The Broadview Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Seattle, Washington.
- Location
- 13023 Greenwood Avenue North, Seattle, Washington 98133
- CMS Provider Number
- 505416
- Inspections on file
- 30
- Latest survey
- April 17, 2026
- Citations (last 12 mo.)
- 15 (1 serious)
Citation history
Health deficiencies cited at The Broadview Center during CMS and state inspections, most recent first.
A resident who was cognitively intact but dependent on staff for bathing was care planned and scheduled to receive regular showers or baths, with facility policy requiring at least twice-weekly tub or shower baths and documentation of any refusals. Over a 30-day period, the EHR showed only two bed baths documented and no showers, and nursing notes contained no refusals of care. The resident reported wanting and needing staff assistance for showers and stated they could not get out of bed or bathe independently. Staff interviews confirmed that CNAs are responsible for providing and documenting showers/bed baths and notifying nurses of refusals, and the DON acknowledged the resident, who was dependent for ADLs, did not receive bathing as scheduled.
A resident with a recent fracture and altered mental status experienced a decline in consciousness and oxygen saturation, but staff did not consistently monitor vital signs, initiate oxygen therapy when indicated, or offer prompt hospital transfer. Despite clear signs of deterioration and a full treatment POLST, appropriate escalation of care was not documented, and the resident later died following emergency intervention.
A resident was allowed to vape unsupervised in their room despite a facility policy prohibiting smoking and vaping, with staff failing to secure the device or complete a required smoking assessment. In a separate incident, a staff member's unleashed dog entered the dining area, startled a resident in a wheelchair, and caused the resident to fall and sustain a head laceration, violating the facility's pet policy requiring animals to be leashed and supervised at all times.
The facility's assessment lacked a completed risk assessment, a detailed list of medical and non-medical equipment, and documentation of contracts or agreements with third parties for services or equipment during both routine and emergency operations. Administrators confirmed the absence of these required elements and could not locate referenced appendices, resulting in an incomplete evaluation of the facility's capacity to meet resident needs.
The facility did not conduct thorough investigations or implement corrective actions following alleged abuse and a resident-to-resident altercation. Investigations lacked key details, such as the timing of incidents, and interviews with residents about safety concerns were not properly conducted or documented. Residents with severe cognitive impairment were inappropriately interviewed, and care plans were not updated to address new behaviors or protect those involved. Staff acknowledged these deficiencies, and required procedures for investigation and care plan revision were not followed.
The facility did not consistently provide or document scheduled bathing and showering for several dependent residents. In multiple cases, residents received only one or two showers or bed baths over a month, with no record of care being offered or refused on other scheduled days. Staff interviews confirmed that refusals should have been documented, and the absence of such documentation indicated the care was not provided as required by policy.
The facility did not accurately complete and post daily nurse staffing forms with actual hours worked, instead displaying only scheduled hours. Staff interviews confirmed that actual hours were not updated on the same day, and the administrator acknowledged this practice did not meet requirements for informing residents and visitors.
The facility did not maintain proper food temperatures during meal service, as food items were served below the required 140°F despite being transported on warm plates and in covered carts. Several residents without cognitive impairment reported that their meals were consistently cold or lukewarm, leading to dissatisfaction and, in some cases, decreased food intake. Staff were aware of ongoing complaints about food temperature and palatability, but the issue persisted.
A facility licensed for over 200 residents failed to employ a qualified full-time social worker as required, with none of the reviewed social workers meeting the necessary educational or supervised experience standards. Administrators were unable to provide documentation of qualifications or job descriptions, and interviews confirmed a lack of compliance with regulatory requirements.
Two residents' preferences for bathing routines were not honored, as care plans and EHR schedules did not reflect their stated wishes for shower or bed bath frequency and timing. Staff confirmed that these preferences were not accommodated, resulting in unmet care needs.
Two residents did not have comprehensive care plans addressing their use of assistive devices, independent community outings, or refusal of incontinent care. One resident regularly used a motorized wheelchair and left the facility unsupervised, but this was not documented in the care plan, nor were safety interventions included. Another resident consistently refused incontinent care, but the care plan did not reflect this behavior or the intervention to notify the resident's representative. Staff interviews confirmed these omissions.
A resident with a history of muscle weakness and cauda equina syndrome reported right ankle pain after an incident involving their motorized wheelchair and ankle-foot orthosis. The resident's pain was initially documented and treated with pain medication, but there was no ongoing monitoring or timely provider assessment for several days, despite facility policy. The lack of communication between therapy and nursing, and failure to continue alert charting, led to a delayed diagnosis of a tibial fracture and subsequent complications, as confirmed by staff interviews and internal investigation.
A resident with chronic Stage 4 pressure injuries and osteomyelitis did not receive the recommended Dolphin Mattress for pressure relief, despite repeated wound care consultant recommendations. Instead, staff provided a different mattress that did not meet the specified requirements, and the recommended mattress was never replaced, as confirmed by staff and administration interviews.
Two residents missed multiple doses of ordered IV antibiotics for serious infections because the facility's pharmacy stopped delivering IV medications, and staff were unclear on how to obtain them. One resident experienced symptoms after missed doses, while another was transferred to the hospital after not receiving any IV antibiotics.
Staff failed to consistently keep isolation room doors closed and did not use required PPE, such as N95 respirators and gowns, when caring for two residents with active COVID-19. Observations showed staff entering and exiting rooms without proper protection, and interviews confirmed that these actions were not in line with facility policy or posted instructions.
The facility did not maintain or make accessible the required three years of survey results and associated plans of correction, as only the most recent survey documents were available in the designated binder. This prevented residents, their representatives, and visitors from reviewing past survey outcomes and the facility's corrective actions, as confirmed by the DON and Administrator.
The facility did not ensure guardianship papers were current for a resident with intellectual disabilities and failed to offer or document assistance with advance directives for two other residents, including one who wished to designate a DPOA. Staff interviews revealed confusion about responsibility for maintaining these records, and required discussions and documentation were missing from the EHR.
The facility did not consistently monitor or document side effects and target behaviors for residents prescribed psychotropic medications, including both antidepressants and antipsychotics. Required assessments, such as the AIMS for antipsychotic use, were not completed within the recommended timeframe, and staff confirmed that expected documentation was missing from medical records.
Surveyors found that multiple residents did not have comprehensive care plans developed or implemented for essential needs such as nail care, toileting hygiene, bed positioning, nutrition, dental care, pain management, and activities. Observations and interviews revealed that care was not provided or documented as required, and residents' specific needs and preferences were not addressed, resulting in unmet care needs.
The facility did not accurately complete and post daily nurse staffing forms with actual hours worked for each shift, as required by policy. Observations and staff interviews confirmed that only planned hours were displayed, and actual hours worked were omitted from the posted forms over a seven-day period.
The facility did not consistently complete or document monthly Medication Regimen Reviews (MRRs) for several residents, including missing pharmacist recommendations and incomplete physician follow-up. Staff interviews confirmed that required MRRs were not available in the EHR or facility records for multiple months, contrary to facility policy and regulatory expectations.
Surveyors found expired medications and medical supplies on several medication carts and in a storage room, with staff confirming these items should have been discarded according to facility policy. Additionally, daily temperature logs for a medication room refrigerator were incomplete, with several days missing entries, despite staff expectations for daily monitoring. These deficiencies were confirmed through staff interviews and review of facility policy.
Surveyors found that food items in the kitchen and dining room storage areas were not consistently labeled with open or use-by dates, and several expired items were not discarded as required by facility policy. Staff confirmed that bread, condiments, dairy products, and prepared foods were not properly dated or removed when expired, despite clear policies mandating these practices.
The facility did not review its infection control policies annually as required, failed to keep a urinary catheter drainage bag off the floor for a resident with obstructive uropathy, and did not disinfect a sit-to-stand lift between uses for two residents. Staff also did not consistently use required PPE or perform hand hygiene when providing care to two residents on Enhanced Barrier Precautions, as confirmed by staff interviews.
A resident with severe cognitive impairment and limited mobility had their bed positioned against the wall without assessment, evaluation, or informing the resident or their representative about the risks and benefits. Staff interviews and record reviews confirmed the absence of a physician order and lack of required communication or documentation.
Two residents did not have their preferences for twice-weekly showers or baths honored, as documented in their care plans. ADL records and staff interviews confirmed that both residents received fewer showers or baths than preferred, with no refusals documented, due to staffing issues and changes in staff assignments. Facility policy required honoring resident bathing preferences, but these were not consistently followed.
Two residents had their medical information discussed and assessments performed by an ARNP in common areas, including the TV room and a bench near the nurse's station, without privacy. Staff confirmed that these interactions did not meet expectations for confidentiality and privacy during provider visits.
A resident reported concerns about inadequate supplies and described this as a form of elder abuse. The facility's investigation included reviewing supply records and interviewing the resident, but did not include interviews with other residents or staff. The administrator later acknowledged that the investigation was incomplete and did not follow usual procedures.
A resident was discharged from hospice services, but the required Significant Change in Status Assessment (SCSA) MDS was completed 13 days late, beyond the 14-day regulatory timeframe. Staff interviews and record reviews confirmed that the MDS coordinator was responsible for the delay, and the DON acknowledged the assessment was not completed on time.
Surveyors identified that three residents had inaccurate MDS assessments: one was incorrectly coded as receiving antidepressants, another was not marked as edentulous despite documentation and observation, and a third was marked as receiving hospice care without supporting orders or documentation. Staff interviews confirmed the inaccuracies and the expectation for accurate MDS completion.
The facility failed to complete and document required PASARR screenings for two residents. One resident did not receive a new Level I PASARR after remaining in the facility beyond the exempted hospital discharge period, and another resident's Level II PASARR referral was not documented despite indications of mental health decline. These actions did not follow the facility's policy for screening and referral for mental disorders or intellectual disabilities.
The facility did not notify the State PASARR Coordinator or mental health authority after three residents with mental health or intellectual disability diagnoses experienced significant changes in condition. Required referrals for PASARR Level II evaluations were either delayed or not completed, as confirmed by documentation and staff interviews.
Care plans for three residents were not updated to reflect significant changes, including discontinuation of hospice services, initiation of comfort care, and stopping of antidepressant medication. Staff and DON confirmed that care plans still contained outdated information and did not accurately represent current care needs.
