Valley View Skilled Nursing And Rehabilitation
Inspection history, citations, penalties and survey trends for this long-term care facility in Renton, Washington.
- Location
- 4430 Talbot Road South, Renton, Washington 98055
- CMS Provider Number
- 505202
- Inspections on file
- 34
- Latest survey
- March 24, 2026
- Citations (last 12 mo.)
- 21
Citation history
Health deficiencies cited at Valley View Skilled Nursing And Rehabilitation during CMS and state inspections, most recent first.
Homelike Environment Deficiencies: The facility failed to maintain a homelike environment in resident rooms and the dining room. In the 100 Unit, wall gouges, missing and torn window screens, and other room damage were observed; in the 200 East Unit, a resident’s closet door and handle had dried dark red stains that the resident said had been reported weeks earlier; and the dining room was being used to store equipment and remodeling supplies, which the ADM stated did not contribute to a homelike environment.
Failure to complete discharge and transfer documentation: A resident who left AMA had no documentation of provider notification, discharge summary, medication or oxygen arrangements, home health services, or PCP follow-up scheduling. In addition, multiple residents transferred to the hospital had no documented nurse-to-nurse report to the receiving facility, and some had no documented bed hold offer or written transfer notice. Staff interviews confirmed the missing documentation.
PASRR screening was inaccurate for one resident when the Level 1 PASRR did not reflect the resident’s substance use history, despite hospital records showing Alcohol Use Disorder and the resident’s MDS showing TBI, cognitive communication deficit, and antidepressant use. PASRR Level 2 referrals were also missed for two residents whose records showed anxiety, depression, PTSD, and, for one resident, non-Alzheimer’s dementia; both had PASRR 1 screenings requiring PASRR 2, but no PASRR 2 was completed.
Incomplete and inaccurate pre/post HD assessments were documented for 3 residents receiving HD. The facility’s HD policy required ongoing assessment before and after treatment and no BP on an arm with HD access, but records showed missing HD site assessments, use of historical vitals and weights, and BP checks on an arm with access. Staff and the DON acknowledged the assessments were not completed accurately or timely.
Surveyors found multiple medication rooms, medication carts, and a treatment cart unsecured or improperly labeled. An unlocked medication cart and treatment cart were left unattended with medications, syringes, creams, wound products, and other supplies accessible, and several opened medications in storage rooms lacked resident names or opening dates. Staff stated carts should be locked when unattended and medications should be labeled for resident safety.
Hand hygiene, PPE, and linen handling failures were observed during resident care. An LPN and CNAs used the same gloves across dirty and clean tasks while providing ostomy, catheter, and incontinence care, and staff changed gloves without performing HH between tasks. Staff also failed to use a gown for a resident on EBP, another resident’s EBP status was not properly identified at the room, and clean linens in the laundry room dragged across the floor and shoes before being placed on a clean linen cart.
The facility failed to obtain valid informed consent for mobility bars, vaccines, and treatment for two residents. One resident had moderately impaired cognition and bed grab bars were used without documentation that risks and benefits were discussed with the resident or representative. Another resident had severe cognitive impairment and a physician-documented inability to make medical decisions, yet staff documented consent for vaccines and mobility bars without showing that the legal decision makers received education or provided consent.
A facility failed to keep care plans comprehensive and person-centered for three residents. One resident on HD had a care plan that did not identify where dialysis access devices were located, even though staff were taking BPs on either arm; another resident’s fall mat intervention remained in the care plan and Kardex after it was no longer needed; and a third resident’s care plan and Kardex did not describe required PT, OT, or SLP services, their frequency, or how staff should prepare the resident for therapy.
A resident with a neurological disorder and seizure disorder did not receive ordered bowel care when no BM occurred for 3 days, and the same resident was given PRN pain medication when pain scores were above the ordered range. In addition, a resident with a CVC had an overdue dressing change, and another resident with a rectal pressure injury did not receive ordered wound care during peri-care, with staff noting the ABD pad was not staying in place.
Failure to monitor skin changes and manage bowel meds: One resident with cognitive decline, poor circulation, and limited ROM had a weekly skin check order, but staff observed painful redness on the foot during care and the area was not documented on the skin assessment. A second resident who was dependent for care, always incontinent of bowel, tube fed, and had an open full-thickness coccyx wound had repeated loose stools, yet scheduled constipation meds were still given on those days despite care plan directions to monitor diarrhea and keep skin clean and dry.
A facility failed to keep resident areas free of accident hazards and to maintain current safety checks for three residents. One resident had fall mats inconsistently left in place after they were no longer needed, another had fabric wedged under the mattress that elevated and tilted the bed surface, and a third used an electric wheelchair seat belt without quarterly safety assessments of the device or the resident’s ability to self-release it.
A resident with severe pressure ulcers and limited mobility did not receive consistent monitoring of their air mattress, as required by their care plan. The air mattress was found deflated, and staff had no documentation or physician order to check its function prior to the incident, resulting in worsening skin condition.
Staff failed to cover ready-to-eat food items, left a dirty wash rag bin uncovered near a handwashing sink, and distributed uncovered meal trays without performing hand hygiene between residents. The meal cart used was also found to be dirty, and staff confirmed these practices were not isolated incidents. These actions violated the facility's food service policy and exposed residents to unsanitary conditions.
The facility's kitchen staff failed to maintain sanitary conditions, as observed during a survey. Staff neglected proper hand hygiene and glove use, leading to potential cross-contamination. Personal items were found in food preparation areas, and staff handled raw food and kitchen items without proper sanitation. Additionally, food temperatures were not adequately monitored, and soiled equipment was used during meal service, risking food-borne illnesses for residents.
The facility failed to provide newly admitted residents with timely information about their rights and services, as required. Three residents did not have their admission packets completed within the expected timeframe due to staffing changes, placing them at risk of not understanding their rights and services.
The facility failed to maintain a homelike environment in several areas, including resident rooms, the main dining room, and a shower room. Observations revealed issues such as non-latching doors, holes in floor tiles, missing window screens, exposed drywall, and a missing toilet. Cleanliness issues included dirty privacy curtains and strong urine odors. Staff acknowledged the importance of timely repairs, but limitations in authority to order supplies hindered prompt action, leaving residents at risk for a diminished quality of life.
The facility did not follow the dietician-approved menu and portion sizes during meal service, affecting three residents. All residents were served canned peach cobbler instead of fresh, and portion sizes were not adjusted for those on special diets. The Dietary Manager intervened to correct portion sizes, and the Regional Administrator stressed the importance of adhering to dietary guidelines.
The facility failed to prepare appetizing and palatable meals, leading to resident dissatisfaction and potential decreased nutritional intake. Observations showed food was placed on the steam table too early, resulting in poor quality meals. Residents expressed dissatisfaction, and staff confirmed the expectation for timely meal preparation was not met.
The facility failed to ensure arbitration agreements were explained to residents in a manner they understood, affecting three residents. Despite being alert and oriented, the residents were unaware of the agreements they signed, and staff interviews revealed a lack of proper communication. The admissions coordinator responsible for this process was no longer employed, leading to a disconnect in explaining the agreements' legal implications.
A resident reported a missing Grabber Reacher, an assistive device, to the nursing staff, but the facility failed to document and address the grievance promptly. Despite initial efforts to locate the item, the resident did not receive timely feedback or a suitable replacement, leading to frustration. Staff interviews revealed a lack of adherence to the grievance policy, which required formal documentation and investigation of grievances.
