Washington State Walla Walla Veterans Home
Inspection history, citations, penalties and survey trends for this long-term care facility in Walla Walla, Washington.
- Location
- 92 Wainwright Drive, Walla Walla, Washington 99362
- CMS Provider Number
- 505530
- Inspections on file
- 51
- Latest survey
- April 14, 2026
- Citations (last 12 mo.)
- 28
Citation history
Health deficiencies cited at Washington State Walla Walla Veterans Home during CMS and state inspections, most recent first.
A resident with severe cognitive impairment and dependence for ADLs was subjected to repeated physical and verbal abuse by another cognitively impaired resident with known behavioral disturbances. The abusive resident’s care plan documented a history of verbally and physically abusive behavior and included an intervention to avoid seating this resident near certain others at meals, noting a preference to sit with the victim. Despite this, the abusive resident became irritable and accused the other of taking their dinner plate, then struck the resident’s arm, and on another occasion, after becoming verbally aggressive with an RN over a missing inhaler, left their room, positioned next to the same resident, stated that the resident was not helping, and hit the resident’s arm twice.
The facility did not follow its abuse prevention and protection policies when one cognitively impaired resident with dementia and behavioral disturbance repeatedly exhibited escalating aggression toward another cognitively impaired resident who required maximum assistance with ADLs. Nursing notes documented that the aggressive resident became increasingly irritable, yelled, used profanity, and physically struck the other resident on more than one occasion, including punching the resident’s arm after an earlier altercation with an RN. Despite these documented behaviors, staff continued to encourage the two residents to sit together because they viewed the relationship as companionship, and the DON later acknowledged that, contrary to facility policy requiring separation after abuse is identified, the residents were not separated after the first incident.
The facility failed to adequately supervise and update the care plan for two cognitively impaired residents, one with dementia and behavioral disturbances and one with Alzheimer’s disease, after repeated resident-to-resident altercations. Existing care plan interventions for aggressive behavior, such as avoiding certain seating arrangements, providing alternate locations, and positioning staff for quick intervention, were not effectively implemented or revised despite multiple incidents in which one resident became irritable, left assigned areas, sat next to the other resident, and struck them on the arm. Staff reported that one resident viewed the other as a surrogate spouse and had become increasingly agitated and verbally abusive, while the other resident had become more agitated and harder to redirect, yet the RN responsible acknowledged that the care plan was not updated and the facility’s safety and supervision policy was not followed.
A resident with impaired vision and a powered w/c fell after driving off a curb and sustained a serious leg fracture requiring hospital and surgical repair. The resident had an indoor mobility assessment that noted need for staff help with ramps, backing up, and obstacles, but the facility did not reassess after a new powered w/c was obtained, did not develop a w/c care plan, and did not complete the incident investigation within the required timeframe or obtain witness statements.
Inaccurate PASARR screening affected several residents whose records showed mental health diagnoses that were not fully reflected on the Level I forms. One resident’s dementia was omitted, another resident’s anxiety and dementia were not properly listed and no updated PASARR was found after an exempted hospital stay extended beyond the allowed period, a third resident’s PTSD was not documented, and a fourth resident’s bipolar disorder and substance abuse were not included; staff also stated there was no tracking process for exempted hospital discharges and several inaccurate PASARRs were found on audit.
Expired foods, unlabeled items, and dirty or damaged kitchen equipment were found across multiple kitchen areas and dry storage. Surveyors observed expired juice, Jello, yogurt, cereal, and other foods stored without dates or use-by information, along with dirty ice machine vents, refrigerator surfaces, oven vents, and broken equipment such as a cracked stove top and damaged ice machine parts. Staff interviews showed there was no consistent process for checking old food, documenting nightly cleaning, or monitoring whether cleaning and food-labeling tasks were actually completed.
PRN psychotropic meds were not properly limited to 14 days or supported by documented rationale for extended use, and non-pharmacological interventions were not consistently documented for two residents. One resident had PRN Prochlorperazine ordered for nausea/vomiting with no timely non-pharm documentation and repeated administrations, while another resident had PRN Ativan ordered without an end date and used over several months for comfort, agitation, sleep, and other symptoms without the required justification.
A resident with anemia, HF, and kidney disease showed a clear decline with poor intake, shakiness, SOB, pallor, confusion, slurred speech, and hypotension before being sent to the ER and later found to need PRBCs, IV fluids, and treatment for severe hyperkalemia. The facility also did not accurately follow fluid restriction orders for two residents with renal disease/HF, with staff estimating intake, failing to account for all fluids, and keeping water containers in rooms. In addition, discharge orders for a resident with CHF and fluid retention were not entered correctly, including delayed baseline weights, missing weight-based diuretic directions, and late daily weight orders.
A resident with PTSD, bipolar disorder, anxiety, insomnia, and substance abuse history did not receive a TIC screening or individualized care plan for trauma-related triggers. The resident reported being triggered when not heard or understood in conversation, and staff acknowledged that the required TIC assessment and care planning process was not completed despite documented trauma history and military background.
QAPI failed to include thorough data collection and analysis of adverse events. A resident fell outside the facility, sustained substantial fractures, and was sent to the hospital, but the QAA/QAPI meeting only documented a safety concern about painted curbs and did not show review of the incident, PDSA, or RCA. The IP/QAPI coordinator, DNS, and Administrator stated adverse events and resident safety concerns from the incident log were not brought into QAPI, and the fall was handled in a safety committee meeting instead.