A resident who was cognitively intact and expressed interest in specific activities was not provided with an ongoing activity program or access to leisure supplies, as required by facility policy and their care plan. Observations and interviews confirmed the resident was not offered or participating in group or individual activities, and there was no documentation of activity participation or refusal in the medical record.
Two residents experienced deficiencies in care: one had untreated and undocumented skin injuries following a fall, while another did not have required daily weights recorded despite being on diuretic therapy. Staff were unaware of the skin injuries and failed to follow protocols for documentation and monitoring, placing both residents at risk for unmet care needs.
A resident with gastroparesis and Type I diabetes was not provided with the physician-ordered small, frequent meals, instead receiving regular-sized portions despite clear care plan instructions. Staff interviews and record reviews confirmed the failure to follow the therapeutic diet, resulting in significant weight loss for the resident.
Staff did not properly store or label respiratory equipment and failed to consistently document O2 saturation as ordered for a resident with COPD and acute hypoxic respiratory failure. The O2 humidifier bottle was repeatedly undated, and the BiPAP tubing and nasal cannula were found improperly stored, including on the floor. Staff interviews confirmed these practices did not meet facility expectations.
Three residents received calcium and vitamin D supplements that did not match their physician orders, with staff administering different formulations and dosages than prescribed. Both nursing staff and the in-house pharmacy failed to clarify discrepancies with the physician or pharmacist before administration, resulting in medication errors that were confirmed by the unit manager, consultant pharmacist, and DON.
A resident with a broken tooth was not referred for dental services despite staff awareness and facility policy requiring such referrals. The resident experienced difficulty chewing, and interviews with nursing, social services, and the DON confirmed that no referral or documentation was made for dental care.
Two residents with intact cognition did not have their meal preferences honored, as staff failed to follow their menu selections and specific food requests. Despite residents clearly indicating their choices and expressing dissatisfaction, staff delivered meals that did not match their preferences, and multiple staff members acknowledged that the residents' choices should have been followed.
A resident's clinical status, vital signs, and departure for a planned diagnostic procedure were not documented in the medical record. Both the assigned LPN and the DON confirmed the absence of required documentation, resulting in incomplete and inaccurate records for the resident.
A resident was not offered or administered the required annual influenza and pneumococcal vaccines, and there was no documentation of vaccine offers, refusals, or informed consent in the medical record. Staff interviews and record reviews confirmed inconsistent practices and missing documentation, despite facility policy requiring these actions.
The facility did not include a contingency plan or strategies for maximizing direct care staff recruitment and retention in its most recent facility-wide assessment. The Administrator confirmed these omissions during an interview.
A resident with impaired memory and a known history of wandering and elopement risk was able to leave the facility unsupervised, despite being redirected by staff earlier. The resident exited through the front door and was later found walking alone on a busy street, indicating a failure to provide adequate supervision as required by facility policy.
Two residents who were dependent on staff for all ADLs did not receive timely assistance with toileting and changing after incontinence and vomiting incidents. Staff interviews confirmed that one resident was left in a wet bed after a brief change, and another was not promptly changed after soiling clothing and linens. The DON acknowledged that staff did not meet the care needs as outlined in the residents' care plans.
The facility failed to maintain resident dignity by not knocking before entering rooms, inadequately covering urinary catheter bags, leaving mechanical lift slings under residents, and standing while assisting residents with meals. These actions affected multiple residents and were against the facility's policies.
The facility failed to inform residents and/or their representatives of the risks and benefits before implementing safety devices and treatments, including bed placement, use of a tilt-in-space wheelchair, a transfer pole, and psychoactive medication. Staff interviews and record reviews confirmed the lack of required assessments and consents.
The facility failed to periodically review resident rights with all 16 residents reviewed. Resident Council minutes from February 2023 to April 2024 showed no discussions on resident rights. Interviews with residents and staff confirmed that resident rights were not reviewed during Resident Council meetings, and the Administrator acknowledged that this should be done yearly.
The facility failed to provide the website address of the Washington State Long-Term Care Ombudsman on posted contact information in seven areas, including notice boards and an elevator. The Administrator confirmed that the contact information had not been updated recently, acknowledging it should be updated annually. This placed residents at risk of not being able to report concerns online.
The facility failed to maintain the privacy and confidentiality of residents' personal and medical information. Residents' weights were posted publicly, a computer screen with medical records was left unattended, and contact information for residents' representatives was visible from the hallway. Additionally, a resident received a medical treatment in a public area, exposing their back to others.
Failure to Provide Scheduled Bathing Assistance for Dependent Resident
Penalty
Summary
The facility failed to consistently provide bathing or showers for a resident who was dependent on staff for activities of daily living (ADLs), specifically bathing. The facility’s ADL policy, dated 10/01/2021, required that residents unable to perform ADLs independently receive services to maintain grooming and personal hygiene, including tub or shower baths at least twice weekly or as required by law, and that refusals of care be documented along with education on risks and benefits and alternative interventions. The annual MDS dated 02/11/2026 showed the resident had no impaired memory or thinking and was dependent on staff for showers/baths. The resident’s care plan, initiated on 02/12/2025 and revised on 06/30/2025, documented dependence on staff for bathing. Review of the EHR task list for ADL Bath/Shower showed the resident was scheduled for a shower/bath every Tuesday evening and as needed, but during the 30‑day look‑back period from 03/25/2026 to 04/08/2026, only two bed baths were documented (on 03/25/2026 and 04/08/2026), with no additional showers or baths recorded. Nursing progress notes from 03/25/2026 to 04/16/2026 contained no documentation of any refusals of showers or baths. In an interview, the resident reported wanting two showers a week and stated they would be happy with one, noting they sometimes received a bed bath but that it had been a while, and that they could not get out of bed or take a shower independently. Staff interviews confirmed that CNAs document showers/bed baths under the ADL Bath/Shower task and notify a nurse if a resident refuses, and the Resident Care Manager stated most residents are scheduled for at least weekly, usually twice‑weekly, showers/baths. During a joint record review, the DON acknowledged that the resident was dependent on staff for bathing and did not receive showers/bed baths as scheduled.
Failure to Monitor Change in Condition and Initiate Timely Intervention
Penalty
Summary
A deficiency occurred when facility staff failed to adequately monitor a resident who experienced a change in level of consciousness and decreased oxygen saturation. The resident, who had been admitted for rehabilitation following a left leg fracture and had a history of muscle weakness and altered mental status, was initially alert and oriented. Over the course of her stay, documentation showed a decline in her mental status, with increasing somnolence and uncooperative behavior, as well as decreasing oxygen saturation levels, including a reading as low as 88% on room air. Despite these significant changes, staff did not consistently perform or document frequent assessments of the resident's vital signs or mental status as required by facility policy and the medical provider's instructions. Oxygen therapy was not initiated when the resident's oxygen saturation dropped below 90%, and there was no documentation of follow-up assessments or escalation of care. Additionally, neither the resident nor her representative was offered a prompt transfer to the hospital for further evaluation, even though the resident's POLST indicated a preference for full treatment, including hospital transfer if indicated. Interviews with staff revealed a lack of clarity and follow-through regarding monitoring protocols, initiation of oxygen therapy, and the process for offering hospital transfer. Staff acknowledged that vital signs were not taken as frequently as expected and that opportunities to escalate care or offer transfer were missed. The resident ultimately experienced increased respiratory distress, required emergency intervention, and was pronounced dead after resuscitation efforts.
Failure to Supervise Smoking Materials and Restrain Pet Results in Resident Injury
Penalty
Summary
The facility failed to provide adequate assessment and supervision for the use of electronic cigarettes and did not ensure the safe storage of smoking materials for a resident. Despite the facility's policy prohibiting smoking and vaping within the building and on its grounds, a resident with a history of tobacco use and cognitive intactness was observed vaping unsupervised in their room on multiple occasions. Staff were aware of the resident's vaping but did not intervene to secure the device or conduct a required smoking assessment, and there was confusion among staff regarding whether the policy included vaping devices. Documentation showed that the resident had refused nicotine patches and continued to use a vape device independently, with staff failing to follow the policy for safe storage and supervision of smoking materials. Additionally, the facility failed to supervise and restrain a staff member's dog, resulting in an accident involving another resident. The facility's pet policy required that animals be leashed and supervised at all times and prohibited their presence in dining areas. However, the dog was left unleashed and unsupervised, entered the dining room, and crawled under a table where a resident in a wheelchair was eating. The resident was startled, causing their wheelchair to tip backward, resulting in a laceration to the back of their head and requiring transport to the hospital for evaluation. Multiple staff interviews confirmed that the dog was not on a leash and that this was a direct violation of facility policy. These failures led to significant safety hazards, including the risk of fire or explosion from unsupervised vaping and a preventable injury to a resident due to the presence of an unrestrained animal in a resident area. Staff interviews and record reviews consistently indicated a lack of understanding and enforcement of facility policies regarding both smoking materials and pet supervision, directly contributing to the deficiencies identified.
Removal Plan
- Remove the smoking materials in Resident 7's room for safe storage
- Complete a smoking assessment and update Resident 7's care plan with the facility providing supervised vaping
- Interview and observe all residents and their rooms to ensure smoking materials are stored safely
- Educate all residents and/or resident representatives, and staff on the facility's non-smoking policy
Incomplete Facility Assessment and Missing Resource Documentation
Penalty
Summary
The facility failed to ensure that its facility-wide assessment included all required components necessary to determine the resources needed to competently care for residents during both routine operations and emergencies. Specifically, the assessment did not contain a completed facility-based and community-based risk assessment, nor did it include a comprehensive list of medical and non-medical equipment descriptions. Additionally, documentation of contracts, memorandums of understanding, and other agreements with third parties to provide services or equipment during normal and emergency situations was missing. During interviews, facility administrators acknowledged that the assessment was incomplete and that referenced appendices containing critical information could not be located. The assessment also contained outdated information regarding the facility's admission policy for active COVID-19 residents, which did not reflect current practices. These omissions were identified through record review and staff interviews, indicating a lack of thorough documentation and assessment as required by facility policy.
