sent for the resident's hospital transfer.
Care plans did not reflect current diagnoses, medications, or denture status
Penalty
Summary
The facility failed to ensure that care plans were revised and accurately reflected residents’ current status and care needs for 2 of 21 sampled residents. Resident 6 was admitted with diagnoses including heart failure, respiratory failure, and PTSD, and was able to make needs known. The EHR showed Resident 6 also had generalized anxiety disorder and was receiving a psychotropic medication, but the current care plan dated 05/05/2026 documented monitoring for side effects of antipsychotic and anticonvulsant medications even though Resident 6 was not prescribed those medications. The care plan also identified PTSD but did not include generalized anxiety disorder or behaviors to monitor and interventions related to PTSD or anxiety disorder. Staff F, LPN/CC, stated the care plan did not accurately reflect the resident’s current status or prescribed medications, and Staff B, DNS, stated it did not meet expectations because it did not address the anxiety disorder or target behaviors and interventions. Resident 71 was admitted with diagnoses including PTSD, high blood pressure, and depression and was able to make needs known. Observation on 05/06/2026 showed a denture cup by the sink with the resident’s name on the lid and new upper and lower dentures dated 01/12/26. The resident stated the lower dentures did not fit well and that denture adhesive had been provided, but the dentures still did not fit right and the resident had not told staff yet. The focused oral/dental care plan, initiated on 06/23/2026, identified the resident as edentulous and having difficulty chewing, but did not show that the resident had dentures or include interventions related to denture use or maintenance. Staff E, CNA, stated they had not seen the resident wear dentures and were unaware of the new dentures, Staff C, LPN/CC, stated the care plan should have been updated when the dentures were obtained, and Staff B, DNS, stated the care plan should have reflected the dentures and interventions.
Failure to Provide Individualized Activities
Penalty
Summary
The facility failed to provide individualized activities for Resident 5, who was admitted with diagnoses including anxiety disorder, depression, and weakness. The admission MDS dated 01/14/2026 showed the resident was cognitively intact. During interviews on 05/03/2026 and 05/06/2026, Resident 5 stated they could not attend in-person activities because of their legs, wanted more activities to occupy them, mostly stayed in bed watching TV, and did not remember the last time activities staff visited to offer activities. The resident also stated activities staff would need to offer something they were able to do because they had difficulty doing some activities. The activities care plan dated 12/26/2026 showed a goal for Resident 5 to participate in activities two to three times per week. Progress notes documented one visit on 12/22/2026 to provide a welcome packet and encourage participation in daily activities, but no further activity documentation was found in the progress notes. Staff H stated room visits should include puzzles, arts and crafts, visiting, and chatting, and that documentation was placed in tasks, but the task record showed no documentation of activities for the past 30 days. Staff J stated paper documentation existed for room visits and that Resident 5 was on a list for room visits every Monday and Wednesday, while the room visit documentation showed only four visits on 01/26/2026, 02/06/2026, 03/10/2026, and 04/08/2026.
Failure to Maintain Heel Offloading for Reopened DFU
Penalty
Summary
The facility failed to consistently implement pressure reducing strategies for a resident with a left heel diabetic foot ulcer that had reopened. The resident was admitted with diagnoses including left hip fracture with surgical repair, a blood clot of the left lower leg, and dementia, and was dependent on staff for mobility and unable to make needs known. The baseline care plan and care plan both included heel offloading interventions, and the wound care provider initially recommended heel floating with pillows or wedge and pressure relieving boots. The wound later resolved, but a weekly skin assessment documented that the left heel wound reopened and was very painful to touch. After the wound reopened, the contracted wound care provider documented that the DFU to the left heel had reopened and recommended the resident wear pressure relieving boots at all times. The current care plan reviewed after the wound reopened did not include new interventions related to the reopened wound. Observations showed the resident seated in a reclined wheelchair with the left foot/heel resting on the footrest strap and no pressure relieving boots in place, and later lying in bed with both heels directly on the mattress without being floated and without boots. Staff interviews indicated the resident had not refused the boots or heel floating, and the LPN/CC and DON stated the resident should have been assessed and the plan of care updated when the wound reopened.