The facility did not report missing narcotics from the East 2 Narcotic Ledger to the SSA in a timely manner. Discrepancies included missing tablets and pages in the ledger. An LPN reported the issue to the Resident Care Manager and the DON, but the incident was not reported to the SSA. The DON later acknowledged the oversight and the importance of reporting to prevent further issues.
The facility failed to thoroughly investigate discrepancies in the East 2 narcotic ledger, including missing narcotics and torn-out pages. An LPN reported these issues to the DON, who conducted an incomplete audit and missed additional discrepancies. This oversight placed residents at risk for uncontrolled pain and potential misappropriation of medications.
The facility failed to provide timely written transfer/discharge notices to residents and their representatives, as required. Notices for two residents were left at the bedside, inaccessible during their hospital stay, and two other residents did not receive any documentation. Staff confirmed the lack of adherence to policy, risking uninformed transfers.
The facility failed to provide written bed-hold notices to residents or their representatives during hospital transfers, as required by policy. This affected multiple residents, with no documentation found to indicate that the notices were offered or provided. Interviews revealed confusion among staff about responsibility for issuing these notices.
The facility failed to update care plans for two residents, leading to inconsistent care and unmet needs. One resident's care plan was not updated to reflect a physician's order for fall prevention, while another's plan did not include requested vision services. Additionally, required care conferences were not conducted for two residents, limiting their participation in care planning.
The facility failed to assist three residents with ADLs, leading to poor hygiene and grooming. A resident with a leg amputation was not shaved regularly, another with a stroke was found with greasy hair and no shoes, and a third resident received fewer baths than scheduled. Staff did not document refusals or follow care plans, as confirmed by the DON and Resident Care Manager.
The facility failed to follow provider orders and care plans for several residents, leading to deficiencies in care. A resident requiring bed rails for mobility was observed without them, and another resident's oxygen was set incorrectly. A resident with dementia frequently refused meals and medications, but the care plan lacked specific interventions for these refusals. Additionally, the facility did not monitor and document bruises for residents as required.
A resident with impaired vision did not receive necessary assistive devices or an eye exam due to the facility's failure to schedule the appointment, despite multiple requests from the resident's representative. The responsible social worker left the facility without documenting the communication or scheduling the exam, resulting in unmet care needs.
Two residents in an LTC facility did not receive necessary care for pressure ulcers. One resident had an open area on the coccyx that staff failed to document and report, while another resident's refusal of compression wraps was not communicated to the provider. Additionally, a delay in receiving a prescribed dressing was not reported, leading to inadequate care and risk of skin condition deterioration.
The facility failed to ensure a safe environment by not properly storing chemicals, placing residents at risk. Observations showed unsecured insect killer spray in a cabinet, an unlocked housekeeping closet with cleaning chemicals, and an open utility room with no rinse foam cleanser. Staff interviews confirmed the improper storage, with some staff unable to access locked closets, leading to chemicals being placed in unsecured areas. The Regional Administrator acknowledged the policy breach, emphasizing the importance of locking up chemicals to prevent resident exposure.
The facility failed to maintain an accurate narcotic ledger, with discrepancies such as missing tablets and torn pages. An LPN reported these issues to the Resident Care Manager and DON, who instructed corrections but did not verify their completion. A pharmacy audit found no further discrepancies.
The facility failed to remove expired medications from two medication carts and a storage room, risking resident safety. Observations revealed expired medications and unclean conditions in the West 1 and East 2 carts, and numerous expired IV supplies in the East 2 storage room. Staff acknowledged their responsibility to maintain cleanliness and remove expired items, but these actions were not completed.
A resident in a LTC facility did not receive prompt dental services despite being dependent on staff for oral care and having no teeth or dentures. The resident's representative repeatedly requested a dental exam for dentures, but the facility failed to schedule it. The previous social worker did not document the requests or add the resident to the dentist list, and the facility canceled dental visits due to an outbreak.
The facility failed to protect the privacy and confidentiality of resident information for four residents. PHI was left visible and unattended on electronic devices for three residents, and communication regarding another resident's care was not documented. Staff acknowledged the importance of confidentiality but did not secure the information.
The facility failed to maintain an effective infection prevention and control program, with deficiencies including lack of Enhanced Barrier Precautions for residents with indwelling devices, inadequate cleaning of the shower room and ice machine, and failure to adhere to hand hygiene and transmission-based precautions. These lapses were observed in multiple instances, such as a resident returning from the hospital with a catheter not being placed on EBP, and a provider entering a resident's room without PPE.
The facility's pest control program was ineffective, leading to insects in resident rooms and common areas. A resident reported bugs disturbing their sleep, and staff acknowledged the issue, noting ineffective pest control services. Fruit flies were observed in the kitchen and dining areas, with staff seeking pest control assistance. This failure compromised the facility's environment.
The facility failed to submit complete and accurate staffing data to CMS for Q1 2024, as required by PBJ guidelines. Interviews revealed a lack of oversight and potential technical issues as contributing factors. The DON acknowledged responsibility for staffing levels, while the CEO and Administrator recognized the need for improved compliance oversight.
The facility failed to assess and document wound characteristics, monitor, and implement interventions to mitigate worsening of non-pressure skin issues for four residents. This led to unidentified wounds, worsening conditions, and lack of proper medical notifications.
Homelike Environment Deficiencies
Penalty
Summary
The facility failed to provide a safe, clean, comfortable, and homelike environment for residents in the 100 Unit, 200 East Unit, and the dining room. In the 100 Unit, observations showed significant wall gouges behind beds where the bed heads had scraped the walls, a missing flyscreen on one window, and a torn and frayed flyscreen on another window. Staff A, the Administrator, observed these conditions and stated the missing or torn screens did not prevent pests from entering if the window was open and were not homelike, and that the wall scrapes were not homelike and needed to be fixed. In the 200 East Unit, Resident 69’s room contained a white double closet with a dark red vertical line on one door and dried smears of dark red matter on the closet door handle. Resident 69 stated a previous roommate had blood and feces in the shared room and that the blood remained on the closet door, which they found gross and concerning because someone might touch it; they also stated they had reported it to managers, social workers, and nurses weeks earlier and nothing had been done. In the dining room, the narrower half of the space was being used to store facility equipment and remodeling supplies, including tables, a mannequin, a treatment cart, mechanical lifts, a pallet jack, steam table items, fall mats, foam spacers, bagged items, and pallets with supplies. Staff A stated this ad hoc storage did not contribute to a homelike environment.
Failure to Complete Discharge and Transfer Documentation
Penalty
Summary
The facility failed to properly prepare Resident 106 for discharge after the resident left against medical advice. Resident 106 was admitted with respiratory disease, heart failure, cancer, and kidney failure. The record showed a nurse progress note documenting discharge AMA on 12/28/2025, but there was no documentation that the provider was notified, no discharge summary offered or provided, and no documentation of arrangements for medications, oxygen therapy, or home health care services. The record also showed no documentation of a follow-up appointment being scheduled with Resident 106’s primary care provider. During interview and record review, the Resident Care Manager stated there was no documentation that the provider was notified of the AMA discharge and no documentation that prescriptions, medications, or oxygen were offered or arranged. The Resident Care Manager also stated there was no documentation that the PCP follow-up appointment was scheduled or that home health therapy was offered or arranged. The facility also failed to complete required transfer documentation for multiple residents sent to the hospital. Records for Residents 104, 24, 13, 2, 69, and 85 showed no documentation of report to the receiving hospital or receiving facility for their transfers, and Resident 2 also had no documentation of a bed hold being offered or a written transfer notification provided. Resident 8 and Resident 85 had no documentation that a bed hold was offered, and Resident 2 and Resident 85 had no documentation of a written transfer notice. Staff interviews confirmed the missing documentation and stated that nurse-to-nurse report, bed hold offers, and written transfer notices should have been completed.