QAA/QAPI committee meetings did not consistently include the required Medical Director member during the reviewed quarters. The facility’s QAPI plan required the Administrator, DON, IP/QAPI coordinator, and Medical Director to participate quarterly, but records showed the Medical Director missed multiple QAPI meetings in Q3 and Q4. Interviews with the Administrator, DON, and IP/QAPI coordinator confirmed the Medical Director was expected to attend the quarterly QAA/QAPI meetings.
A resident with severe cognitive impairment and multiple medical conditions sustained two injuries, but the facility failed to notify the resident's representative in a timely manner as required by policy. Staff interviews and record reviews confirmed that while internal notifications were made, there was no documentation or recollection of family notification for either incident.
A resident with Alzheimer's, dementia, and PTSD, who was known to have wandering behaviors and required line-of-sight supervision, was left unsupervised during an off-campus outing. While staff assisted other residents onto a bus, the resident wandered away undetected, as only one NA was present and supervision protocols were not followed.
The facility failed to provide palatable and appealing meals, as reported by several residents during a Resident Council meeting. Complaints included lack of flavor, limited vegetarian options, overcooked vegetables, and reliance on processed foods. Observations confirmed these issues, with meals being prepared too far in advance and served in an unappetizing manner. The Dietary Manager acknowledged the residents' complaints and confirmed the deficiencies in meal preparation and presentation.
A resident with chronic lung disease, heart disease, and dizziness was found self-administering a Vitamin D supplement without a proper assessment or directive. The facility's policy required an assessment by the Interdisciplinary Care Planning Team, but the resident's Self-Medication Administration Assessment did not include the Vitamin D supplement. There were no physician's orders or care plan goals for self-administration, and the Director of Nursing confirmed the process was not followed.
A resident with chronic conditions and mobility issues was unable to access their desk and bulletin board due to inadequate room arrangement. Staff were unaware of the resident's needs, relying on residents or families to request accommodations. This oversight risked diminishing the resident's quality of life and increasing dependence on staff.
The facility failed to ensure accurate PASARR and obtain Level II evaluations for two residents, risking their access to necessary mental health care. One resident with MDD, dementia, anxiety, and hallucinations did not have a Level II Behavioral Health Assessment indicated in their PASARR. Another resident, diagnosed with MDD after admission, did not have an updated PASARR reflecting this diagnosis or the need for a Level II Behavioral Assessment. A Psychiatric Social Worker confirmed the need for updated assessments based on significant changes or new diagnoses.
A resident with a history of UTIs and a suprapubic catheter had their care plan inadequately reviewed and revised, despite being treated for UTIs multiple times over the past year. Facility staff failed to address the recurring issue, with the Resident Care Manager and Infection Control RN acknowledging the lack of action and specific education on UTI prevention.
A resident with a suprapubic catheter experienced recurrent UTIs due to the facility's failure to promptly assess and address the issue. Observations showed improper catheter care, and interviews revealed delays in reviewing urine culture results and initiating treatment. Staff were unaware of the urgency required for abnormal lab results, leading to delayed antibiotic treatment.
The facility failed to maintain CPAP and BiPAP machines for two residents, leading to potential health risks. A resident with sleep apnea and other conditions had a BiPAP machine with oily residue and improper water chamber maintenance, possibly contributing to a sinus infection. Another resident with chronic conditions had a CPAP machine that was not cleaned regularly, despite having a cleaning device available. Staff interviews revealed a lack of adherence to cleaning policies and unclear responsibilities.
The facility failed to ensure proper food handling and storage, with opened condiments requiring refrigeration left on dining tables and personal refrigerators lacking temperature monitoring. Staff interviews revealed confusion over responsibilities, leading to non-compliance with food safety protocols and potential risks for residents.
The facility failed to ensure staff followed infection prevention and control measures for PPE and hand hygiene, particularly in handling a resident with C-diff. Observations showed multiple staff members did not perform hand hygiene before donning PPE, did not secure gowns properly, and used ABHS instead of washing hands with soap and water after removing PPE. These actions were contrary to the required protocols and placed individuals at risk of exposure and cross-contamination.
A resident with dementia and a history of wandering left the facility unnoticed due to inadequate supervision and lack of door alarms. The resident's care plan indicated they should not leave unattended, but a sign on their door instructed staff not to disturb them, contributing to the oversight.
Two RNs failed to lock medication carts when left unattended, contrary to facility policy. One RN left the cart unlocked for nine minutes while assisting a resident, and another left it unlocked for four minutes. Both acknowledged the expectation to lock carts when unattended.