Failure to Conduct Thorough Abuse Investigations and Update Care Plans
Penalty
Summary
The facility failed to conduct thorough investigations and implement corrective actions to prevent recurrence of incidents involving alleged abuse and resident-to-resident altercations. For one resident with diagnoses including anxiety disorder, hemiplegia, hemiparesis, and dementia, the investigative summary did not identify when the alleged incident occurred. Additionally, interviews with several residents regarding safety concerns were not conducted correctly, and follow-up on their expressed concerns was inadequately documented. Some residents with severe cognitive impairment were inappropriately interviewed instead of their representatives, contrary to the facility's stated process. In another incident involving two residents, the investigation documented that one resident attempted to push another back to their room, leading to a physical altercation where one resident scratched and hit the other's arms, resulting in visible bruising. The investigation summary and care plans for both residents did not include any new or revised interventions to prevent recurrence of such incidents. Staff interviews confirmed that the only immediate action taken was to separate the residents, and there was no documentation of further corrective actions or care plan updates addressing the behaviors or protection for the involved residents. Facility staff, including the DON, RN Unit Manager, and Administrator, acknowledged gaps in the investigation process, such as lack of documentation regarding corrective actions, failure to update care plans with new interventions, and improper interview procedures for residents with cognitive impairment. The facility's policies required thorough investigation, identification of the incident's specifics, and care plan revisions to minimize recurrence, but these steps were not consistently followed in the reviewed cases.
Failure to Provide and Document Scheduled Bathing and Showering for Dependent Residents
Penalty
Summary
The facility failed to consistently provide bathing and showering assistance to residents who were unable to perform these activities independently, as required by their care plans and facility policy. For four residents reviewed, documentation showed that scheduled showers or bed baths were either not provided or not properly documented as offered or refused. In several cases, the electronic health records (EHR) indicated that showers were only given once or twice in a 30-day period, with the remaining scheduled days marked as "Not Applicable" and lacking any indication of whether care was offered or declined. Specifically, one resident required extensive assistance with bathing and was scheduled for weekly showers, but only received two showers in a 30-day period, with no documentation of offers or refusals for the other days. Another resident, dependent on staff for bathing, received only one shower during a similar timeframe, again with no documentation of refusals. A third resident, who preferred bed baths and required limited assistance, did not receive any bed baths over a nearly two-week period, and there was no documentation to show if the care was offered or refused. A fourth resident, newly admitted and scheduled for weekly showers, did not receive a shower until 11 days after admission, with no documentation of offers or refusals during that period. Interviews with facility staff, including the unit manager RN, DON, and administrator, confirmed that refusals should have been documented and that the lack of documentation meant the care was not provided. The facility's policy required that residents unable to perform ADLs independently receive necessary services, and that refusals be documented along with communication of risks and benefits to the resident or representative. The failure to provide or document bathing and showering as scheduled constituted a deficiency in meeting residents' ADL needs.
Failure to Accurately Post Actual Nurse Staffing Hours
Penalty
Summary
The facility failed to ensure that the daily nurse staffing forms were accurately completed with the actual hours worked for each shift on 7 out of 10 days reviewed. Observations and record reviews showed that the posted forms did not reflect the actual nursing hours worked, but instead displayed the scheduled hours. Interviews with staff revealed that the receptionist posted the scheduled hours in the morning and added evening and night shift hours later, without ever updating the forms to show the actual hours worked. The staffing coordinator confirmed that actual hours were typically filled in the next day or later, rather than on the same day. The administrator acknowledged that actual nursing hours should be posted on the same day to inform residents and visitors, but this was not being done.
Failure to Serve Food at Safe and Appetizing Temperatures
Penalty
Summary
The facility failed to ensure that food was served at proper temperatures on the Transitional Care Unit (TCU), as evidenced by direct observation, interviews, and record review. During a meal service, the Dietary Manager measured food temperatures and found that baked beans, hamburger patties, corn on the cob, and chicken noodle soup were all below the expected 140 degrees Fahrenheit, with some items as low as 105 degrees Fahrenheit. The food had left the kitchen less than ten minutes prior to being tested, yet did not maintain the required temperature. The Dietary Manager acknowledged that the food should have remained at 140 degrees Fahrenheit for up to forty minutes but did not do so, despite being served on warm plates, covered, and transported in a closed food cart. Multiple residents without cognitive impairment reported that their meals were consistently served cold or lukewarm, affecting their willingness to eat and their satisfaction with the food. Residents described the food as always cold, with one stating they sometimes skipped meals due to the temperature, and another expressing a desire to have food delivered from outside the facility. Staff interviews confirmed awareness of ongoing complaints about cold and unpalatable food, and it was noted that previous efforts to address these complaints had not resolved the issue.
Failure to Employ Qualified Social Worker in Facility with Over 120 Beds
Penalty
Summary
The facility, licensed to provide care for 211 residents, failed to employ a qualified full-time social worker who met the educational and supervised experience requirements as mandated for facilities with more than 120 beds. Review of staff records and interviews revealed that none of the four social workers reviewed (including three full-time and one per diem) possessed the required qualifications. Specifically, one social worker held a master's degree in theology, which is not considered a human services field, and another had only an associate's degree without a bachelor's in social work or a related field. The qualifications for the remaining social workers were not provided despite multiple requests. Interviews with facility administrators confirmed a lack of familiarity with the required qualifications for social workers in such a setting. Documentation such as job descriptions, policies, and evidence of one year of supervised social work experience in a healthcare setting were not provided for any of the social workers. This deficiency was identified through staff interviews, record reviews, and email correspondence, with administrators acknowledging gaps in compliance with regulatory requirements.
Failure to Accommodate Resident Bathing Preferences
Penalty
Summary
The facility failed to reasonably accommodate the bathing preferences of two residents, resulting in unmet care needs. For one resident, documentation showed a clear preference for morning showers twice a week, as indicated in both a "Shower Preference Questionnaire" and through staff interviews. However, the resident's care plan did not reflect these preferences, and the electronic health record (EHR) scheduled showers only once a week in the evening, contrary to the resident's stated wishes. Staff confirmed that the resident's preferences were not being honored at the time of review. Another resident expressed a preference for bed baths twice a week in the evening, which was documented in the care plan and confirmed during interviews. Despite this, the EHR showed the resident was scheduled for showers or baths on specific evenings, and records indicated the resident did not receive the preferred bed baths during a specified period. Staff acknowledged that the resident's preferences were not honored and that refusals, if any, were not documented. These failures were in direct conflict with the facility's policy to honor resident choices and preferences regarding activities of daily living.
Failure to Develop Comprehensive Care Plans for Assistive Device Use, Community Outings, and Refusal of Care
Penalty
Summary
The facility failed to develop and implement comprehensive care plans for two residents, as required by policy and regulation. For one resident with a history of muscle weakness and use of a motorized wheelchair, the care plan did not document the use of the assistive device or the resident's independent community outings, despite the resident regularly leaving the facility unsupervised in their motorized wheelchair. Staff interviews revealed a lack of awareness regarding the resident's use of the motorized wheelchair and their independent outings, and the care plan lacked specific interventions or safety measures related to these activities. For another resident diagnosed with anxiety disorder, hemiplegia, hemiparesis, and dementia, the care plan did not address the resident's consistent refusal of incontinent care. Facility documentation and staff interviews confirmed that the resident often refused to be changed, which posed a risk for skin breakdown. Although staff were instructed to notify the resident's representative and re-approach the resident when care was refused, these interventions were not included in the resident's care plan. The facility's policy required that comprehensive, person-centered care plans be developed for each resident, incorporating identified problem areas, risk factors, and promoting resident safety. However, the care plans for both residents lacked documentation of key needs and interventions, including assistive device use, independent outings, and refusal of care, as well as associated safety measures and communication protocols.
Failure to Monitor and Promptly Evaluate Change in Condition After Resident Injury
Penalty
Summary
The facility failed to ensure appropriate monitoring and prompt medical evaluation for a resident who experienced a change in condition following an incident involving their right ankle. The resident, who had a history of generalized muscle weakness and cauda equina syndrome and was cognitively intact, reported injuring their right foot when their ankle-foot orthosis became caught on a store display while using a motorized wheelchair outside the facility. Upon return, the resident reported the incident and pain to a physical therapist, who performed passive range of motion but did not notify nursing, as the resident was not on the therapy caseload. The resident later reported pain to a CNA, who notified a nurse. The nurse documented the pain and administered oxycodone, noted the incident in the communication book, and placed the resident on alert charting for monitoring. Despite the initial documentation, there was no evidence of continued alert charting or provider assessment for the resident's right ankle pain over the following three days. The resident continued to receive pain medication and non-pharmacological interventions such as rest and cold/ice, but there was no documentation of ongoing monitoring or follow-up assessments by nursing or the medical provider during this period. The facility's policies required prompt notification of the provider and ongoing documentation for changes in a resident's condition, but these were not followed. The lack of communication between therapy and nursing, as well as the absence of continued monitoring, resulted in a delay in medical evaluation. Eventually, the resident was assessed by a provider, who ordered an x-ray that revealed a right tibial fracture, leading to the resident's transfer to the hospital. During hospitalization, the resident was also diagnosed with a left leg deep vein thrombosis and acute pulmonary embolism, conditions attributed to immobilization following the fracture. Interviews with facility staff confirmed that the expected procedures for monitoring and documentation were not followed, and the incident was not communicated effectively among the interdisciplinary team. The facility's internal investigation corroborated that the resident was not placed on alert charting as required, and there was no evidence of timely provider follow-up.
Failure to Provide Recommended Pressure-Relieving Mattress for Pressure Ulcer Care
Penalty
Summary
The facility failed to provide or replace a pressure-relieving Dolphin Mattress for a resident with a history of chronic Stage 4 pressure injuries and osteomyelitis, despite multiple recommendations from a wound care consultant. The resident, who required assistance with bed mobility and transfers, had a documented need for a Dolphin Mattress to prevent further skin breakdown and assist in wound healing. The wound care consultant repeatedly communicated the necessity of this specific mattress to the nursing staff, noting that the replacement mattress in use was not sufficient for offloading pressure. Despite these recommendations, the facility replaced the broken Dolphin Mattress with a MATT-EASY AIR mattress, which operates by alternating air rather than fluid. Staff interviews confirmed that the wound care recommendations were received and acknowledged, but the Dolphin Mattress was never replaced. The Director of Nursing indicated that the previous administration was aware of the recommendation but opted not to replace the mattress, possibly due to cost concerns. At the time of observation, the resident continued to use the non-recommended mattress, contrary to the wound care consultant's orders.