PASRR Screening and Level 2 Referral Failures
Penalty
Summary
PASARR screening was inaccurate for one resident when the facility failed to ensure the Level 1 PASRR reflected the resident’s mental health conditions. The resident’s admission MDS showed a traumatic brain injury, cognitive communication deficit, and use of an antidepressant medication. The hospital history and physical documented a history of Alcohol Use Disorder, but the 01/26/2026 Level 1 PASRR flagged Serious Mental Illness indicators for mood and anxiety disorders and did not capture the resident’s substance use history. A corrected Level 1 PASRR was later submitted to include a Substance Use Disorder indicator. Staff stated the Admissions department reviewed PASRRs before admission, but did not review other hospital admission documentation to verify the information was accurate. PASRR Level 2 referrals were not completed timely for two residents whose records showed PASRR 1 screenings requiring PASRR 2 evaluations. One resident’s MDS listed anxiety, depression, and PTSD, and the record showed a PASRR 1 dated 03/26/2025 with a referral for PASRR 2, but no PASRR 2 was completed. Another resident’s MDS listed non-Alzheimer’s dementia, anxiety, depression, and PTSD, and the record showed a PASRR 1 dated 07/18/2025 with a referral for PASRR 2, but no PASRR 2 was completed. Staff reviewed both records and stated PASRR 2 was not completed and that timely follow-up on the referrals was not done, so they were missed.
Incomplete and inaccurate pre/post HD assessments
Penalty
Summary
Provide safe, appropriate dialysis care/services for residents who required hemodialysis was deficient because the facility did not ensure accurate and complete pre- and post-HD assessments for 3 of 3 residents reviewed for dialysis. The facility’s HD policy stated that residents were to receive ongoing assessment before and after dialysis and that blood pressures were not to be taken on the arm with an HD device. The deficiency involved Residents 86, 24, and 13, all of whom had ESRD and required HD treatment. For Resident 86, the record showed physician orders for pre/post HD assessments on Monday, Wednesday, and Friday treatment days and documented HD fistulas in the left arm, right arm, and right thigh. The resident’s HD care plan stated not to take blood pressure on limbs with an HD access device, but did not identify where the access devices were located. Review of multiple HD assessment forms showed they were inaccurate and/or incomplete. The resident stated staff checked blood pressure on either arm, and during observation staff took the resident’s blood pressure on the right arm. Staff later stated HD assessments should include checking fistula function, vital signs, and signs of bleeding, and that blood pressure should not be taken on a limb with HD access. The DON stated the pre/post HD assessments should have been completed completely, accurately, and timely but were not. For Residents 24 and 13, review of numerous pre/post HD assessment forms showed the assessments were incomplete and inaccurate. The forms did not show the HD site was assessed, and historical vital signs and weights were used instead of current pre/post HD measurements. Staff reviewed the records and stated the assessments were incomplete and inaccurate, and that staff were expected to obtain current vitals and weights and thoroughly assess the HD sites for function, location, bleeding, dressings, and signs of infection or complications.
Unlocked and Unlabeled Medications and Treatment Supplies
Penalty
Summary
The facility failed to ensure proper storage and labeling of medications in 2 of 4 medication rooms, 2 of 4 medication carts, and 1 of 4 treatment carts reviewed. In the [NAME] I unit medication cart, surveyors observed two loose pills in the top drawer, and later found the lower right drawer unlocked and unattended with no staff supervising it. That drawer contained a bottle of medicated laxative powder, syringes, smoking cessation patches, a tube of pain-relieving cream, testing kit packs, and scissors. Staff R stated the cart should be locked so no one could access it and that this was important to protect residents from access to medications. In the [NAME] I medication storage room, surveyors observed an open bottle of eye drops and an open bottle of pills that did not identify which resident they belonged to. In the [NAME] II medication storage room, surveyors observed a tube of pain-relieving cream, pain patches, and smoking cessation gum without resident names. The central medication cart was observed unlocked and unattended, and Staff P stated they forgot to lock it before leaving. The [NAME] II treatment cart was also observed unlocked with the key in the lock and no licensed staff nearby; its drawers contained medicated honey, pain-relieving creams, medicated shampoo, wound packing material, scissors, medicated wipes, antifungal creams, antimicrobial wound gel, antiseptic solution, wound cleansers, and surface cleaning wipes. Staff B stated nurses were expected to lock medication and treatment carts before walking away, and Staff F stated the treatment cart should be locked because residents should not have access to treatments and supplies.
Hand Hygiene, PPE, and Linen Handling Failures
Penalty
Summary
The facility failed to ensure appropriate hand hygiene and glove use during resident care for three residents. During care for a resident with an ileostomy, suprapubic catheter, and incontinence needs, an LPN used the same soiled gloves across multiple tasks, including wiping the ileostomy site, securing a new pouch, handling the suprapubic catheter tubing and bag, and cutting and inserting new catheter tubing without removing gloves or performing hand hygiene. A CNA assisting with brief care for the same resident also handled a clean brief while wearing the same gloves used for soiled care before removing gloves and performing hand hygiene. For another resident receiving incontinence care, CNAs removed soiled briefs and cleaned the resident’s skin, then continued with clean tasks such as applying a clean brief, adjusting clothing and bed linens, moving the bed, placing clean linens, bagging garbage, placing a sling, and dressing the resident while wearing the same gloves and without performing hand hygiene between dirty and clean tasks. For a third resident, two staff members provided incontinence care and handled urine-soaked linens, clean linens, wipes, disinfecting wipes, and the resident’s gown while repeatedly changing gloves without performing hand hygiene between tasks. One staff member also touched the door handle and retrieved disinfecting wipes while wearing gloves used to handle soiled linens. The facility also failed to ensure Enhanced Barrier Precautions were used as ordered and failed to prevent clean linens from contacting soiled surfaces. For one resident on EBP, a CNA removed soiled linens, wiped the mattress, and made the bed while wearing gloves but without a gown. For another resident with an EBP order related to indwelling medical devices and enteral nutrition, the room lacked a sign indicating EBP and PPE supplies at the entrance, and staff stated the resident should have been on EBP. In the laundry room, a laundry staff member folded clean sheets, fitted sheets, and gowns without using the folding table, allowing the linens to drag across the floor and the tops of the staff member’s shoes before being placed on the clean linen cart.