Failure to Protect a Resident From Repeated Abuse by Another Resident
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident from physical and verbal abuse by another resident. The facility’s abuse and neglect policy, dated 12/18/2024, defined physical abuse as willful actions inflicting bodily injury, such as striking, slapping, or shoving, and mental abuse as willful verbal or nonverbal actions that threaten, humiliate, harass, coerce, intimidate, isolate, or punish a vulnerable adult. Resident 1 had age-related cognitive decline, Alzheimer’s disease, an anxiety disorder, and severely impaired cognition, and required maximum assistance from one to two staff for ADLs. Resident 2 had dementia with behavioral disturbance, Alzheimer’s disease, an irregular heart rhythm, and severely impaired cognition, and required moderate to maximum assistance for ADLs. Resident 2’s care plan, dated 04/08/2026, documented episodes of verbally and physically abusive behavior and included an intervention to avoid seating Resident 2 near specific residents at meals whenever possible, noting that Resident 2 preferred to sit with Resident 1 and that seating Resident 1 at another table might persuade Resident 2 to sit away from other residents. Record review showed that on 02/02/2026 at 5:15 PM, Resident 2 was irritable and having difficulty getting along with other residents. After Resident 1 received their dinner plate, Resident 2 accused Resident 1 of taking their plate and became angry, hitting Resident 1 on the left arm. A subsequent facility investigation dated 04/04/2026 documented that on 04/03/2026 at 6:00 PM, Resident 2 became agitated with a registered nurse during medication administration, accused the nurse of stealing their inhaler, and became verbally aggressive. Resident 2 was redirected to their room to calm down but did not remain there, instead wheeling themselves to sit next to Resident 1. Resident 2 then stated to Resident 1, “you are not helping me,” and hit Resident 1 twice on the left arm. These documented incidents show that despite knowledge of Resident 2’s history of verbally and physically abusive behavior and a care plan intervention to avoid seating Resident 2 near certain residents, Resident 1 was subjected to repeated physical and verbal abuse by Resident 2.
Failure to Separate Aggressive Resident and Protect Cognitively Impaired Resident From Repeated Abuse
Penalty
Summary
The facility failed to implement its abuse prevention and protection policies for a resident with severe cognitive impairment. The facility’s Resident Abuse Prevention policy required identifying, correcting, and intervening in situations where abuse, neglect, or misappropriation of resident property was likely to occur, including through sufficient staffing, staff knowledge of resident care needs, and assessment and monitoring of residents with behaviors that might lead to conflict. The Abuse and Neglect policy required the Administrator or designee, upon receiving notice of alleged abuse, to take reasonable and prudent actions to ensure the safety and protection of the alleged victim and other residents. Resident 1 had diagnoses including age-related cognitive decline, Alzheimer’s disease, and anxiety disorder, with a comprehensive assessment showing severely impaired cognition and a need for maximum assistance from one to two staff for ADLs. Resident 2, who also had severely impaired cognition and diagnoses including dementia with behavioral disturbance and Alzheimer’s disease, exhibited escalating aggressive behaviors. A nursing progress note documented that Resident 2 became increasingly irritable, yelled at others, used profanity toward staff, believed Resident 1 was eating from their dinner plate, and hit Resident 1. A later progress note documented that after an altercation with an RN over medication, Resident 2 was placed in their room due to escalating behaviors of hitting, kicking, and cursing, but then returned to the common area, approached Resident 1, stated “you are not helping me,” and punched Resident 1 twice on the left arm. Staff interviews confirmed that Resident 2 had increased behaviors over the prior month and that, despite Resident 2 being an aggressor who became angry with and cursed at Resident 1, staff encouraged the two residents to sit together because they believed it was good companionship. The DON stated that once abuse was identified, residents should be separated to protect the alleged victim and acknowledged not knowing why the residents were encouraged to sit together and not separated after the first incident, confirming that facility policy was not followed.
Failure to Supervise and Update Care Plan After Repeated Resident-to-Resident Altercations
Penalty
Summary
The facility failed to provide adequate supervision and update care plan interventions to prevent resident-to-resident altercations involving a resident with dementia and behavioral disturbances and another resident with severe cognitive impairment. The facility’s policy on Safety and Supervision of Residents required the interdisciplinary team to analyze assessment and observation data to identify accident risks and implement targeted interventions, including adequate supervision. Resident 1 had age-related cognitive decline, Alzheimer’s disease, anxiety disorder, and severely impaired cognition, requiring maximum assistance for ADLs. Resident 2 had dementia with behavioral disturbance, Alzheimer’s disease, an irregular heart rhythm, and severely impaired cognition, requiring moderate to maximum assistance for ADLs. Resident 2’s care plan included interventions for verbally and physically abusive behavior, such as avoiding seating them near certain residents at meals, encouraging them to sit at other tables for activities, providing quiet time in their room or on the patio, going for walks, positioning staff for quick intervention, and removing them from situations as needed. Despite these identified needs and interventions, Resident 2 was involved in multiple altercations with Resident 1. On one occasion, Resident 2 became irritable at dinner, accused Resident 1 of taking their dinner plate, and hit Resident 1 on the left arm. On another occasion, after becoming verbally aggressive with an RN during medication administration and being redirected to their room, Resident 2 left the room, wheeled to sit next to Resident 1, stated that Resident 1 was not helping them, and hit Resident 1 twice in the left arm. Staff interviews revealed that Resident 2 viewed Resident 1 as a surrogate spouse and increasingly became more agitated, angry, and verbally abusive toward Resident 1 over the prior month, while Resident 1 had become more agitated and difficult to redirect. An RN acknowledged that the existing care plan interventions, though previously appropriate, had not been updated in response to the new abuse allegations and resident-to-resident altercations, and that the facility did not follow its own safety and supervision policy.