Failure to Provide IV Antibiotics Due to Pharmacy Service Disruption
Penalty
Summary
The facility failed to ensure that two residents were free from significant medication errors related to the administration of intravenous (IV) antibiotics. One resident, who had been readmitted with a diagnosis of pelvic osteomyelitis, had physician orders for Meropenem IV every 8 hours. The medication was not administered on four occasions over a two-day period due to the facility's inability to obtain the IV antibiotic from the pharmacy. Nursing documentation confirmed the missed doses, and the resident reported experiencing symptoms such as chills and feeling feverish after missing the antibiotics. Staff interviews revealed that the pharmacy previously contracted to provide IV medications had ended their service, and nursing staff were unclear about how to obtain IV medications under the new arrangement. Another resident was admitted with a right hip peri-prosthetic joint infection and had physician orders for Daptomycin and Ertapenem IV antibiotics. The resident did not receive the ordered IV antibiotics because the pharmacy was unable to deliver them, resulting in the resident being transferred back to the hospital the day after admission. Staff interviews confirmed that the facility was unable to secure IV antibiotics for this resident due to the change in pharmacy services, leading to missed doses and the need for hospital transfer.
Failure to Maintain Aerosol Contact Precautions and PPE Use for COVID-19 Positive Residents
Penalty
Summary
The facility failed to implement proper aerosol contact precautions for residents who tested positive for COVID-19. Observations revealed that doors to isolation rooms, which were required to remain closed per facility policy and posted signage, were found open on multiple occasions. Staff members, including nursing assistants, were observed entering and exiting these rooms without wearing the required personal protective equipment (PPE), such as N95 respirators, gowns, gloves, and face shields. Specifically, one staff member was seen wearing only a surgical mask while exiting a COVID-19 isolation room, contrary to the posted instructions and facility policy. Interviews with staff, including nursing assistants, LPNs, the unit manager, and the director of nursing, confirmed that the expectation was for doors to remain closed and for staff to use appropriate PPE when entering rooms under aerosol contact precautions. Documentation showed that two residents had tested positive for COVID-19 and were admitted to the transitional care unit with orders for isolation and appropriate PPE use. Despite these protocols, staff did not consistently follow the required infection prevention and control measures, as evidenced by both direct observation and staff admissions during interviews.
Failure to Provide Access to Required Survey Results and Plans of Correction
Penalty
Summary
The facility failed to ensure that the survey result binder included the most recent three years of recertification survey results and their associated plans of correction, as required by policy. Upon review, it was found that the binder only contained the 2024 annual recertification survey results and plan of correction, while the 2022 and 2023 survey results and their associated plans of correction were missing. This omission was confirmed during multiple reviews of the binder and through interviews with the Director of Nursing and the Administrator, both of whom acknowledged the absence of the required documents. The facility's policy mandates that copies of the most recent and three preceding years of standard surveys, including any follow-up reports and state-approved plans of correction, be accessible in an area frequented by residents, their representatives, and visitors. The lack of the 2022 and 2023 survey results and plans of correction in the binder prevented residents, their representatives, and visitors from exercising their right to review past survey results and the facility's responses to deficiencies.
Failure to Maintain Guardianship Documentation and Offer Advance Directives
Penalty
Summary
The facility failed to obtain and/or renew guardianship papers and did not offer or document assistance in formulating advance directives for three of four residents reviewed. For one resident with a diagnosis of unspecified intellectual disabilities, guardianship papers were found to be expired, and there was no clear assignment of responsibility among staff for ensuring these documents were current and available in the electronic health record (EHR). Interviews with staff revealed confusion about who was responsible for maintaining up-to-date guardianship documentation, and the administrator was unaware of the process. Another resident with intact cognition had no documentation in their EHR regarding advance directives, nor was there evidence that the topic was discussed or that assistance was offered. Staff confirmed that there was no record of such a discussion, despite facility policy requiring that residents be offered information and assistance with advance directives upon admission. A third resident, who was their own decision-maker, expressed interest in designating a Durable Power of Attorney (DPOA) for health care but reported that the facility did not request a copy of an advance directive or offer the option to establish one. The social worker acknowledged that a conversation with the resident’s contact about DPOA was not documented. The administrator confirmed that residents should be given the opportunity to delegate DPOA and that these directives should be documented and accessible, but this was not done for the resident in question.
Failure to Monitor and Document Psychotropic Medication Use
Penalty
Summary
The facility failed to ensure adequate monitoring and documentation for residents prescribed psychotropic medications, including antidepressants and antipsychotics. For one resident, an antidepressant was initiated and the dose increased, but there was no monitoring or documentation of target behaviors or potential adverse side effects in the Medication Administration Record (MAR). Staff confirmed that such monitoring and documentation were expected but missing from the records. Another resident had been on antipsychotic medication for an extended period, but the required Abnormal Involuntary Movement Scale (AIMS) assessment was completed late, exceeding the recommended six-month interval. The consultant pharmacist had previously advised the facility to document AIMS assessments every six months to remain compliant, but staff acknowledged that the assessment was overdue. Additional residents were also prescribed antipsychotic medications without evidence of monitoring for side effects or target behaviors in the physician's orders or MAR. Staff interviews confirmed that monitoring and documentation were expected for all residents on psychotropic medications, but these were not present in the records reviewed. The facility's policy required nursing staff to observe and document the effectiveness of interventions and monitor for side effects, but this was not consistently followed.
Failure to Develop and Implement Comprehensive Care Plans
Penalty
Summary
Multiple deficiencies were identified in the facility's development and implementation of comprehensive care plans for several residents. For nail care, a resident who required substantial assistance with personal hygiene was observed to have long, discolored, and unclean fingernails and toenails. Despite the resident's requests for help and staff acknowledgment of responsibility for nail care or referral to a podiatrist, there was no care plan addressing nail care, no documentation of podiatrist visits, and no evidence that nail care was provided. In the area of toileting hygiene, a resident dependent on staff for toileting and incontinent care reported not receiving assistance during the night shift, despite care plans specifying assistance every 2-3 hours and the resident's request to be woken for changes. Documentation showed frequent missing entries for toileting hygiene, and staff interviews confirmed that care was expected but not consistently documented or provided, with no records of resident refusal. Additional deficiencies included the lack of a care plan for bed positioning for a resident with a leg fracture and severe cognitive impairment, whose bed was placed against the wall without assessment or documentation of risks and benefits. Another resident with gastroparesis did not receive the prescribed small, frequent meals, and a resident with a broken tooth was not referred to dental services as indicated in their care plan. Furthermore, a resident with pain-related diagnoses had no pain management care plan, and a cognitively intact resident did not receive or have documentation of participation in activities as outlined in their care plan. These failures to develop and implement care plans resulted in unmet care needs for multiple residents.
Failure to Accurately Post Daily Nurse Staffing Information
Penalty
Summary
The facility failed to ensure that the daily nurse staffing form was accurately completed and posted with actual hours worked after the start of each shift for seven consecutive days. Observations revealed that the posted staffing forms only displayed planned hours and did not include the actual hours worked by staff, as required by the facility's own policy. The policy specified that the posting must include the facility name, current date, resident census, total number and actual hours worked by staff, and reflect staff absences due to callouts and illness for each shift. However, multiple observations on different days confirmed that the actual hours worked were not shown on the posted forms. Interviews with the staffing coordinator, DON, and administrator confirmed that the posted forms were missing a column for actual hours worked and that this information was not being displayed as expected. The staffing coordinator stated that planned hours, callouts, and illness were documented in the schedule book but not on the posted form. Both the DON and administrator acknowledged that the forms should have included the total number and actual hours worked per shift, but this was not being done. No information was provided regarding any specific residents affected or their medical conditions.
Failure to Complete and Document Monthly Medication Regimen Reviews
Penalty
Summary
The facility failed to ensure that monthly Medication Regimen Reviews (MRRs) were consistently completed and documented for several residents, as required by both facility policy and regulatory guidelines. For one resident, a pharmacist's recommendation to order a new Basic Metabolic Panel due to persistently high Blood Urea Nitrogen levels was not completed by the physician, and the corresponding form was not finalized or scanned into the resident's electronic health record (EHR). Staff interviews confirmed that the expected process for handling pharmacist recommendations was not followed, resulting in incomplete documentation and lack of physician response. Additionally, two other residents did not have documented MRRs for multiple months, with no records found in either the facility's MRR binder or the residents' EHRs for the specified periods. Despite written requests for additional documentation, staff were unable to provide evidence that the required monthly reviews had been performed. Both the administrator and the director of nursing acknowledged that MRRs should be completed monthly and available in the EHR, but the documentation was missing for the residents in question.
Expired Medications and Incomplete Refrigerator Temperature Monitoring
Penalty
Summary
Surveyors observed multiple instances where expired medications and medical supplies were not disposed of in a timely manner across several medication carts and storage rooms. Specifically, expired scalpels, dermal curettes, and wound care supplies were found in the medication storage room, and staff interviews confirmed these items should have been discarded. Additionally, expired medications such as Neomycin eye ointment, Milk of Magnesia, Hemoccult Sensa Developer, Sani-cloth bleach wipes, Bisacodyl suppositories, silver collagen wound gel, and Nitroglycerin tablets were found on various medication carts. Staff acknowledged that these items were expired and should have been removed according to facility policy, which requires the disposal or return of outdated drugs and supplies. Further deficiencies were identified in the monitoring and documentation of medication refrigerator temperatures. Temperature logs for the 500-unit medication room refrigerator showed missing daily entries for both May and June, contrary to staff expectations that temperatures should be checked and recorded daily. Staff interviews confirmed that the lack of daily monitoring was not in line with facility procedures. The facility's policy mandates that all drugs and biologicals be stored safely and securely, and that expired or discontinued items be promptly removed, but these standards were not consistently met as evidenced by the survey findings.
Failure to Properly Label, Date, and Discard Food Items
Penalty
Summary
Surveyors identified multiple failures in the facility's food handling and storage practices across various locations, including the kitchen dry storage room, several kitchen refrigerators, a seasoning shelf, and dining room refrigerators. Observations revealed that numerous food items, such as bread, condiments, dairy products, and prepared foods, were not labeled with expiration or use-by dates as required by facility policy. In several instances, opened food items were found without proper dating, and some items were past their use-by or expiration dates but had not been discarded. Staff interviews confirmed that the facility's process required food items removed from the freezer or opened to be labeled with the date and, when applicable, a use-by date. However, staff acknowledged that these procedures were not consistently followed. For example, bread removed from the freezer was not dated, and various condiments and dairy products in the refrigerators lacked use-by dates. Additionally, expired items such as Dijon mustard, cherry filling, ground coriander, cranberry juice, thickened apple juice, and a sandwich were found and had not been discarded as required. The facility's policies on food receiving, storage, and date marking were reviewed and clearly stated the need for labeling and timely discarding of food items. Despite these policies, the observed deficiencies placed residents at risk for foodborne illness and cross-contamination. The administrator confirmed that the expectation was for staff to regularly check, date, and discard food items as appropriate, but this was not consistently done.