Failure to Obtain Valid Informed Consent for Mobility Bars, Vaccines, and Treatment
Penalty
Summary
The facility failed to ensure informed consents explaining the potential risks, benefits, and alternatives of bed mobility rails, vaccines, and treatment were obtained before use for two residents. For Resident 82, the 03/05/2026 MDS showed moderately impaired cognition, and the resident had diagnoses including heart failure and dementia. A 10/20/2025 Safety Device Assessment recommended grab bars to assist with bed mobility and transfers and promote independence, but the assessment did not show why the grab bars would not be a restraint or that the risks and benefits were discussed with the resident or their representative. On 03/18/2026, quarter rails were observed in place on the resident’s bed, and the resident was not able to speak to the specifics of their care. The DON reviewed the assessment and stated the risks and benefits should have been discussed but were not. For Resident 2, the admission MDS showed severe cognitive impairment and diagnoses including multiple fractures and developmental delay. A Capacity for Medical Decisions form signed on 11/03/2025 stated the resident was unable to comprehend the risks, benefits, and alternatives to medical decisions and had two family representatives as legal decision makers. Despite this, staff documented consent and education for a pneumonia vaccine and an RSV vaccine without showing who received the education or who provided consent. Progress notes showed staff attempted to contact the representatives for RSV vaccine consent, but the resident gave consent instead. Resident 2 also signed a Consent to Admission and Treatment form and an Informed Consent for Use of Mobility (Grab/Enabler) Bar form, even though staff stated the representative was the decision maker and documentation of representative education and consent for the mobility bars was not found.
Care Plans Missing Key Resident-Specific Details
Penalty
Summary
The facility failed to ensure care plans were comprehensive and person-centered for Resident 86, Resident 26, and Resident 5. Resident 86 was admitted with end stage renal disease, dependence on renal dialysis, and a history of kidney transplant failure, and was receiving hemodialysis. The hemodialysis care plan stated not to draw blood or take blood pressure on the arm with a graft, but it did not identify where Resident 86’s dialysis access devices were located, even though physician orders showed devices in the left arm, right arm, and right thigh. Staff interviews and observation showed blood pressures were taken on either arm, including the right arm during a pre-HD assessment, and staff stated the care plan and Kardex should identify the correct limb for blood pressure measurements. Resident 26’s fall-related care was also not accurately reflected. Although a physician order for fall mats on both sides of the bed had been discontinued and an interdisciplinary note stated the resident no longer required them, an observation showed fall mats still placed on both sides of the bed, and the fall risk care plan and Kardex still included the mats as an intervention. Resident 5 was dependent for ADLs, received nutrition through a feeding tube, and received PT, OT, and SLP therapy, but the comprehensive care plan and Kardex did not describe the therapies required, their schedule or frequency, or how nursing assistants should prepare the resident for therapy. Staff stated the care plans should reflect residents’ care needs and be comprehensive.
Bowel Care, Pain Medication, and Ordered Treatments Not Completed as Ordered
Penalty
Summary
The facility failed to administer bowel care in accordance with a physician order for a resident with a progressive neurological disorder and seizure disorder. The resident had an order from 12/23/2023 directing staff to give a laxative if there was no bowel movement for three days. Review of the resident’s ADL documentation showed no bowel movement from 02/25/2026 until 03/01/2026, but the MAR showed staff did not administer the laxative as ordered. Nursing notes showed the laxative was only offered on the fourth day without a bowel movement. The resident stated they had no concerns related to bowel care, and the DON confirmed staff should have offered the ordered laxative to prevent potential medical complications from constipation. The facility also administered pain medication outside the parameters of the physician order for the same resident. The resident’s MDS showed pain almost constantly, and physician orders included a narcotic pain patch every seven days and a non-narcotic pain medication every eight hours as needed for pain on a scale of one to five out of ten. The March 2026 MAR showed the non-narcotic pain medication was given on multiple occasions when the resident’s pain ratings were six or seven out of ten. The DON stated staff should have followed the order parameters and notified the physician when pain levels were above the ordered range. The facility failed to complete ordered treatments for a central venous catheter and a rectal pressure injury for two other residents. One resident had a CVC with an order to change the dressing every seven days, but observation showed the dressing remained dated 03/09/2026 when it should have been changed on 03/11/2026. Another resident had orders for treatment of a rectal pressure injury, including cleansing, applying medicated topical cream, and placing an ABD pad with every peri-care, yet observations showed soiled briefs, an open wound to the rectal opening, and no ABD pad in place during peri-care on multiple occasions. Staff stated the ABD pad was not staying in place and that the provider had not been notified for a new order.
Failure to Monitor Skin Changes and Manage Bowel Medications
Penalty
Summary
The facility failed to ensure appropriate treatment and care were provided according to orders, resident preferences, and goals for two residents. One resident with cognitive decline, poor circulation to the lower legs, and impaired range of motion had a physician order for weekly skin checks to identify new skin issues. During incontinent care, staff observed both legs contracted and turned to the right side of the bed, with the inside edge of the left foot and outside edge of the right foot resting directly on the mattress. The resident reported foot pain, and a reddened area was seen on the inner ball of the left foot below the great toe. The resident continued to report pain in the left foot on later observations, and the reddened area remained present. A licensed nurse later observed the left inner foot resting directly on the mattress and confirmed the reddened area, along with a second reddened area on the outside edge of the left foot. The nurse stated the physician should be notified, the areas should be monitored, and pressure-relieving measures needed to be implemented. However, the weekly skin assessment completed the next day did not document the redness on the left foot, and the nurse caring for the resident stated they were unaware of any new skin issues. A second resident, who was dependent for toileting and bed mobility, always incontinent of bowel, malnourished, and receiving nutrition through a feeding tube, had orders for two constipation medications twice daily. The resident also had an open full-thickness pressure wound on the coccyx and care plans directing staff to monitor and report diarrhea, clean the resident after each incontinence episode, and keep the skin clean and dry. Bowel charting documented loose stools on multiple dates, yet the constipation medications were still administered on those days. The DON stated that with a full-thickness open wound, loose stools could soil the dressing and wound, and that the constipation medication should have been held on those dates but was not.
Accident hazards and incomplete safety assessments
Penalty
Summary
The facility failed to ensure resident rooms were free of accident hazards and that safety interventions were kept current for three residents reviewed. The report states that this failure involved no longer needed safety interventions left in place or removed inconsistently, a mattress that was not positioned correctly on its bed frame, and periodic safety assessments that were not completed as expected. The deficiency was identified through observations, interviews, and record review. For one resident with impaired vision, intact cognition, incontinence, and a history of a fall, the record showed prior orders and care plan interventions for fall mats on both sides of the bed when unattended. After a witnessed assisted fall during therapy, documentation stated the resident no longer needed floor mats and that they should be discontinued, but observations later showed the resident in bed without the mats and then with the mats again present. The DON stated the mats had been discontinued because they were no longer needed, and that they should not have been in place when observed. For a second resident with severely impaired cognition, dementia, a vision problem, and use of a wheelchair and walker, observation showed bundled fabric wedged between the mattress and bedframe, elevating one corner of the mattress and causing it to slope. The Administrator observed the bed and stated the fabric bundle was an accident hazard and made the bed less safe. For a third resident with a progressive neurological disorder, muscle weakness, and a seizure disorder, observation showed use of an electric wheelchair with a seat belt in place, while the resident stated the facility had not checked the belt and did not remember being assessed for use of the belt or ability to self-release it. Staff stated the safety assessment should have been completed quarterly, but the record showed assessments only on two dates rather than quarterly.