Powered wheelchair safety assessment and care planning failure
Penalty
Summary
The facility failed to identify hazards and risks to keep a resident’s environment free from accident hazards while using a powered wheelchair. Resident 80 had diagnoses including bladder cancer, wet macular degeneration, and myopia, and the comprehensive assessment showed intact cognition, impaired vision, eyeglasses use, need for one to two staff assistance with ADLs, and mobility by powered wheelchair. The resident also had a history of refusing some care and often refused to wear eyeglasses. The resident was found outside in the parking lot after driving the powered wheelchair off the end of a sidewalk/curb and falling onto the pavement. Staff observed that the resident’s body was twisted, the left leg appeared deformed, and the resident had cuts and scrapes to the left knee, hands, fingers, and toes. The resident believed there was a ramp at the end of the sidewalk and realized too late that there was not one. Paramedics were called and the resident was sent to the hospital, where records showed surgical repair of a comminuted, angulated, and displaced fracture to the upper left leg. Record review showed the resident had a powered-mobility indoor driving assessment that was completed in the SNF indoor environment and concluded the resident could drive independently with no restrictions indoors, despite also documenting that the resident required staff assistance or supervision for ramps, backing up, and maneuvering unexpected obstacles, and was hesitant, required several tries, and bumped walls and objects lightly in congested areas. The resident was not reassessed after receiving a new powered wheelchair, and staff stated the resident had not been assessed outdoors because they had no plans to use the wheelchair outside independently. The care plan addressed impaired vision but did not include a care plan for powered wheelchair use and safety. The incident investigation was not completed within five days, had no witness statements from staff who observed or found the resident, and there were no documented education or in-services regarding wheelchair safety or following the care plan.
Inaccurate PASARR Screening for Residents With Mental Health Diagnoses
Penalty
Summary
The facility failed to ensure PASARR Level I screening accurately reflected residents’ mental health conditions for 4 of 8 residents reviewed for unnecessary medications. Resident 5 was admitted with diagnoses including PTSD, depression, anxiety, and dementia, but the PASARR Level I form updated 05/06/2025 did not list dementia even though it was documented in the medical record. Resident 12 was admitted with diagnoses including dementia, depression, anxiety, and PTSD, but the PASARR Level I form dated 10/28/2025 did not list anxiety as a serious mental health indicator and did not list dementia; the form also showed an exempted hospital discharge status, and there was no updated PASARR Level I form in the record after the resident stayed beyond the exempted period. Resident 13 was admitted with diagnoses including PTSD and depression, but the PASARR Level I form dated 10/01/2025 identified a serious mental illness indicator of mood disorder and did not document PTSD. Resident 7 was admitted with diagnoses including PTSD, insomnia, bipolar disorder, anxiety, and substance abuse, but the PASARR Level I form dated 01/13/2026 marked PTSD and anxiety and did not include bipolar disorder or substance abuse; the resident was also treated as an exempted hospital discharge and no Level II referral was sent at the time it was due. During interview, the Social Worker stated the facility screened referrals on admission, completed Level II evaluations when indicated, and should complete an accurate Level I PASARR if diagnoses were not listed on the admission packet, but also stated there was no tracking process for residents admitted under exempted hospital status and that several inaccurate PASARRs were identified during an audit.
Expired Foods and Poor Kitchen Sanitation
Penalty
Summary
The facility failed to discard expired foods and failed to consistently complete daily cleaning tasks in multiple kitchens and a dry storage area. During observations, surveyors found numerous expired and unlabeled food items, including expired orange juice, strawberry Jello, cottage cheese, yogurt, prune juice, and hot cereal, along with opened foods that had no dates or use-by information. Surveyors also observed frozen and refrigerated items stored in clear baggies or containers without labels, dates, or use-by dates, and several items that staff could not identify as to how long they had been stored once opened. In several kitchens, surveyors observed dirty and damaged food service equipment and surfaces. The ice machine vents had dried food splatters and dust buildup, and in one kitchen the ice machine cover was removed, exposing coils with a thick layer of gray, fuzzy dust. Surveyors also observed dirty refrigerator doors and handles, crumbs and dirt in shallow areas, warped cupboards with missing laminate exposing wood or particle board, dust hanging from oven vents, and a broken plastic piece on the ice machine leaving a hole and sharp edges. In another kitchen, the glass stove top was broken with jagged edges and a crack across the surface. Staff interviews showed inconsistent oversight of food storage, labeling, and cleaning. One cook stated expired or old food was supposed to be checked and discarded, but did not know how often frozen foods should be kept once opened. Another cook stated there was no process for checking expired or old foods and that nightly cleaning was not documented. The dietary manager stated cooks had been given new labels and educated, but the process was still a work in progress, and staff did not monitor whether cleaning audits or daily cleaning were actually completed. The administrator stated they expected the dietary manager to monitor kitchen cleanliness, task completion, and broken equipment, and said they were not aware of the cracked ice machine, broken stove top, or missing laminate in the cupboards.