Infection Control Deficiencies: Policy Review, Equipment Disinfection, and PPE Use
Penalty
Summary
The facility failed to ensure that its Infection Prevention and Control Program (IPCP) policies and procedures were reviewed annually as required. The Infection Control Program policy was last reviewed on 10/24/2022, despite the policy stating that reviews should occur at least annually. Interviews with the Infection Preventionist, Director of Nursing, and Administrator confirmed that the policy had not been reviewed within the required timeframe, even though all acknowledged the expectation for annual review. During observations, a resident with a diagnosis of obstructive uropathy and an ostomy was found lying in bed with their urinary catheter drainage bag touching the floor. Staff entering the room did not correct the issue, and the Certified Nursing Assistant (CNA) later admitted that the drainage bag should not have been on the floor but did not know how it happened. Both the Registered Nurse Unit Manager and the Director of Nursing confirmed that catheter drainage bags should not touch the floor, as this is an infection control issue. Additionally, staff failed to disinfect or sanitize medical equipment between resident use. A CNA was observed moving a sit-to-stand lift from one resident's room to another without cleaning or disinfecting it, only wiping the handle with an adult washcloth and not using the proper disinfectant wipes. Furthermore, staff did not consistently follow Enhanced Barrier Precautions (EBP) for residents on EBP, as staff were observed transferring residents without wearing the required gowns and gloves and, in one instance, not performing hand hygiene after care. Staff interviews confirmed that the expected protocols for PPE and equipment disinfection were not followed.
Failure to Inform Resident or Representative About Bed Positioning Risks and Benefits
Penalty
Summary
A deficiency occurred when the facility failed to inform a resident and/or their representative about the risks and benefits of positioning the resident's bed against the wall. The facility's policy requires that residents be fully informed of their health status and any changes in care or treatment, but review of the electronic health record (EHR) showed no evidence that the resident was assessed, evaluated, or informed regarding the bed's position. The resident in question had severe cognitive impairment, was unable to walk, and had limited range of motion in both lower legs. Multiple observations confirmed the bed was positioned against the wall on several occasions. Interviews with facility staff, including registered nurses and the Director of Nursing, revealed that there was no physician order for the bed's position and no documentation that the resident or their representative had been informed or involved in the decision. Staff acknowledged that the expected process of assessment, evaluation, and communication regarding the bed's position had not occurred for this resident.
Failure to Honor Resident Bathing Preferences
Penalty
Summary
The facility failed to honor and facilitate resident choices and preferences regarding showering and bathing for two residents reviewed for Activities of Daily Living (ADLs). Facility policy required that residents be offered at least two full baths or showers per week, with their preferences for type and frequency of bathing to be considered and honored. However, documentation and interviews revealed that these preferences were not consistently followed. One resident with moderate cognitive impairment had a care plan indicating a preference for showers twice a week. Review of ADL records showed that this resident received a combination of bed baths and tub baths, and did not receive showers as preferred, with at least one week where no shower was provided and no refusal was documented. Staff interviews confirmed that the resident's preference for twice-weekly showers was not met, often due to staffing issues and the absence of a regular shower aide. Another resident with intact cognition also had a care plan specifying a preference for bathing twice a week. ADL records indicated that this resident did not receive a bath or shower during a specific week and only had one tub bath the following week, with no refusals documented. Staff interviews corroborated that the resident's bathing preferences were not honored as outlined in their care plan, and that changes in management and staff assignments contributed to the inconsistency in providing preferred bathing routines.
Failure to Ensure Privacy During Provider Visits
Penalty
Summary
The facility failed to maintain privacy and confidentiality of medical information during provider visits for two residents. Observations showed that an Advanced Registered Nurse Practitioner (ARNP) conducted medical discussions with one resident in the Memory Care Unit (MCU) TV room, a common area where other residents were present. The ARNP discussed specific medical conditions and laboratory results with the resident in this public setting. Staff interviews confirmed that the visit occurred in a common area and that privacy was not provided, contrary to facility expectations. A second resident was seen by the same ARNP while seated on a bench between the MCU nurse's station and dining room, another public area. The ARNP asked about specific medical conditions and attempted a physical assessment in this location. Staff interviews again confirmed that the visit was not conducted in private and that the expectation was for such visits to occur in a private setting. The Director of Nursing also acknowledged that provider visits should be conducted privately.
Failure to Conduct Thorough Abuse Investigation
Penalty
Summary
The facility failed to conduct a thorough investigation into an allegation of abuse made by a resident. The resident reported concerns about inadequate resources, such as running out of trash bags, briefs, moisturizers, and wipes, and expressed the belief that this constituted a form of elder abuse. The facility's investigation included notifying the state agency, informing the administrator and DON, interviewing the resident, revising the care plan, reviewing supply invoices, and checking supply rooms for adequate stock. However, the investigation report did not include interviews with other residents or staff members. During a subsequent interview, the administrator acknowledged that the investigation was not as thorough as usual and confirmed that interviews with other residents and staff were not documented or conducted. This incomplete investigation did not meet the facility's policy or regulatory requirements for a systematic and comprehensive review of abuse allegations.
Late Completion of Significant Change in Status Assessment After Hospice Discharge
Penalty
Summary
The facility failed to timely complete a Significant Change in Status Assessment (SCSA) Minimum Data Set (MDS) for one resident following a significant change in condition, specifically after the resident was discharged from hospice services. According to the Long-Term Care Resident Assessment Instrument (RAI) 3.0 User's Manual, an SCSA MDS must be completed within 14 days of a resident revoking hospice benefits. In this case, the resident was discharged from hospice, but the SCSA MDS was completed 13 days late, exceeding the required timeframe. Record reviews and staff interviews confirmed that the MDS coordinator was responsible for updating the SCSA MDS after such significant changes. Both the Registered Nurse and the MDS Coordinator acknowledged that the assessment was not completed within the required period. The Director of Nursing also confirmed that the assessment was late, which did not meet the facility's expectations for timely completion of MDS assessments.
Inaccurate MDS Assessments for Medications, Oral Status, and Hospice Care
Penalty
Summary
The facility failed to ensure accurate completion of the Minimum Data Set (MDS) assessments for three residents, resulting in deficiencies related to oral/dental status, medication use, and hospice care. For one resident, the quarterly MDS indicated the use of an antidepressant medication during the seven-day look-back period, but the Medication Administration Record (MAR) showed the antidepressant had been discontinued and was last administered prior to the assessment period. The MDS Registered Nurse acknowledged that Section N was not coded accurately based on the resident's actual medication administration. Another resident's admission MDS failed to indicate that the individual was edentulous, despite both a nutritional risk assessment and direct observation confirming the absence of natural teeth. The MDS nurse stated that Section L should have been coded to reflect the resident's edentulous status, as supported by documentation and resident interview. The Director of Nursing confirmed the expectation that MDS assessments be completed accurately. A third resident's quarterly MDS was marked to indicate receipt of hospice care, but a review of physician orders and the electronic health record did not show any documentation of hospice services. Staff interviews confirmed that the resident was not under a hospice program but was instead receiving comfort care. The MDS nurse acknowledged that hospice care should not have been marked in the assessment. The Director of Nursing reiterated the facility's expectation for accurate MDS coding.
Deficient PASARR Screening and Documentation for Residents with Mental Health Needs
Penalty
Summary
The facility failed to ensure proper completion and documentation of the Preadmission Screening and Resident Review (PASARR) process for two residents. For one resident, the Level I PASARR was marked as 'No level II evaluation indicated at this time due to exempted hospital discharge,' with a note that a Level II must be completed if discharge does not occur. Despite the resident remaining in the facility for more than 30 days, no new Level I PASARR was completed as required. Staff interviews confirmed that a new Level I PASARR should have been completed after the 30-day stay, but it was not found in the resident's electronic health record. For another resident, a Level I PASARR identified a diagnosis of mood disorders and a recent decline in mood, indicating the need for a Level II PASARR referral. Although staff stated that a referral was made, there was no documentation in the electronic health record to confirm that the referral was sent. The facility's policy requires that all new admissions and readmissions be screened for mental disorders, intellectual disabilities, or related disorders, and that referrals for Level II evaluations be made when indicated by the Level I screen. The lack of documentation and failure to complete required screenings resulted in deficiencies in the PASARR process for both residents.
Failure to Notify PASARR Coordinator After Significant Change in Condition
Penalty
Summary
The facility failed to notify the State PASARR Coordinator or appropriate mental health authority after residents with mental disorders or intellectual disabilities experienced a significant change in condition. For three residents reviewed, documentation and interviews confirmed that required referrals for PASARR Level II evaluations were either delayed or not completed at all. In one case, a resident with major depressive disorder and PTSD was discharged from hospice, which constituted a significant change, but the referral to the PASARR Coordinator was not made promptly. Staff interviews confirmed the delay and acknowledged the expectation for timely notification. Another resident with anxiety disorder and major depressive disorder had a Level I PASARR indicating the need for a Level II referral upon significant change, but there was no evidence of a completed Level II evaluation or timely follow-up with the PASARR Coordinator. Additionally, a resident with bipolar disorder had a significant change in status, but no new or updated PASARR was completed, and the Coordinator was not notified. Staff interviews consistently revealed lapses in following the required notification and referral process after significant changes in condition for residents with mental health or intellectual disability diagnoses.
Failure to Timely Revise Care Plans for Changes in Hospice, Comfort Care, and Medication
Penalty
Summary
The facility failed to ensure that care plans were revised in a timely and accurate manner to reflect significant changes in residents' care, including discontinuation of hospice services, initiation of comfort care, and discontinuation of medication. For one resident, the care plan continued to indicate enrollment in hospice for end-of-life care even after hospice services had been discontinued, as confirmed by both nursing staff and the DON. Another resident's care plan inaccurately stated that the resident was receiving a low dose of antidepressant medication, despite the medication having been discontinued and no current physician order for it. Staff interviews confirmed that the care plan had not been updated to reflect this change. Additionally, a third resident who had transitioned to an end-of-life comfort care program did not have this change reflected in their care plan. Staff interviews and record reviews confirmed that the care plan lacked documentation of comfort care or end-of-life goals and treatments. In each case, staff acknowledged that the care plans should have been updated promptly to reflect the residents' current status and care needs, but this was not done.