Failure to Monitor Air Mattress Results in Pressure Ulcer Care Deficiency
Penalty
Summary
The facility failed to ensure that a resident with multiple medical conditions, including heart disease, respiratory failure, systemic infections, unstable blood sugar, and bilateral leg amputations, received necessary treatment and services consistent with professional standards for pressure ulcer management. The resident, who was bedbound and had two Stage 4 pressure ulcers, was assessed to require an air mattress as a pressure-relieving intervention. However, there was no routine monitoring procedure established to ensure the air mattress was functioning properly. The care plan and safety device assessment indicated the need for the air mattress, but there was no physician order or documentation directing staff to monitor the device until after an incident occurred. On one occasion, the resident's representative found the air mattress deflated, with the resident lying on the metal bars of the bed. Staff who responded did not initially notice the malfunction. The following day, the wound nurse observed worsening redness on the resident's back, prompting the representative to request hospital evaluation. Interviews with staff confirmed the air mattress was unplugged and that there was no record of when it was last checked. The Director of Nursing acknowledged that staff were responsible for checking the air mattress each shift, but no monitoring order was in place prior to the incident.
Failure to Maintain Sanitary Food Preparation and Service Conditions
Penalty
Summary
The facility failed to maintain sanitary conditions during food preparation and service on one nursing unit. Observations revealed that ready-to-eat salads and desserts were left uncovered on resident meal trays in the kitchen, with small black insects flying around the uncovered food. Staff interviews confirmed ongoing issues with insect infestation and acknowledged that food items were routinely left uncovered during transport to the units. Additionally, a bin of wet, dirty wash rags was left uncovered near a handwashing sink, also attracting insects. Staff admitted that bins should be kept covered to prevent contamination but failed to do so. Further observations showed that a CNA distributed uncovered food trays in the hallway, passing rooms on transmission-based precautions, and did not perform hand hygiene between serving different residents. The meal cart used for lunch service was found to be dirty, with dried liquid spills and brownish sediments lining the bottom. Staff interviews confirmed the lack of cleanliness and the expectation that the cart should be kept sanitary. These actions and inactions were in direct violation of the facility's food preparation and service policy, which requires adherence to safe food handling and hygiene practices.
Sanitation and Food Safety Deficiencies in Facility Kitchen
Penalty
Summary
The facility failed to maintain sanitary conditions in its kitchen, as observed during a survey. Staff CC, a dietary cook, repeatedly neglected proper hand hygiene and glove use while preparing food. On multiple occasions, Staff CC was seen removing gloves and putting on new ones without washing their hands with soap and water. Additionally, Staff CC was observed touching potentially contaminated surfaces, such as garbage cans and face masks, and then continuing food preparation without proper hand hygiene. These actions were contrary to the facility's policy, which required staff to wash hands for at least 20 seconds with soap and water between tasks and glove changes. Cross-contamination was another significant issue identified in the facility's kitchen. Staff members were observed engaging in practices that could lead to contamination of food. For instance, a staff member's personal phone was found in a bin of condiment packets, and Staff DD was seen placing fingers inside the cup ledge while filling juice cups. Staff CC handled raw chicken with gloved hands, then touched various kitchen items without changing gloves or sanitizing surfaces. Furthermore, during meal service, staff handled meal tray tickets and tongs in a manner that could lead to contamination of food items, such as rolls and cucumbers. The facility also failed to adequately monitor food cooking temperatures, as required by their policy. Staff CC did not check the final internal temperature of beef stroganoff before serving, which was supposed to reach 165 degrees Fahrenheit. The facility's food temperature logs showed no recorded temperatures for lunch items once cooking was completed. Additionally, the dish cart used for clean plates was found to be soiled with dried food and debris, yet it was still used during meal service. These lapses in maintaining sanitary conditions and monitoring food safety placed residents at risk of food-borne illnesses and compromised their quality of life.
Failure to Provide Timely Admission Information to Residents
Penalty
Summary
The facility failed to ensure that newly admitted residents were informed in a timely manner of their rights and responsibilities, as well as the services provided by the facility. This deficiency was identified for three residents (Residents 85, 139, and 339) out of five reviewed. The facility's admission packet, which includes information on resident rights, facility policies, and consent forms, was not completed for these residents within the expected timeframe. Resident 85 was admitted over 30 days prior to the review, Resident 139 over two weeks prior, and Resident 339 two weeks prior, yet none had their admission packets completed by staff upon admission. During an interview, Staff O, the Vice President for the Business Office, acknowledged the importance of having residents or their representatives review and sign the admission packet to ensure they are informed of their rights and the services they will receive. Staff O attributed the delay in completing the admission packets to staffing changes and stated that it was their expectation for the admission packet to be reviewed and signed within 72 hours of admission. This failure placed residents at risk of not understanding their rights and diminished their ability to self-advocate.
Facility Fails to Maintain Homelike Environment
Penalty
Summary
The facility failed to maintain a homelike environment in several areas, including 17 resident rooms, the main dining room, and a shower room. Observations revealed various deficiencies such as doors that did not latch, holes in floor tiles, missing window screens, exposed drywall, and a missing toilet in a bathroom. Additionally, there were issues with cleanliness, such as dirty privacy curtains, strong urine odors, and scattered personal belongings on the floor. These conditions were noted during observations and interviews with staff, who acknowledged the importance of timely repairs to maintain a homelike environment. In the main dining room, a cabinet was observed with peeling paint and warped wood surfaces, which was not cosmetically appealing. Staff interviews confirmed that the cabinet was not in good repair and emphasized the importance of maintaining an environment that is in good condition, as the facility serves as the residents' home. The West 2 Shower Room was found to have a broken door with dents and mold on the ceiling, further contributing to the failure to provide a homelike environment. Staff interviews revealed that while daily rounds were conducted to identify needed repairs, there were limitations in the authority to order supplies for repairs. The facility was aware of the issues, such as missing blinds and damaged tiles, and was considering different options for repairs. However, the lack of timely action to address these deficiencies left residents at risk for a diminished quality of life and a less than homelike environment.
Failure to Follow Dietician-Approved Menu and Portion Sizes
Penalty
Summary
The facility failed to adhere to the dietician-approved menu and portion sizes during meal service, affecting three residents. On the specified date, the lunch menu was supposed to include beef stroganoff over noodles, buttered brussel sprouts, peach cobbler made from fresh peaches, and a dinner roll. However, observations revealed that all residents were served a canned fruit version of peach cobbler instead of the fresh peach cobbler as directed. Additionally, the portion sizes for residents on a low concentrated sweets diet were not adjusted as required, with all residents receiving the same portion size. Specific issues were noted with the meal preparation for three residents. Resident 83 received a 3 oz serving of brussel sprouts instead of the required 4 oz. Residents 3 and 16 did not receive the large portions of food as indicated on their tray tickets. The Dietary Manager, Staff K, intervened multiple times to correct the portion sizes during the meal service. Staff K admitted that they were not usually present to oversee the tray line but were instructed to do so during the survey. The Regional Administrator, Staff C, emphasized the importance of following the dietician's recipes and portion sizes to meet dietary needs and restrictions.