PRN Psychotropic Medications Not Limited to 14 Days or Supported by Documentation
Penalty
Summary
The facility failed to ensure that PRN psychotropic medications were limited to 14 days or had a documented rationale for extended use, and failed to ensure non-pharmacological interventions were consistently attempted and documented for 2 of 5 residents reviewed for unnecessary medications. The facility policy titled, Psychotropic Medication Use, dated February 2025, stated PRN psychotropic medications were limited to 14 days unless the provider documented a clinical rationale for extending use, and that residents on psychotropic medications were to be monitored for behavioral and non-pharmacological interventions with documentation in the medical record. Resident 7 was admitted with diagnoses including PTSD, insomnia, bipolar disorder, anxiety, substance abuse, and a systemic infection, and later returned to the hospital and was re-admitted with an abdominal infection. The resident’s 02/03/2026 comprehensive assessment showed they were cognitively intact, able to make needs known, and taking an antipsychotic medication. On 01/28/2026, Prochlorperazine was ordered PRN every 6 hours for nausea and vomiting with an indefinite duration. Monitoring/non-pharmacological interventions were not ordered until 02/03/2026, six days later, and the MAR showed the medication was administered 10 times from 02/06/2026 through 02/25/2026. The MAR contained no documentation of non-pharmacological attempts related to the medication. Resident 35 was admitted with diagnoses including Alzheimer’s disease, insomnia, and anxiety, and the 12/12/2025 comprehensive assessment showed substantial to dependent assistance needs and severe impaired cognition. The MAR showed a 10/21/2025 order for Ativan 1 mg PRN every 6 hours for end-of-life care, agitation, seizure, or intractable nausea and vomiting, with no end date, and 10 administrations from November 2025 through February 2026. Staff interviews reflected differing explanations for the order, including comfort care, sleep, air hunger, and behavioral control, while the DON stated the resident did not have a diagnosis for end of life and that a PRN medication used beyond 14 days needed justification, which was not present.
Failure to Recognize Change in Condition and Follow Fluid Restriction and Discharge Orders
Penalty
Summary
The facility failed to recognize and respond to a change in condition for a resident with iron deficiency anemia, heart failure, and kidney disease. The resident had been independent with ambulation and transfers and had no memory issues on the comprehensive assessment, but nursing and social services notes documented a decline in condition. On 11/21/2025, the resident was not eating, reported being too shaky, refused therapy because of shortness of breath when not using CPAP, and was described as pale, anxious, and lying in bed with CPAP in place while awake. The social worker documented that nursing and the primary care provider were notified of the resident’s concerns. Two days later, the resident was observed lying in bed attempting to catch speckles and dots, was not at baseline, was oriented only to self, believed they were at their brother’s house, had slurred speech, and had a blood pressure of 91/53 mmHg. The primary care provider was notified and recommended transfer to the emergency room. The resident was then transferred out of the facility and later received two units of packed red blood cells, a fluid bolus, and medication to lower a potassium level of 7.0 mmol/L at the receiving hospital. The facility also failed to follow physician orders as written for fluid restrictions and related fluid intake documentation for multiple residents. One resident with kidney failure, hypertension, and heart failure had a 1500 mL/day fluid restriction, but staff documented intake inconsistently, kept a water tumbler in the room that was refilled daily, and did not include all fluids such as coffee in the charting. Staff stated the restriction was more of an estimate and that the resident likely exceeded the limit. Another resident with ESRD, dialysis dependence, diabetes, and heart failure had an 1800 mL fluid restriction, but staff could not state the exact amount consumed, the resident kept a water jug and other drinks in the room, and the resident reported not being asked how much was consumed or knowing the daily allowance. The DON stated the staff were not following the facility’s fluid restriction process. The facility also did not accurately enter and follow hospital discharge orders for a resident with CHF and respiratory failure who had been hospitalized for fluid retention and required 17 pounds of fluid removal. The discharge instructions included specific weight-based directions for bumetanide and metolazone, including obtaining a baseline weight on readmission and using weight gain parameters to guide dosing. However, the resident’s baseline weight was not obtained until three days after readmission, the bumetanide order was not updated to reflect the discharge instructions, and daily weights were not ordered until four days after readmission. The DON stated the expected process was for one nurse to enter the discharge orders and a second nurse to verify them, and that this process was not followed correctly.
Failure to Complete Trauma-Informed Assessment and Care Planning
Penalty
Summary
The facility failed to ensure that a resident with a history of trauma received culturally competent, trauma informed care with identified triggers and individualized interventions. Resident 7 was admitted with diagnoses including a system wide infection, PTSD, insomnia, bipolar disorder, anxiety, and substance abuse, and the record showed the resident was cognitively intact and able to make needs known. The resident stated during interview that they had discussed past traumatic experiences with staff and identified triggers such as not being heard during conversations, not getting the whole story from another person, or not feeling understood. Record review showed no TIC screening or assessment had been completed for Resident 7, and the care plan contained no individualized TIC focus or interventions related to trauma history, potential triggers, or modifications to resident care approaches to reduce exposure to triggers. A progress note documented social services had noted the resident's childhood trauma, military history, substance abuse, PTSD, and night terrors, but staff interviews confirmed the required TIC process was not completed. Social services and nursing leadership both stated the resident should have been assessed for trauma experiences and triggers and that an individualized care plan should have been developed, but this was not done.