Failure to Provide and Document Resident Activity Program
Penalty
Summary
The facility failed to provide an ongoing activity program to meet the needs of a resident who was cognitively intact and had expressed preferences for specific activities, such as listening to music, keeping up with the news, engaging in favorite activities, and going outside for fresh air. Despite the facility's policy requiring daily activities and resident involvement in planning and participation, observations and interviews revealed that the resident did not have access to leisure activity supplies in their room and was not participating in group or individual activities as outlined in their care plan. The resident reported not being offered activities and only going outside once with a visitor. Record reviews showed a lack of documentation regarding the resident's participation or refusal of activities, contrary to facility policy and staff expectations. The Activities Director acknowledged that the resident was not attending group activities and had not received one-on-one visits as planned. The Administrator confirmed that activities should have been offered and documented for each instance of participation or refusal, but this was not done for the resident in question.
Failure to Assess and Treat Skin Injuries and Monitor Weights for Residents on Diuretics
Penalty
Summary
The facility failed to perform appropriate skin evaluations and implement necessary monitoring and treatment for a resident who sustained skin injuries. One resident was observed with multiple scabs on their knees and shins, which were not being treated. Staff interviews revealed that the injuries were not documented in the resident's weekly skin assessments, and nursing staff were unaware of the injuries. The facility's protocol required that all skin injuries be documented, reported to the provider and family, and treated according to physician orders, but these steps were not followed for this resident. Additionally, the facility did not monitor and obtain daily weights for another resident who was on diuretic therapy. Documentation showed that daily weights were missing for several consecutive days, despite the resident receiving two diuretic medications. Staff confirmed that daily weights should have been recorded for residents on diuretics, but this was not done. These failures were identified through observation, interviews, and record reviews.
Failure to Provide Prescribed Therapeutic Diet for Resident with Gastroparesis
Penalty
Summary
The facility failed to follow a prescribed therapeutic diet of small, portioned meals for a resident diagnosed with gastroparesis and Type I diabetes mellitus. The resident's care plan and electronic health record (EHR) included clear instructions for small, frequent meals—specifically, 4-5 small meals per day and a small particle diet. Despite these orders, multiple observations showed the resident consistently received regular-sized meal portions, and staff interviews confirmed that the resident was not provided with the prescribed small portions. The dietary manager also confirmed that the meal slip did not indicate the need for small-portioned meals, and the kitchen provided regular servings. The resident experienced a significant weight loss of more than five percent within one month, as documented in the EHR. Staff, including a registered dietician and the director of nursing, acknowledged that the resident should have been receiving small, frequent meals in accordance with their care plan and medical needs. The failure to provide the prescribed therapeutic diet was confirmed through observation, record review, and staff interviews, with no evidence that the dietary orders were being followed.
Failure to Properly Store, Label, and Document Respiratory Care Equipment and Monitoring
Penalty
Summary
Facility staff failed to ensure proper storage and labeling of respiratory equipment and did not consistently document oxygen saturation levels as ordered for a resident with chronic obstructive pulmonary disease and acute hypoxic respiratory failure. Observations revealed that the resident's oxygen humidifier bottle was repeatedly found undated and unlabeled on multiple occasions. The BiPAP tubing nose piece and nasal cannula were observed not properly stored, with the nasal cannula found laying on the floor several times. Staff interviews confirmed that the equipment should have been labeled, dated, and stored in a clean manner, such as in a clear plastic bag when not in use, but these practices were not followed. Additionally, review of the resident's medical records showed missing documentation of required oxygen saturation checks during several night shifts, despite a physician's order to monitor and record these values each shift. Staff acknowledged the expectation to document oxygen saturation per the physician's order and to maintain proper storage and labeling of respiratory equipment, but these procedures were not consistently implemented for the resident.
Failure to Administer and Clarify Physician-Ordered Medications as Prescribed
Penalty
Summary
The facility failed to ensure that physician orders for medication administration were followed and/or clarified in accordance with professional standards of practice for three residents. For one resident, the physician order specified administration of Calcium 600+D3 (Calcium Carbonate-Cholecalciferol) 600-10 mg-mcg once daily, but staff administered Citracal + D (Calcium citrate-Vitamin D3) 315 mg-250 IU instead. This was observed during medication administration, and both the nurse and the unit manager confirmed that the medication given did not match the physician's order in terms of both formulation and dosage. For two other residents, physician orders required administration of Calcium Carbonate-Vitamin D Oral Tablet 600-5 mg-mcg, but staff administered Caltrate + D (Calcium Carbonate-Vitamin D3) 600 mg-400 IU, which did not match the prescribed dosage of Vitamin D. Both the LPN and the unit manager acknowledged that the medications administered differed from the physician's orders and that clarification with the physician and pharmacist should have occurred prior to administration. The facility's in-house pharmacy dispensed the medications that did not match the physician orders, and the consultant pharmacist confirmed that the orders should have been clarified with the physician before dispensing. The Director of Nursing also stated that staff were expected to clarify medication orders with the physician and that the pharmacist was expected to dispense medications as prescribed.
Failure to Refer Resident for Dental Services After Broken Tooth
Penalty
Summary
The facility failed to ensure that dental services were offered or provided to a resident who had a broken tooth. The resident's representative notified facility staff about the broken tooth, but there was no documentation or evidence that the resident was referred to dental services. Staff interviews confirmed that both nursing and social services staff were aware of the broken tooth but did not initiate a referral, with some staff stating that a referral was not made because the resident was not experiencing discomfort. The facility's policy required routine and emergency dental services to be available in accordance with the resident's assessment and plan of care, including referrals to community dentists or other dental providers. Observations showed the resident had difficulty chewing food, which was corroborated by the resident's own statements about the challenges of eating due to the broken tooth. Multiple staff members, including the Director of Nursing, acknowledged that a referral should have been made for the broken tooth, but no such referral or documentation was found. The lack of action resulted in the resident not receiving necessary dental care as required by facility policy.
Failure to Honor Resident Meal Preferences
Penalty
Summary
The facility failed to honor and provide meal preferences for two residents with intact cognition, as evidenced by direct observations, interviews, and record reviews. One resident consistently marked their menu selection to indicate disliked items and circled preferred foods, but the kitchen staff did not follow these preferences, resulting in the resident receiving unwanted food items. Both a Certified Nursing Assistant and a Licensed Practical Nurse confirmed that the resident's menu choices were not followed, and the resident expressed annoyance and dissatisfaction with the meals provided. Another resident reported not always receiving their menu or the food they requested, and was observed receiving a tuna sandwich that did not match their specific request. The resident became upset and teary-eyed, stating that the sandwich was not prepared as requested, and staff confirmed that the resident's preferences were not honored. Multiple staff members, including the Dietary Manager, Registered Nurse, and Director of Nursing, acknowledged that the residents' meal choices and preferences should have been followed, but were not in these instances.
Incomplete and Inaccurate Medical Record Documentation for Resident
Penalty
Summary
The facility failed to ensure that clinical and medical records were complete and accurate for one resident. Review of the resident's face sheet and Minimum Data Set indicated admission and a completed death assessment, but there was no documentation in the nursing progress notes or electronic health record regarding the resident's clinical status or condition on the relevant date. Vital signs, including blood pressure, heart rate, and breathing rate, were last documented prior to the date in question, and there was no record of these measurements on the day the resident left the facility for a planned diagnostic procedure. Interviews with the LPN assigned to the resident and the Director of Nursing confirmed the absence of documentation regarding the resident's clinical status, the planned medical appointment, or the resident's departure from the facility. The Director of Nursing acknowledged that there was no documentation about the resident's clinical status or death in the medical record, and that such documentation was expected. The lack of documentation resulted in incomplete and inaccurate medical records for the resident.
Failure to Offer and Document Influenza and Pneumococcal Vaccinations
Penalty
Summary
The facility failed to ensure that the pneumococcal and influenza vaccines were offered to a resident, as required by policy and regulation. Review of the resident's immunization record showed that the resident had received an influenza vaccine in the previous year and a pneumococcal vaccine dose several years prior, but there was no documentation that the annual influenza vaccine or the most current pneumococcal vaccine was offered or administered. Additionally, there was no evidence in the electronic health record that the resident was informed about the risks and benefits of these vaccines or that any refusal was documented. Interviews with facility staff, including the Infection Preventionist, RN Unit Manager, Consultant Pharmacist, and Director of Nursing, revealed inconsistent practices and a lack of documentation regarding vaccine offers, administration, and consent. Staff were unable to locate records of vaccine offers, refusals, or administration for the resident in question, and the state immunization database indicated the resident was past due for both vaccines. The facility's policies required that vaccines be offered and documented, but these procedures were not followed for the resident reviewed.
Facility Assessment Lacked Contingency and Staffing Plans
Penalty
Summary
The facility failed to update its facility-wide assessment to include a contingency plan and strategies for maximizing direct care staff recruitment and retention. Review of the facility's assessment document, last updated on 04/25/2025, showed that it did not contain documentation of these required elements. During an interview, the Administrator confirmed that the contingency plan and staff recruitment and retention plans were not referenced in the most recent assessment.
Failure to Supervise Resident at Risk for Elopement
Penalty
Summary
The facility failed to provide necessary supervision to prevent an elopement for one resident who was assessed as being at risk for wandering and elopement. The resident, who had impaired memory and required assistance to walk safely, was documented as wandering in the nursing unit and was redirected from the front desk/lobby area twice by staff. Despite these interventions, the resident was not observed on the unit, and it was discovered that they had exited the facility through the front door and were seen walking on a busy street outside. The resident was found approximately a block away from the facility. Interviews with staff and review of records confirmed that the resident had a history of wandering and elopement risk, as indicated in the initial admission elopement risk assessment. Staff acknowledged that the resident did not receive the level of supervision required to prevent them from leaving the building. The facility's elopement policy required assessment for exit-seeking and wandering behaviors, but the necessary supervision was not maintained, resulting in the resident's unsupervised exit.