Deficiency in Meal Preparation and Service
Penalty
Summary
The facility failed to prepare food in a manner that ensured meals were appetizing and palatable for four residents, leading to dissatisfaction and potential decreased nutritional intake. Observations revealed that the facility did not adhere to its own guidelines, which directed staff to place food on the tray line no more than 30 minutes prior to meal service. Instead, noodles were placed on the steam table an hour and a half before the tray line service began, resulting in brown crusted noodles stuck to the bottom of the bin. These noodles were then served to residents, along with mushy and tasteless brussel sprouts. Interviews with residents indicated widespread dissatisfaction with the food quality. One resident described the food as bland and overcooked, while another frequently ordered food from outside the facility due to dissatisfaction. Staff interviews confirmed that the expectation was for food to be on the steam table no more than 30 minutes before service, as prolonged exposure to heat could affect food quality and nutritional value. The failure to adhere to these guidelines contributed to the deficiency in meal preparation and service.
Failure to Explain Arbitration Agreements to Residents
Penalty
Summary
The facility failed to ensure that the arbitration agreement was explained in a form and manner that the residents and/or their representatives understood. This deficiency was identified for three residents who were reviewed for arbitration agreements. The facility's policy required that the arbitration agreement be explained to residents upon admission in a language and manner they understood, with the admissions coordinator responsible for addressing any questions. However, interviews with the residents revealed that they were not aware of the arbitration agreements they had signed, nor were they informed about the 30-day revocation period. Resident 49, who was alert and oriented, stated they were unaware of the arbitration agreement and its terms. Similarly, Resident 23 did not recall signing the agreement or being informed about it, and Resident 43, who had impaired vision, signed the agreement without understanding its purpose. The facility's staff interviews indicated a lack of proper communication and explanation regarding the arbitration agreements. The Director of Nursing stated that the admission coordinator was responsible for the arbitration agreement process, but the coordinator was no longer employed at the facility. The Vice President for the Business Office acknowledged that staff should have explained the arbitration agreement details to residents or their representatives before signing. This oversight placed residents at risk of not understanding the legal implications of the arbitration agreement, including the forfeiture of their right to a jury or court trial.
Failure to Implement Grievance Policy for Missing Assistive Device
Penalty
Summary
The facility failed to implement its grievance policy for a resident who reported a missing assistive device, specifically a Grabber Reacher. The resident, who was dependent on staff for various daily activities due to complex medical conditions, reported the missing item to the nursing staff. Despite the staff's initial efforts to locate the item, the resident did not receive timely feedback or a replacement, leading to frustration and a diminished quality of life. The facility's policy required grievances to be documented and investigated promptly, but this process was not followed. Interviews with staff revealed that the grievance was not formally documented, and the resident care manager admitted to not always using grievance forms, preferring to resolve issues informally. The Director of Nursing confirmed that staff were expected to document grievances using designated forms to ensure proper tracking and resolution. The failure to document and address the grievance promptly resulted in a delay in providing the resident with an appropriate replacement for the missing item.
Failure to Report Missing Narcotics to SSA
Penalty
Summary
The facility failed to report missing narcotics to the State Survey Agency (SSA) within the required timeframe, as observed in the East 2 Narcotic Ledger. The ledger showed discrepancies, including missing tablets and pages that were crossed off or ripped out. Specifically, one tablet was missing from a transferred count, and several pages had no corresponding medication cards in the lock box. Staff I, an LPN, reported the missing narcotics to the Resident Care Manager and the Director of Nursing (DON), Staff B, but the incident was not reported to the SSA as required. Staff B acknowledged being informed of the missing narcotics and ledger pages but did not report the incident to the SSA. During an interview, Staff B admitted to not knowing the requirement to report the missing narcotics and ledger pages at the time of the incident. However, after reviewing the guidelines, Staff B understood the importance of reporting such incidents to ensure a thorough investigation and prevent further misappropriation or diversion of controlled substances within the facility.
Failure to Investigate Missing Narcotics and Ledger Discrepancies
Penalty
Summary
The facility failed to conduct a thorough investigation into discrepancies found in the East 2 narcotic ledger, which included missing controlled substances and torn-out pages. Staff I, an LPN, reported these discrepancies to Staff B, the Director of Nursing (DON), who acknowledged the missing narcotics and ledger pages. Despite conducting a narcotic audit, Staff B did not reach a conclusion regarding the missing items and failed to ensure that corrective notations were made in the ledger by the RN Managers, Staff F and Staff H. Additionally, a pharmacy narcotic audit was ordered, but no further discrepancies were reported. Upon further review, it was discovered that Staff B missed additional discrepancies on several pages of the narcotic ledger. Staff B admitted to not performing a comprehensive page-to-page investigation during the initial audit, which should have been done. The failure to identify and reconcile these discrepancies during the initial investigation placed residents at risk for uncontrolled pain and potential misappropriation of narcotic medications.
Failure to Provide Timely Transfer/Discharge Notices
Penalty
Summary
The facility failed to ensure that residents and their representatives received the required written notices at the time of transfer or discharge, or as soon as practicable, for several residents. Specifically, for Residents 65 and 139, the facility did not provide the Nursing Home Transfer or Discharge Notice, which includes appeal rights, until after the residents returned to the facility from an acute care hospital. The notices were left at the bedside, rendering them inaccessible to the residents during their hospital stay. Staff E, responsible for completing these notices, confirmed that it was not their practice to provide the notice once a resident left the facility urgently and did not provide the notices to the residents' representatives unless requested. Additionally, for Residents 18 and 39, there was no documentation indicating that the required written transfer notifications were provided at the time of their discharge to an acute care hospital. Staff J and Staff B acknowledged the absence of documentation for Resident 18, while Staff E admitted that Resident 39 did not receive a written transfer notification. The facility's failure to follow its policy on providing timely written notifications placed residents at risk of being uninformed about their transfer or discharge, including their appeal rights.
Failure to Provide Bed-Hold Notices
Penalty
Summary
The facility failed to provide written notice of its bed-hold policy to residents or their representatives at the time of transfer to a hospital or within 24 hours, as required by their policy. This deficiency was identified for three sample residents and one supplemental resident who were transferred to acute care hospitals. The facility's policy, revised in December 2022, mandates that such notice be given to inform residents and their representatives of the duration of the bed hold and the conditions for the resident's return to the facility. However, records for Residents 65, 18, 39, and 139 showed no documentation of such notice being provided. Interviews with facility staff revealed a lack of clarity regarding responsibility for issuing bed-hold notices. Staff E, the Director of Social Services, expected the admissions department to handle bed holds, while Staff M, the Admissions Director, believed it was the responsibility of the social services department or nurses. Both Staff E and Staff M confirmed that no documentation was found in the records of the affected residents to indicate that bed-hold notices were offered or provided, as required by the facility's policy.
Failure to Update Care Plans and Conduct Care Conferences
Penalty
Summary
The facility failed to ensure that care plans were updated to reflect changes in residents' care needs, specifically for two residents. Resident 3's care plan was not updated to reflect a physician's order to change the placement of floor mats, which were intended to prevent fall-related injuries. Observations showed that no floor mats were placed as directed, and the Registered Nurse Manager confirmed that the care plan was not updated, leading to inconsistent and uncoordinated care. Resident 39's care plan did not reflect their need for vision services, despite requests from their representative for an eye exam to obtain glasses. The social worker who communicated with the representative left the facility, and there was no documentation of these communications in the resident's records. The Social Service Director acknowledged that the care plan should have been updated to include the resident's wishes for vision services. Additionally, the facility failed to conduct care conferences as required. Resident 39 was only offered one care conference since admission, and their representative confirmed that no further conferences were scheduled. Similarly, Resident 49 was not offered quarterly care conferences as expected, with only two conferences documented since admission. The Social Service Director stated that care conferences should be offered upon admission, quarterly, and as needed, to allow residents to participate in their care plans and address any concerns.