QAPI Did Not Review Adverse Event Data or Analysis
Penalty
Summary
The facility failed to maintain its QAPI program by not including thorough data collection, feedback, and systematic investigation or analysis of adverse events. The facility’s QAPI policy stated that the QAA/QAPI committee included the Administrator, DNS, IP/QAPI coordinator, Medical Director, and other management staff, and that the committee was responsible for monitoring adverse events from incident reports and clinical review meetings, prioritizing areas for improvement, and using PDSA and RCA processes for systematic action and analysis. Review of the incident log showed that on 12/28/2025, Resident 80 fell outside of the facility, sustained substantial fractures, and was sent to the hospital. However, the quarterly QAA/QAPI meeting held on 01/15/2026 documented discussion of painted curbs as a potential safety concern, but did not document collection or analysis of data related to Resident 80’s adverse event. The meeting record also did not show that a PDSA or RCA had been completed regarding the event, problem-prone areas, or contributing factors affecting quality of care, quality of life, or resident safety. During interviews, Staff A, the Administrator, Staff B, the DNS, and Staff GG, the IP/QAPI coordinator, stated that adverse events such as Resident 80’s fall were not reviewed in the QAA/QAPI meeting. Staff GG stated the committee focused on quality measures and did not include adverse events or resident safety concerns, and said the fall was not reviewed because it was not a pattern. Staff B stated adverse events and potential abuse concerns from the incident logs were not brought into QAPI, and Staff A stated the adverse event investigation was reviewed in a safety committee meeting instead of QAA/QAPI, with no review of that information during the QAPI meeting.
QAA/QAPI Committee Did Not Include Required Member at Quarterly Meetings
Penalty
Summary
The facility failed to ensure the Quality Assessment and Assurance (QAA) committee included the required members and met at least quarterly for 2 of 4 quarters reviewed. The facility’s policy titled Quality Assurance Performance Improvement (QAPI) Plan, dated 05/15/2025, stated the QAA/QAPI committee would include the Administrator, Director of Nursing Services, Infection Preventionist/QAPI coordinator, and the Medical Director, and that the committee would meet quarterly to identify and prioritize areas of improvement. Record review of quarterly QAPI meeting documents from the facility’s last annual recertification survey through 02/27/2026 showed Q1 and Q2 meetings included the required members, but in Q3 the Medical Director did not attend the 08/21/2025 and 09/18/2025 QAPI meetings, and in Q4 the Medical Director did not attend the 10/16/2025 QAPI meeting. During interviews, the Administrator, DNS, and the IP/QAPI Coordinator stated the QAA/QAPI meetings were held together and that the Medical Director was a required committee member who should attend quarterly. After reviewing the documents, the IP/QAPI Coordinator acknowledged the Medical Director did not attend the QAPI meetings in Q3 or Q4 as required.
Failure to Notify Resident Representative of Injuries
Penalty
Summary
The facility failed to notify the resident's representative (RR) in a timely manner regarding two separate injuries sustained by a resident with diagnoses including heart failure, dementia with behavioral disturbance, and anxiety. The resident was dependent on two staff members for activities of daily living and had severely impaired cognition. The first injury involved bleeding from the resident's toe, and the second was a skin tear to the left wrist that required steri-strips and a dressing. In both cases, there was no documentation that the RR was notified of the injuries, despite facility policy requiring timely family notification and documentation of such contact in the incident report and nursing progress notes. Interviews with nursing staff and the Director of Nursing revealed that while the provider and internal facility leadership were notified, there was no evidence that the RR was informed of either injury. Staff members could not recall notifying the family, and documentation to verify notification was not found. The administrator confirmed the lack of documentation and stated that one injury had been brought to the facility's attention by the RR, not by staff notification. This failure to notify the RR as required by policy and regulation was confirmed through record review and staff interviews.
Failure to Supervise Resident at Risk for Elopement During Outing
Penalty
Summary
The facility failed to provide adequate supervision to prevent elopement for a resident with a history of wandering and severe cognitive impairment. The resident, who had diagnoses including Alzheimer's disease, dementia, and PTSD, was assessed as having severely impaired cognition and was known to be at risk for elopement. The resident's care plan specified that they should be kept in line of sight when outside the memory care unit. During an off-campus outing to a city parade, the resident was left unsupervised on a bench while staff assisted other residents onto a bus. Staff did not maintain line-of-sight supervision, and the resident wandered away from the group undetected. Interviews with facility staff revealed that only one nursing assistant accompanied the group, and the process for supervising residents at risk for wandering was not adequately followed. The recreation specialist and the director of nursing both acknowledged that residents from the memory care unit, especially those with wandering behaviors, should have one-on-one supervision during outings. The lack of appropriate supervision and failure to adhere to the resident's care plan resulted in the resident's elopement, as staff did not realize the resident was missing until minutes later.
Deficient Meal Quality and Presentation
Penalty
Summary
The facility failed to provide palatable, appetizing, and appealing meals for eight residents who expressed dissatisfaction with the food quality during a Resident Council meeting and other interviews. The residents reported issues such as lack of flavor, limited vegetarian options, overcooked vegetables, and a lack of variety in meals. Specific complaints included the frequent serving of baked potatoes and green salads as vegetarian alternatives, overcooked vegetables, and a predominance of chicken dishes. Additionally, residents noted the use of processed and frozen foods, which they felt were unhealthy and full of preservatives. Observations and interviews with staff confirmed these issues. During a test tray observation, the meal consisted of previously frozen and unappealing items, such as soggy breaded fish, mushy vegetables, and undercooked French fries. The alternative meal was also unsatisfactory, with a wilted salad served on a warm plate. The Dietary Manager acknowledged the residents' complaints about the lack of flavor and confirmed that the meal preparation and presentation were not up to standard, with meals being prepared too far in advance and served in an unappetizing manner.