Failure to Provide Timely ADL Assistance for Dependent Residents
Penalty
Summary
The facility failed to provide timely and necessary assistance with activities of daily living (ADLs) for two residents who were dependent on staff for care. One resident, with impaired thinking and memory, was found in a wet environment after their brief had been changed but the bed remained soaked with urine, indicating incomplete care. Staff interviews confirmed that the resident had not been changed for a while and was soaked through to the bed linens. The resident's care plan documented total dependence on staff for toileting and incontinence care. Another resident, also dependent on staff for all ADLs and with moderately impaired thinking, was left in soiled clothing and bed linen after vomiting, and was not changed for a significant amount of time. Staff interviews revealed that while rounds were conducted, the frequency and thoroughness of care varied depending on the resident's needs. The Director of Nursing Services acknowledged that the nursing staff did not meet the care needs of these residents, as required by their care plans and facility policy.
Failure to Maintain Resident Dignity
Penalty
Summary
The facility failed to maintain and promote resident dignity in several instances. Staff O, a Certified Nursing Assistant (CNA), entered Resident 34's room without knocking or identifying themselves, which was against the facility's policy. Both Staff H, a Registered Nurse (RN), and Staff B, the Director of Nursing Services, confirmed that staff are expected to knock, introduce themselves, and ask for permission before entering a resident's room. This failure to follow protocol compromised Resident 34's right to privacy and dignity. The facility also failed to ensure the privacy of residents using urinary catheters. Resident 110's catheter bag was observed multiple times with the bottom exposed and visible from the hallway, and it was even touching the ground. Staff J, a CNA, and Staff H acknowledged that the catheter bag covers were inadequate for privacy. Similarly, Resident 17's urinary catheter bag was visible to their roommate and from the hallway, and Staff Q, an RN, confirmed that it should have been covered. Staff B reiterated that catheter bags should be covered to maintain resident privacy. Additionally, the facility did not properly manage the use of mechanical lift slings and meal assistance. Resident 99 was observed sitting on a mechanical lift sling left underneath them, which Staff O and Staff EEE admitted was due to the difficulty of reapplying the sling. Staff GGG, an RN, and Staff B confirmed that the sling should have been removed after the transfer. Furthermore, staff were observed standing while assisting residents with meals, including Residents 99, 46, and 16, which is against the facility's policy. Staff PP, a Resident Care Manager, and Staff B stated that staff should be seated at eye level when assisting residents with meals to maintain dignity and provide proper care.
Failure to Obtain Informed Consent for Safety Devices and Medications
Penalty
Summary
The facility failed to inform residents and/or their representatives of the risks and benefits before implementing certain safety devices and treatments. Specifically, two residents had their beds placed against the wall without documented consent or an explanation of risks and benefits. One resident expressed that they liked their bed against the wall, while another stated that no one asked for their consent. Staff interviews confirmed that assessments and consents were required but were not documented in the residents' clinical records. Additionally, a resident was observed using a tilt-in-space wheelchair without documented consent or an explanation of risks and benefits. Staff interviews revealed that an assessment, physician order, and consent should have been obtained before the use of the wheelchair, but these were not found in the resident's clinical records. Another resident used a transfer pole daily for mobility, but there was no documented consent for its use, as confirmed by staff during interviews and record reviews. Lastly, a resident was administered a psychoactive medication, sertraline, without a signed consent form. Although verbal consent was initially obtained from the resident's representative, the signed consent was not documented in the medical records. Staff interviews confirmed that a signed consent should have been obtained as soon as possible after the verbal consent. These failures placed the residents at risk of not being fully informed before making decisions regarding their healthcare and treatment options.
Failure to Review Resident Rights Periodically
Penalty
Summary
The facility failed to periodically review resident rights with residents during their stay for all 16 residents reviewed. This was evidenced by the absence of resident rights discussions in the Resident Council minutes from February 2023 to April 2024. Interviews with residents confirmed that staff did not review their rights with them. The Social Worker acknowledged that resident rights were not reviewed during Resident Council meetings and could not recall the last time it was done. The Administrator admitted that resident rights should be reviewed yearly and noted that it used to be part of the Resident Council meeting agenda in the past.
Failure to Update Ombudsman Contact Information
Penalty
Summary
The facility failed to provide the website address of the Washington State Long-Term Care Ombudsman on the posted contact information in seven facility areas, including notice boards in units 100, 300, 400, 500, 600, 700, and inside one elevator. Observations on multiple occasions showed that the posted information lacked the website address. During a joint observation and interview with the Administrator, it was confirmed that the contact information had not been updated recently, and the Administrator acknowledged that it should have been updated at least annually. This deficiency was identified based on observation, interview, and record review, and it placed residents at risk of not being able to report their concerns online to the State Long-Term Care Ombudsman.
Failure to Maintain Resident Privacy and Confidentiality
Penalty
Summary
The facility failed to maintain the privacy and confidentiality of residents' personal and medical information. Observations revealed that residents' weights were posted on pieces of paper outside the shower room on the 300 unit, making this private information visible to anyone passing by. Staff members, including a CNA, Resident Care Manager, and the Director of Nursing Services, acknowledged that this information should not have been publicly displayed in the hallway. Additionally, a computer screen displaying a resident's Medical Administration Record (MAR) was left unattended and visible in the hallway, further compromising resident privacy. In another instance, the facility did not ensure the privacy of residents' representatives' contact information. Observations showed that the names and phone numbers of Resident 17's representatives were posted on a whiteboard above the sink, visible to the roommate and from the hallway. Similarly, Resident 16 had family members' names and phone numbers posted on the wall by their bed and sink, which were also visible from the hallway. Staff members admitted that this information should have been placed in a more private location within the residents' rooms. Lastly, the facility failed to provide privacy during the administration of medication. Resident 100 had a Lidocaine patch applied to their lower back in the dining room, exposing their back in the presence of other staff and residents. Although the resident had requested the patch be applied in the dining room, staff acknowledged that treatments should be conducted in private settings. These incidents collectively demonstrate a failure to uphold the privacy and confidentiality standards expected in the care of residents.
Latest citations in Washington
Inaccurate PASARR screening affected two residents. One resident with vascular dementia, depression, and adjustment disorder had a PASARR level one that did not reflect mental health diagnoses, and staff stated it was inaccurate. Another resident with PTSD had a PASARR level one that did not include the PTSD diagnosis, with no additional PASARR level one or level two found in the EHR; staff stated the screening was not accurate and should have been repeated.
Undated open meds were found on 2 medication carts, including an open insulin vial and multiple open eye drop bottles with no dates. An LPN and an RN both stated the items should have been dated when opened, and the DON stated open multidose vials or bottles found without a date should be discarded immediately.
A resident with respiratory failure, HTN, and anxiety became SOB and diaphoretic, received a breathing tx, and was sent by EMS to the hospital. The facility could not locate the required SNF/NF to Hospital Transfer form or other transfer records showing what information was communicated to the receiving provider.
Care plans for two residents were not updated to match their current status and care needs. One resident had PTSD and generalized anxiety disorder and was receiving a psychotropic medication, but the care plan listed monitoring for antipsychotic and anticonvulsant meds that were not prescribed and did not include the anxiety diagnosis or related behaviors and interventions. Another resident had new upper and lower dentures, but the oral/dental care plan only noted edentulous status and difficulty chewing, with no mention of dentures or denture-related interventions.
Failure to Provide Individualized Activities: A resident with anxiety, depression, and weakness was cognitively intact but said they could not attend group activities because of leg problems and wanted more in-room activities. The resident mostly stayed in bed watching TV, and staff documentation showed only limited room visits with no consistent activity documentation despite a care plan goal for participation two to three times per week.
Failure to maintain heel offloading for a resident with a reopened DFU. A resident with dementia and dependence for mobility had a left heel wound that had healed and then reopened; the wound care provider recommended heel floating and pressure relieving boots at all times, but observations showed the resident in bed with heels on the mattress and later reclined in a wheelchair with the heel resting on the footrest strap and no boots in place. Staff stated the resident had not refused the boots or heel floating, and the care plan was not updated after the wound reopened.
Failure to Address Hearing and Vision Services for a Resident: A resident with dementia, bilateral hearing loss, and impaired vision was observed without eyeglasses or a hearing device, despite records showing admission with eyeglasses and a personal sound amplifier. The care plan addressed vision only and did not include hearing-related interventions, while staff interviews confirmed the resident’s hearing was strained and that the resident’s device use and vision needs were not fully reflected in the plan of care.
Respiratory care was not provided consistently for two residents receiving O2. One resident with COPD and chronic respiratory failure had an O2 order missing the indication for use and Sats parameters, no MAR documentation of O2 therapy, and inconsistent Sats charting. Another resident with respiratory failure was observed on continuous O2 via NC, but provider orders for O2 therapy and tubing changes were not present after readmission, despite the care plan stating the resident was dependent on O2.
A resident with dementia, hearing loss, and missing lower teeth had an MDS showing obvious or likely cavities or broken natural teeth, and the care plan identified oral/dental health problems with an intervention to coordinate dental care and transportation. Staff stated the resident’s dental needs were captured on the MDS, but no referral was made for dental services or follow-up with the dentist, and the DON said the lack of referral did not meet expectations.
Inaccurate Meal Intake Documentation: A resident with DM, dysphagia, and protein-calorie malnutrition was observed eating less than 25% of a meal, but the POC documented 76-100% intake. The CNA said the resident usually ate only 25-50% of meals and that intake was sometimes documented based on what a coworker reported. The LPN/RCM and DON stated meal intake should be documented accurately.
Inaccurate PASARR Screening for Two Residents
Penalty
Summary
The facility failed to ensure that two residents were screened for additional mental health supports through the PASARR process. Resident 97 was admitted with diagnoses including vascular dementia, depression, and adjustment disorder, and was able to make needs known. Review of the PASARR level one dated 04/10/2026 showed no mental health diagnoses and no need for a PASARR level two, even though the resident’s record included mental health diagnoses. During interview, the Regional Social Services staff and the Administrator stated the PASARR was inaccurate, needed modifications, and did not meet expectations. Resident 6 was admitted with diagnoses including heart failure, respiratory failure, and PTSD, and was able to make needs known. Review of the PASARR level one dated 03/30/2026 showed no serious mental illness indicators marked and no PASARR level two indicated, and the EHR contained no other documented PASARR level one or level two. The Social Services Director stated the hospital-provided PASARR was reviewed for accuracy and, if inaccurate, another level one would be completed, and stated this resident’s PASARR did not include PTSD and should have had another level one completed. The Administrator also stated the PASARR was not accurate and another level one needed to be conducted, but none could be located in the EHR.