Failure to Assist Residents with ADLs and Maintain Hygiene
Penalty
Summary
The facility failed to provide adequate assistance with Activities of Daily Living (ADL) for three residents, leading to issues with cleanliness and grooming. Resident 18, who was cognitively intact and required assistance with personal hygiene due to a left leg amputation, was observed multiple times with long facial hair and fingernails. Despite expressing a desire to be shaved every other day, Resident 18 reported that staff only provided shaving assistance on shower days. The Director of Nursing acknowledged that the facility did not document Resident 18's preferences or provide the necessary assistance. Resident 22, who was dependent on staff for bathing, dressing, and personal hygiene due to a stroke and delusional disorder, was observed with greasy hair, long eyebrows, and facial hair. The resident's room smelled of urine, and they were wearing a hospital gown without shoes. Although staff claimed that Resident 22 refused showers, there was no documentation of such refusals. The Director of Nursing was unaware of the shoe issue and stated that refusals should be documented and reported to a supervisor. Resident 3, who required assistance with bathing due to altered mental status and limited range of motion, was scheduled for two showers per week. However, documentation showed that Resident 3 only received one shower per week over a 32-day period, despite the Health Care Power of Attorney's preference for two baths per week. The Resident Care Manager confirmed that the facility failed to follow the care plan and document refusals properly.
Deficiencies in Following Provider Orders and Resident Care Plans
Penalty
Summary
The facility failed to follow provider orders for several residents, leading to deficiencies in care. Resident 35, who was assessed to require bilateral bed rails for mobility and safety, was observed without them on multiple occasions. Despite having a care plan and physician's orders for bed rails, staff did not install them, and the Treatment Administration Records (TARs) were inaccurately signed, indicating compliance. Interviews with staff confirmed the oversight and the expectation to follow provider orders. Resident 27, who required continuous supplemental oxygen at 2 liters per minute due to chronic respiratory failure, was observed with the oxygen setting at 2.5 liters per minute. This discrepancy was noted over several days, despite the Medication Administration Record (MAR) indicating the correct setting. Staff interviews revealed a lack of adherence to the physician's order and the need for proper monitoring and adjustment of oxygen settings. Resident 71, who had multiple health issues including dementia and depression, frequently refused meals and medications. The care plan lacked specific interventions for handling these refusals, and there was no documentation of actions taken when refusals occurred. The resident experienced significant weight loss, and staff interviews highlighted the absence of a coordinated response to the resident's nutritional and care refusals. Additionally, the facility failed to monitor and document bruises for Residents 139, 15, and 45, as required by their care plans and physician's orders.
Failure to Provide Vision Services
Penalty
Summary
The facility failed to ensure that residents with vision deficits were assessed and provided with necessary assistive devices, specifically impacting one resident who was reviewed for vision needs. Resident 39, who was readmitted to the facility with moderately impaired vision without corrective lenses, was unable to see their television and did not have any visual assistive devices available. Despite the resident's representative requesting an eye exam multiple times, the facility did not schedule the exam, leaving the resident without the necessary corrective lenses. The facility's policy required the social worker to assist residents in accessing vision services, but the social worker responsible for Resident 39's case left the facility without documenting the communication or scheduling the necessary eye exam. The social worker had assured the resident's representative that the resident would be added to the list for the eye doctor, but this did not occur. The lack of documentation and follow-through resulted in the resident not receiving the needed vision services, as the previous social worker had cleared their data before leaving the facility.
Failure to Provide Adequate Pressure Ulcer Care
Penalty
Summary
The facility failed to provide necessary care and services for two residents, Resident 71 and Resident 1, to promote healing and prevent new pressure ulcers. Resident 71, who had non-Alzheimer's dementia, diabetes, depression, and muscle weakness, was at risk for pressure ulcers. Despite the care plan's instructions to monitor and report skin breakdown, staff failed to document and notify the nurse about a new open area on Resident 71's coccyx. The area was observed without a dressing, and staff did not follow the facility's policy to report skin changes promptly. Resident 1, who had morbid obesity, back pain, severe nerve pain, and osteoporosis, was dependent on staff for personal hygiene and had recurring moisture-associated skin damage. The care plan required staff to keep the skin clean and dry and follow wound care recommendations. However, staff did not notify the provider or social services about Resident 1's refusal of compression wrap treatments, nor did they document discussions with the resident about the refusals. Additionally, there was a delay in applying the prescribed skin graft dressing due to unavailability, and staff failed to notify the physician about the missing dressing. The facility's failure to adhere to its pressure injury prevention and management policy resulted in inadequate monitoring, assessment, and reporting of skin conditions for both residents. This lack of timely intervention and communication with healthcare providers placed the residents at risk for deterioration in their skin conditions, as evidenced by the observations and interviews conducted during the survey.
Improper Chemical Storage Poses Risk to Residents
Penalty
Summary
The facility failed to ensure a safe environment free from accident hazards by not properly storing chemicals, which placed residents at risk of exposure to unsafe substances. Observations revealed that on the second-floor central hall, a bottle of insect killer spray was found in an unsecured and unlocked drawer within a facility cabinet. Additionally, the housekeeping supply closet on the same floor did not have a lock, and contained bottles of enzymatic cleaner and spray polish and cleanser on a shelf. Furthermore, the utility room near the stairwell was found open, with several bottles of no rinse foam cleanser conditioning for hair and skin, which had a warning label for external use only. Interviews with staff members confirmed the improper storage of chemicals. Staff P, a Housekeeping Aid, acknowledged that chemicals should not be in the utility room or housekeeping closet and noted that some staff might have placed chemicals in the unlocked closet due to difficulty accessing other locked closets. Staff C, the Regional Administrator, reiterated that all chemicals should be locked up according to facility policy to prevent residents from ingesting them. The facility's failure to adhere to its policy on chemical storage was evident, as not all housekeeping closets were equipped with locks, compromising resident safety.
Inaccurate Narcotic Ledger Management
Penalty
Summary
The facility failed to ensure the accuracy of the East 2 Narcotic Ledger, which was one of the two narcotic ledgers reviewed for accuracy. During an observation and record review, discrepancies were found in the narcotic ledger, including missing tablets and pages that were crossed off without proper documentation. Specifically, page 83 showed a discrepancy of one missing tablet when transferred to page 101, and pages 96, 99, and 103 had crossed-off entries with no corresponding medication cards in the lock box. Additionally, pages 111 and 112 were missing, having been ripped out of the ledger. Staff I, an LPN, reported the missing narcotics and torn pages to Staff F, the Resident Care Manager, and Staff B, the Director of Nursing, after first noticing the discrepancies during a count with the night nurse. Staff B acknowledged being informed of the issue and instructed Staff F and Staff H, both Registered Nurse Managers, to make notations on the incorrect pages. However, Staff B did not verify if these corrections were made. A pharmacy narcotic audit was ordered and completed, but no further discrepancies were reported by the pharmacist at that time.