Failure to Conduct Thorough Assessment for Self-Administration of Medications
Penalty
Summary
The facility failed to conduct a complete and thorough assessment for self-administration of medications for Resident 39, who was reviewed for safe self-medication administration. Resident 39, who had diagnoses of chronic lung disease, heart disease, and dizziness, was found to have an over-the-counter Vitamin D supplement at their bedside, which they had been self-administering without proper assessment or directive. During an observation, Staff U, a Registered Nurse, discovered the Vitamin D supplement and noted that Resident 39 was unsure of the correct dosage, indicating a lack of proper education and assessment for self-administration. The facility's policy required an assessment by the Interdisciplinary Care Planning Team, including the physician, to determine if a resident could safely self-administer medications. However, the Self-Medication Administration Assessment for Resident 39 did not include the Vitamin D supplement, and there were no physician's orders or care plan goals for self-administration of this medication. Staff B, the Director of Nursing, confirmed that the process for self-medication administration was not followed for Resident 39, as there was no complete assessment, education, or care plan in place for the Vitamin D supplement.
Failure to Accommodate Resident's Needs and Preferences
Penalty
Summary
The facility failed to accommodate the needs and preferences of Resident 6, who was admitted with chronic kidney disease, chronic lung disease, and muscle weakness. The comprehensive assessment indicated that Resident 6 had intact cognition and required assistance for transfers and toileting, using an electric wheelchair for mobility. However, the room arrangement did not allow Resident 6 to access or clean their bulletin board, which was important for them to hang Christmas cards. The pathway between the bed and desk was less than two feet, making it difficult for Resident 6 to maneuver their wheelchair and access the desk and bulletin board. Interviews with staff revealed a lack of awareness and follow-up regarding Resident 6's needs. Staff E, the Psychiatric Social Worker, stated that they assisted with furniture planning upon admission but did not follow up on furniture needs afterward. Staff V, an RN, and Staff W, the Resident Care Manager, both stated they relied on residents or their families to request accommodations, and were unaware of Resident 6's difficulties. The Director of Nursing, Staff B, also stated they were unaware of the issue and emphasized that staff should observe and report any environmental concerns. This lack of awareness and proactive accommodation placed Resident 6 at risk for a diminished quality of life and increased dependence on staff.
Failure to Ensure Accurate PASARR and Level II Evaluations
Penalty
Summary
The facility failed to ensure the accuracy of the Pre-Admission Screening and Resident Review (PASARR) and obtain Level II comprehensive evaluations for two residents, which placed them at risk of not receiving necessary mental health care and services. Resident 10, who was admitted with major depressive disorder (MDD), dementia, anxiety, and hallucinations, had a PASARR updated on 10/16/2023 that did not indicate the need for a Level II Behavioral Health Assessment despite serious mental illness indicators. Similarly, Resident 70, admitted with anxiety, insomnia, and dementia, was diagnosed with MDD on 04/02/2024, but their PASARR completed on 03/08/2024 did not reflect this new diagnosis or the need for a Level II Behavioral Assessment. During an interview, Staff D, a Psychiatric Social Worker, acknowledged that the process for updating PASARRs should include a review when there is a significant change or new diagnosis in a resident's physical or mental condition. Staff D confirmed that Resident 10 should have had an updated PASARR and been sent for a Level II Behavioral Health Assessment based on their diagnoses. Additionally, Resident 70 should have had a new PASARR completed following the diagnosis of MDD and been referred for a Level II Behavioral Assessment evaluation.
Failure to Update Care Plan for Resident with Frequent UTIs
Penalty
Summary
The facility failed to review and revise the care plan for a resident with a history of urinary tract infections (UTIs) and a suprapubic catheter. The resident, who was admitted with neuromuscular dysfunction of the bladder, diabetes, and moderate cognitive impairment, had been treated for UTIs four times over the past year. Despite this, the care plan interventions related to the resident's catheter and UTI history had not been updated since August 2023, even though the last revision was noted in November 2023. Interviews with facility staff revealed a lack of awareness and action regarding the frequency of the resident's UTIs. The Resident Care Manager acknowledged the oversight in reviewing recurring issues and updating care plans. The Infection Control Registered Nurse admitted to not conducting a thorough investigation into the causes of the frequent UTIs and had not provided specific education on UTI prevention and catheter care. The Director of Nursing Services recognized the need for a collaborative effort to address recurring UTIs but confirmed that this had not been done for the resident in question.
Failure to Timely Address Recurrent UTIs in Resident with Suprapubic Catheter
Penalty
Summary
The facility failed to comprehensively assess and address the recurrent urinary tract infections (UTIs) of Resident 17, who had a suprapubic catheter and a history of neuromuscular dysfunction of the bladder and diabetes. Observations revealed that the resident's urinary drainage bag was placed correctly below the bladder level, but contained yellow urine with large pieces of mucous and sediment, and there was a strong odor of urine in the room. The resident reported frequent leakage around the catheter insertion site and had been treated for UTIs multiple times. The medical records showed delays in initiating antibiotic treatment after urine cultures confirmed the presence of Proteus mirabilis, with treatment starting several days after the culture results were available. Interviews with facility staff revealed a lack of urgency in reviewing and acting upon abnormal urine culture results. Staff W, the Resident Care Manager, and Staff C, the Infection Control Registered Nurse, indicated that urine cultures were not considered urgent and were reviewed at the medical provider's convenience. Staff C admitted to not conducting a thorough investigation into the causes of the resident's recurrent UTIs or providing education on suprapubic catheter care. The Director of Nursing Services, Staff B, was unaware of the delay in reviewing urine cultures and stated that abnormal results should be communicated to the medical provider immediately. The facility's administrator also emphasized that UTI treatment should be initiated promptly, highlighting a disconnect between the facility's expectations and actual practices.