Undated Open Medications on Medication Carts
Penalty
Summary
The facility failed to ensure proper storage and labeling of medications for 2 of 3 sampled medication carts reviewed for medication storage and labeling, including carts on the 400 and 500 halls. On the 500 hall medication cart, an open vial of insulin and an open bottle of eye drops were observed with no dates. During interview, an LPN stated that when an insulin vial or bottle of eye drops is opened, it should be dated immediately and said both items should have been dated upon opening; the LPN stated they would dispose of the undated vial and bottle. On the 400 hall medication cart, two open bottles of eye drops were observed with no dates. During interview, an RN stated both bottles should have been dated as soon as they were opened and said they would get new eye drops and dispose of the undated bottles. The DNS/RN stated that if an eye drop was opened it should have been dated immediately and that any open multidose vial or bottle found without a date should be discarded immediately.
Missing Hospital Transfer Documentation
Penalty
Summary
The facility failed to ensure hospital transfer documentation was completed for one resident who was transferred to the hospital after complaining of not being able to breathe and appearing diaphoretic. The resident had diagnoses of respiratory failure, high blood pressure, and anxiety disorder, and was able to make needs known. A breathing treatment was provided, and the provider agreed to send the resident out for further evaluation, after which emergency transportation took the resident to the hospital. Record review found no documentation showing what information was provided or communicated to the receiving facility for the transfer. Staff stated that transfer documentation should have included a SNF/NF to Hospital Transfer form, the resident's face sheet, and the medication and treatment administration records, but they were unable to locate documentation showing these items were completed or sent for the resident's hospital transfer.
Care plans did not reflect current diagnoses, medications, or denture status
Penalty
Summary
The facility failed to ensure that care plans were revised and accurately reflected residents’ current status and care needs for 2 of 21 sampled residents. Resident 6 was admitted with diagnoses including heart failure, respiratory failure, and PTSD, and was able to make needs known. The EHR showed Resident 6 also had generalized anxiety disorder and was receiving a psychotropic medication, but the current care plan dated 05/05/2026 documented monitoring for side effects of antipsychotic and anticonvulsant medications even though Resident 6 was not prescribed those medications. The care plan also identified PTSD but did not include generalized anxiety disorder or behaviors to monitor and interventions related to PTSD or anxiety disorder. Staff F, LPN/CC, stated the care plan did not accurately reflect the resident’s current status or prescribed medications, and Staff B, DNS, stated it did not meet expectations because it did not address the anxiety disorder or target behaviors and interventions. Resident 71 was admitted with diagnoses including PTSD, high blood pressure, and depression and was able to make needs known. Observation on 05/06/2026 showed a denture cup by the sink with the resident’s name on the lid and new upper and lower dentures dated 01/12/26. The resident stated the lower dentures did not fit well and that denture adhesive had been provided, but the dentures still did not fit right and the resident had not told staff yet. The focused oral/dental care plan, initiated on 06/23/2026, identified the resident as edentulous and having difficulty chewing, but did not show that the resident had dentures or include interventions related to denture use or maintenance. Staff E, CNA, stated they had not seen the resident wear dentures and were unaware of the new dentures, Staff C, LPN/CC, stated the care plan should have been updated when the dentures were obtained, and Staff B, DNS, stated the care plan should have reflected the dentures and interventions.
Failure to Provide Individualized Activities
Penalty
Summary
The facility failed to provide individualized activities for Resident 5, who was admitted with diagnoses including anxiety disorder, depression, and weakness. The admission MDS dated 01/14/2026 showed the resident was cognitively intact. During interviews on 05/03/2026 and 05/06/2026, Resident 5 stated they could not attend in-person activities because of their legs, wanted more activities to occupy them, mostly stayed in bed watching TV, and did not remember the last time activities staff visited to offer activities. The resident also stated activities staff would need to offer something they were able to do because they had difficulty doing some activities. The activities care plan dated 12/26/2026 showed a goal for Resident 5 to participate in activities two to three times per week. Progress notes documented one visit on 12/22/2026 to provide a welcome packet and encourage participation in daily activities, but no further activity documentation was found in the progress notes. Staff H stated room visits should include puzzles, arts and crafts, visiting, and chatting, and that documentation was placed in tasks, but the task record showed no documentation of activities for the past 30 days. Staff J stated paper documentation existed for room visits and that Resident 5 was on a list for room visits every Monday and Wednesday, while the room visit documentation showed only four visits on 01/26/2026, 02/06/2026, 03/10/2026, and 04/08/2026.
Failure to Maintain Heel Offloading for Reopened DFU
Penalty
Summary
The facility failed to consistently implement pressure reducing strategies for a resident with a left heel diabetic foot ulcer that had reopened. The resident was admitted with diagnoses including left hip fracture with surgical repair, a blood clot of the left lower leg, and dementia, and was dependent on staff for mobility and unable to make needs known. The baseline care plan and care plan both included heel offloading interventions, and the wound care provider initially recommended heel floating with pillows or wedge and pressure relieving boots. The wound later resolved, but a weekly skin assessment documented that the left heel wound reopened and was very painful to touch. After the wound reopened, the contracted wound care provider documented that the DFU to the left heel had reopened and recommended the resident wear pressure relieving boots at all times. The current care plan reviewed after the wound reopened did not include new interventions related to the reopened wound. Observations showed the resident seated in a reclined wheelchair with the left foot/heel resting on the footrest strap and no pressure relieving boots in place, and later lying in bed with both heels directly on the mattress without being floated and without boots. Staff interviews indicated the resident had not refused the boots or heel floating, and the LPN/CC and DON stated the resident should have been assessed and the plan of care updated when the wound reopened.
Failure to Address Resident Hearing and Vision Needs
Penalty
Summary
The facility failed to address one resident’s hearing and vision needs. Resident 112 was admitted with diagnoses including a leg fracture, dementia, and hearing loss in both ears, and was able to make needs known. The record showed the resident lost their glasses and was given readers, but the resident did not wear them because they were concerned that wearing glasses that were not their prescription would further degrade their vision. Observation did not show glasses in the resident’s room, and the resident stated they did not use a hearing aid. The resident was observed to be hard of hearing, requiring an elevated voice and repeated questions to understand. The admission MDS dated [DATE] documented adequate hearing with hearing aid and adequate vision with corrective lenses, while the significant change MDS dated [DATE] documented moderate difficulty hearing without a hearing aid and impaired vision without corrective lenses. The care plan initiated 02/24/2026 addressed impaired vision with interventions to arrange consultation with eye care practitioners as needed and remind the resident to wear glasses, but it did not include a focus area or interventions for hearing loss or use of hearing aids. A resident clothing list showed the resident admitted with one pair of eyeglasses and one Super Ear headset personal sound amplifier, yet observation and interview showed the resident in bed without eyeglasses or a hearing device, with the amplifier stored in the bedside table drawer. Staff interviews confirmed the resident’s hearing was strained, that the hearing device and glasses were not being used, and that the resident’s hearing device use should have been included in the plan of care and the resident should have been referred for eye care assessment.
Respiratory Care Orders and Documentation Not Maintained
Penalty
Summary
The facility failed to provide respiratory care consistent with professional standards of practice for two residents receiving oxygen therapy. One resident with COPD and chronic respiratory failure with hypoxia was observed multiple times lying in bed receiving oxygen at 2 L via nasal cannula. The resident’s oxygen order, dated 02/15/2026, allowed 1 to 4 L per minute continuously via nasal cannula, but it did not include an indication for use or oxygen saturation parameters. The April and May 2026 MARs did not show documentation of oxygen therapy being provided, and the TARs showed only an order to change oxygen tubing if damaged or visibly soiled, not an order for oxygen therapy. Oxygen saturations were not documented consistently daily from 04/01/2026 through 05/04/2026. A second resident with respiratory failure, high blood pressure, and anxiety disorder was observed in the room receiving oxygen at 6 L via nasal cannula on multiple occasions. The resident stated they needed oxygen therapy to breathe, and the care plan identified the resident as dependent on oxygen and to receive oxygen per provider orders. However, provider orders reviewed on 05/04/2026 showed no orders for oxygen therapy or for changing oxygen tubing. Staff stated the oxygen and tubing-change orders had been discontinued when the resident went to the hospital and were not added back to the MAR or TAR when the resident readmitted to the facility.
Failure to Refer Resident With Identified Dental Needs
Penalty
Summary
The facility failed to ensure that Resident 112 received needed dental care. Resident 112 was admitted with diagnoses including a leg fracture, dementia, and hearing loss in both ears. Observation on 05/03/2026 showed the resident had missing lower teeth. The admission MDS, dated [DATE], documented obvious or likely cavities or broken natural teeth, and the care plan dated 02/24/2026 identified oral/dental health problems related to likely cavities or broken teeth with an intervention to coordinate dental care and provide transportation. During interviews, Staff G, Regional Social Services, stated Resident 112's dental needs were captured on the 02/24/2026 MDS and the resident was not referred for dental services. Staff M, Social Services Director, stated residents with dental needs should be referred to social services to be scheduled for assessment by a dental care practitioner, and that Resident 112 should have been referred after the MDS assessment. Staff B, DON, stated residents with identified dental needs should be referred for follow-up with a dentist and that Resident 112 should have been referred to the in-house dental provider; Staff B stated the lack of referral did not meet expectations.
Inaccurate Meal Intake Documentation
Penalty
Summary
The facility failed to accurately document the amount of food eaten for Resident 13, who was admitted with diagnoses including diabetes mellitus, dysphagia, and protein-calorie malnutrition. The quarterly MDS dated 02/12/2026 showed the resident was moderately cognitively impaired. During observation on 05/05/2026 at 12:09 PM, a meal tray was delivered to the resident’s room, set up on a bedside table, and the resident was observed eating slowly, eating less than 25% of the meal, then laying back in bed and closing their eyes while the tray remained in the room. Staff later removed the tray, but the POC documentation for lunch on 05/05/2026 recorded that Resident 13 ate 76-100% of the meal. During interview, the CNA stated the resident typically ate 25-50% of meals and never ate all of the food, and that if they did not pick up a tray they would ask a coworker what the resident ate before documenting it. The CNA stated they were told the resident ate 75-100% of lunch, so that is what was entered. The LPN/RCM stated staff should document meal intake accurately in POC, and the RN/DNS stated it was their expectation that all staff document meal intake accurately.
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