Failure to Address Resident Hearing and Vision Needs
Penalty
Summary
The facility failed to address one resident’s hearing and vision needs. Resident 112 was admitted with diagnoses including a leg fracture, dementia, and hearing loss in both ears, and was able to make needs known. The record showed the resident lost their glasses and was given readers, but the resident did not wear them because they were concerned that wearing glasses that were not their prescription would further degrade their vision. Observation did not show glasses in the resident’s room, and the resident stated they did not use a hearing aid. The resident was observed to be hard of hearing, requiring an elevated voice and repeated questions to understand. The admission MDS dated [DATE] documented adequate hearing with hearing aid and adequate vision with corrective lenses, while the significant change MDS dated [DATE] documented moderate difficulty hearing without a hearing aid and impaired vision without corrective lenses. The care plan initiated 02/24/2026 addressed impaired vision with interventions to arrange consultation with eye care practitioners as needed and remind the resident to wear glasses, but it did not include a focus area or interventions for hearing loss or use of hearing aids. A resident clothing list showed the resident admitted with one pair of eyeglasses and one Super Ear headset personal sound amplifier, yet observation and interview showed the resident in bed without eyeglasses or a hearing device, with the amplifier stored in the bedside table drawer. Staff interviews confirmed the resident’s hearing was strained, that the hearing device and glasses were not being used, and that the resident’s hearing device use should have been included in the plan of care and the resident should have been referred for eye care assessment.
Respiratory Care Orders and Documentation Not Maintained
Penalty
Summary
The facility failed to provide respiratory care consistent with professional standards of practice for two residents receiving oxygen therapy. One resident with COPD and chronic respiratory failure with hypoxia was observed multiple times lying in bed receiving oxygen at 2 L via nasal cannula. The resident’s oxygen order, dated 02/15/2026, allowed 1 to 4 L per minute continuously via nasal cannula, but it did not include an indication for use or oxygen saturation parameters. The April and May 2026 MARs did not show documentation of oxygen therapy being provided, and the TARs showed only an order to change oxygen tubing if damaged or visibly soiled, not an order for oxygen therapy. Oxygen saturations were not documented consistently daily from 04/01/2026 through 05/04/2026. A second resident with respiratory failure, high blood pressure, and anxiety disorder was observed in the room receiving oxygen at 6 L via nasal cannula on multiple occasions. The resident stated they needed oxygen therapy to breathe, and the care plan identified the resident as dependent on oxygen and to receive oxygen per provider orders. However, provider orders reviewed on 05/04/2026 showed no orders for oxygen therapy or for changing oxygen tubing. Staff stated the oxygen and tubing-change orders had been discontinued when the resident went to the hospital and were not added back to the MAR or TAR when the resident readmitted to the facility.
Failure to Refer Resident With Identified Dental Needs
Penalty
Summary
The facility failed to ensure that Resident 112 received needed dental care. Resident 112 was admitted with diagnoses including a leg fracture, dementia, and hearing loss in both ears. Observation on 05/03/2026 showed the resident had missing lower teeth. The admission MDS, dated [DATE], documented obvious or likely cavities or broken natural teeth, and the care plan dated 02/24/2026 identified oral/dental health problems related to likely cavities or broken teeth with an intervention to coordinate dental care and provide transportation. During interviews, Staff G, Regional Social Services, stated Resident 112's dental needs were captured on the 02/24/2026 MDS and the resident was not referred for dental services. Staff M, Social Services Director, stated residents with dental needs should be referred to social services to be scheduled for assessment by a dental care practitioner, and that Resident 112 should have been referred after the MDS assessment. Staff B, DON, stated residents with identified dental needs should be referred for follow-up with a dentist and that Resident 112 should have been referred to the in-house dental provider; Staff B stated the lack of referral did not meet expectations.
Inaccurate Meal Intake Documentation
Penalty
Summary
The facility failed to accurately document the amount of food eaten for Resident 13, who was admitted with diagnoses including diabetes mellitus, dysphagia, and protein-calorie malnutrition. The quarterly MDS dated 02/12/2026 showed the resident was moderately cognitively impaired. During observation on 05/05/2026 at 12:09 PM, a meal tray was delivered to the resident’s room, set up on a bedside table, and the resident was observed eating slowly, eating less than 25% of the meal, then laying back in bed and closing their eyes while the tray remained in the room. Staff later removed the tray, but the POC documentation for lunch on 05/05/2026 recorded that Resident 13 ate 76-100% of the meal. During interview, the CNA stated the resident typically ate 25-50% of meals and never ate all of the food, and that if they did not pick up a tray they would ask a coworker what the resident ate before documenting it. The CNA stated they were told the resident ate 75-100% of lunch, so that is what was entered. The LPN/RCM stated staff should document meal intake accurately in POC, and the RN/DNS stated it was their expectation that all staff document meal intake accurately.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release June 24, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