Expired Medications and Unclean Storage in Facility
Penalty
Summary
The facility failed to ensure that expired medications were removed in a timely manner from two medication carts and one medication storage room. During observations and interviews, it was found that the West 1 and East 2 medication carts contained expired medications, including a bottle of laboratory testing solution, laxatives, and pain medication with an illegible expiration date. Additionally, the East 2 medication cart had expired medication cards with remaining tablets and loose pills in the drawers. Staff members acknowledged that they were expected to clean the carts and remove expired medications before handing them off to the next shift, but this was not done. In the East 2 medication storage room, numerous expired intravenous (IV) supplies, including IV start kits, IV sets, IV lock caps, IV flushes, and syringes, were found. Staff members admitted that they were responsible for keeping the storage room free of expired medications and supplies, but these items were not disposed of by their expiration dates. The Director of Nursing confirmed the expectation for nursing staff to dispose of expired medications and maintain cleanliness in medication carts and storage rooms.
Failure to Provide Prompt Dental Services
Penalty
Summary
The facility failed to ensure prompt dental services for Resident 39, who was dependent on staff for oral care and had no teeth or dentures available. Despite the resident's ability to communicate and understand others, and the resident representative's repeated requests for a dental exam to be fitted for dentures, the facility did not schedule the necessary dental appointment. The resident had been waiting for months without being offered an exam since their admission to the facility. The social services department was responsible for scheduling the dental exam, but the previous social worker, who had communicated with the resident's representative, left the facility without documenting the requests or adding the resident to the dentist list. The Social Service Director acknowledged the oversight and mentioned that the facility had canceled dental visits due to an infectious outbreak, and the dentist had also canceled due to illness. However, there was no documentation of the communication with the resident's representative, and the resident was never placed on the list to be seen by the dentist.
Failure to Protect Resident Privacy and Confidentiality
Penalty
Summary
The facility failed to maintain the confidentiality of Protected Health Information (PHI) for four residents, leading to a violation of their right to privacy. For Resident 340, an electronic wall device displayed their full name and care information in a hallway, unattended, allowing a visitor to view the PHI. Staff Q admitted to leaving the device open due to being in a rush. Similarly, Staff S left a medication cart with a computer open to Resident 80's medical records, and Staff I did the same with Resident 10's records. Both staff members acknowledged the importance of keeping resident information confidential and admitted to not securing the computers. For Resident 39, a representative showed text message communications with a facility social worker, which were not documented in the resident's records. The social worker involved had left the facility and cleared their data before leaving, resulting in a lack of documentation. Staff E, the Social Service Director, confirmed the absence of documentation, and Staff B, the Director of Nursing, emphasized the expectation for staff to maintain confidentiality and ensure accurate documentation of resident records.
Infection Control Deficiencies in LTC Facility
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by multiple deficiencies observed during the survey. Resident 18, who returned from the hospital with an indwelling catheter, was not placed on Enhanced Barrier Precautions (EBP) as required by the physician's order. The absence of isolation signage and the lack of implementation of EBP for Resident 18 were confirmed by the Infection Control Preventionist, Staff D, who acknowledged the oversight. In the shower room on the West-1 unit, the facility failed to maintain cleanliness, as evidenced by the presence of debris and dried hair on the shower drain cover. The cleaning log indicated that the last cleaning was documented several months prior, and observations showed that the drain remained uncleaned even after resident use. Staff J, a Registered Nurse Manager, admitted the need for staff training and a cleaning schedule to address the buildup of debris. The facility also failed to adhere to proper hand hygiene and transmission-based precautions. Staff J was observed performing wound care for Resident 80 without changing gloves or performing hand hygiene, leading to potential cross-contamination. Additionally, a provider entered Resident 339's room without the required personal protective equipment (PPE) despite the presence of a contact precautions sign. The provider continued to visit other residents' rooms without donning PPE, contrary to the facility's infection control policies. Furthermore, the ice machine was found to be inadequately cleaned, with visible debris and slime, indicating a lapse in regular maintenance and cleaning protocols.
Ineffective Pest Control Program in Facility
Penalty
Summary
The facility failed to maintain an effective pest control program, resulting in the presence of insects in resident rooms and common areas. Resident 49 reported bugs in their room, which disturbed their sleep, and despite multiple reports to staff, no resolution was communicated. Staff N, the Regional Plant Operation Manager, acknowledged the issue, noting that the monthly pest control services were ineffective, possibly due to open windows with missing screens. This situation was observed in multiple areas, including the West Central Hallway Sink, where ants were previously present, and fruit flies were noted in the Second Floor Hallway, Resident 43's room, Resident 22's room, and the West Central Office. In the kitchen and dining room, fruit flies were observed in the dry food storage area, with a trap and a bowl containing fruit flies. Flies were also seen in the dining room and above food in the tray line assembly area during food service. Staff K, the Dietary Manager, confirmed that fruit flies had been a persistent problem, and assistance from pest control was being sought. These observations indicate a failure to provide a safe, clean, comfortable, and homelike environment for residents, as required by the facility's pest control policy.
Incomplete PBJ Staffing Data Submission
Penalty
Summary
The facility failed to submit complete and accurate direct care staffing information to the Centers for Medicare and Medicaid Services (CMS) for the first quarter of 2024, as required by the Payroll Based Journal (PBJ) guidelines. The PBJ system mandates that long-term care facilities electronically submit staffing data, including hours worked by all employees and contract workers, in a uniform format. The facility's submission was found to be incomplete, with missing Total Employee Link Records, which are essential for accurate reporting of staffing levels. Interviews with facility staff revealed a lack of oversight and potential technical issues as contributing factors to the incomplete submission. The Director of Nursing acknowledged responsibility for ensuring daily staffing levels but indicated that PBJ data submission was managed at the corporate level. The Regional Operations Manager speculated that a technical issue with payroll might have caused the incomplete data submission, and both the CEO and Administrator recognized the need for more oversight to ensure compliance with the PBJ guidelines.
Failure to Assess and Document Skin Conditions
Penalty
Summary
The facility failed to assess and document wound characteristics, monitor, and implement interventions to mitigate worsening of non-pressure skin issues for four residents. Resident 1 was admitted to the facility and was dependent on staff for toileting hygiene, bathing, and bed mobility. Despite being at risk for skin impairments, no new skin issues were documented in the weekly skin checks. However, a new open area was identified by nursing assistants, but no documented assessment by a licensed nurse was found. Upon discharge, the receiving facility identified multiple open areas and extensive moisture-associated skin damage (MASD) that were not documented by the facility staff prior to discharge. Resident 2 was also dependent on staff for toileting hygiene and bed mobility and had ongoing MASD. Despite this, the facility's documentation did not reflect consistent monitoring or assessment of the skin condition. Nursing assistants documented red and open areas on multiple occasions, but these were not followed up with proper assessments or notifications to the medical doctor. The resident's condition worsened without appropriate documentation or intervention. Resident 3 had an open area on the right great toe that was noted to have become infected but was not consistently monitored or documented. Additionally, the resident had crusted and peeling skin on the face and scalp, which was not reported to the nurse or documented in the medical record. Resident 4 had a rash under the left breast that spread to the underarm, but the facility failed to document the spread or notify the medical doctor. The facility acknowledged concerns regarding skin care and was in the process of implementing changes, but these deficiencies highlight significant lapses in the assessment, documentation, and monitoring of skin conditions for multiple 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.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release June 24, 2026) and official state health department websites — never guesswork.
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