Inadequate Respiratory Care for Residents Using CPAP/BiPAP
Penalty
Summary
The facility failed to provide respiratory care in accordance with accepted standards of practice for two residents using CPAP and BiPAP devices. Resident 17, who has sleep apnea, diabetes, and heart failure, was observed with a BiPAP machine that had not been cleaned daily as per facility policy. The mask and tubing were found with oily residue, and the water chamber was not properly maintained. Resident 17 reported that the staff only cleaned the equipment sometimes, which may have contributed to a sinus infection treated with antibiotics. Resident 6, diagnosed with chronic kidney disease, chronic lung disease, and muscle weakness, also experienced inadequate maintenance of their CPAP machine. Observations revealed that the machine and its components were not cleaned regularly, with oily residue present on the mask. Despite having a cleaning device provided by the family, it was not utilized by the staff. Resident 6 confirmed that the machine had not been cleaned frequently, contrary to the facility's policy. Interviews with staff members, including nursing assistants and registered nurses, revealed a lack of adherence to the facility's cleaning policy for CPAP and BiPAP machines. Staff members were unclear about the specific cleaning frequencies, and there was no verification process to ensure compliance. The Infection Control Registered Nurse acknowledged that the cleaning directions did not align with the facility's policy, highlighting a significant lapse in infection control practices.
Improper Food Handling and Storage Practices
Penalty
Summary
The facility failed to ensure proper food handling and storage practices, particularly concerning residents' personal refrigerators and dining area condiments. Observations revealed that opened condiments requiring refrigeration were left on dining tables in the [NAME] House and Cayuse House, accessible to residents. These condiments, belonging to specific residents, were not stored according to manufacturers' recommendations, posing a risk of bacterial growth and foodborne illness. Additionally, personal refrigerators in residents' rooms were not monitored for temperature compliance. Observations showed that these refrigerators contained various food items, but lacked temperature logs and, in some cases, thermometers. Staff interviews indicated a lack of clarity regarding responsibility for monitoring and documenting refrigerator temperatures, with some staff unaware of the need for such monitoring. The facility's policy required internal thermometers and regular monitoring of personal refrigerators, but this was not adhered to. Staff interviews revealed inconsistencies in understanding and executing these responsibilities, with some staff unaware of the need to refrigerate certain condiments or monitor refrigerator temperatures. This lack of adherence to food safety protocols placed residents at risk of consuming expired or improperly stored food.
Infection Control Deficiencies in PPE and Hand Hygiene
Penalty
Summary
The facility failed to ensure staff adhered to infection prevention and control measures for the use of Personal Protective Equipment (PPE) and hand hygiene in the context of contact enteric precautions. This was observed in six out of seven staff members reviewed for infection control. The deficiencies were noted in the handling of a resident diagnosed with Clostridioides Difficile (C-diff), a highly contagious bacterium. The staff were required to perform hand hygiene, don an isolation gown, secure the straps/ties, and don gloves before entering the resident's room, and upon exiting, they were to remove the PPE and wash their hands with soap and water. Multiple observations revealed that staff members did not follow these protocols. Staff G, for instance, donned gloves and a gown without performing hand hygiene and did not secure the gown properly, leading to potential contamination. Upon exiting the room, Staff G used alcohol-based hand sanitizer (ABHS) instead of washing hands with soap and water. Similarly, Staff H entered the resident's room without performing hand hygiene, removed PPE improperly, and used ABHS instead of soap and water. Staff I also failed to perform hand hygiene before donning gloves and did not use soap and water after removing PPE. Further observations showed Staff L and Staff J also did not adhere to the required protocols. Staff L donned PPE without hand hygiene and exited the room with PPE still on, while Staff J initially entered the room without PPE and later used ABHS instead of washing hands with soap and water. The Infection Control Registered Nurse confirmed that the expectation was for staff to use ABHS, don PPE, and wash hands with soap and water after removing PPE, which was not followed. These actions placed residents, staff, and visitors at risk of exposure and cross-contamination of infectious diseases.
Inadequate Supervision Leads to Resident Elopement
Penalty
Summary
The facility failed to provide adequate supervision for a resident with dementia, who was at risk for elopement due to a history of wandering and exit-seeking behavior. The resident, who had moderately impaired cognition, was able to leave the facility unnoticed during the night and later returned without staff being aware of their absence. The resident's plan of care indicated they should not leave their house unattended after business hours, yet there were no alarms on the exit doors to alert staff of their departure. Additionally, a sign on the resident's door instructed night shift staff not to disturb them, which contributed to the lack of supervision. Staff interviews revealed that the night shift staff did not check on the resident due to the posted sign, and there were no audible alarms to alert them when the resident left the building. The resident had previously exhibited similar behavior, attempting to leave the facility at night, but staff did not implement measures to prevent recurrence. The resident's cognitive impairment and history of wandering were known, yet the facility did not ensure adequate supervision or safety measures to prevent elopement.
Medication Cart Security Lapse
Penalty
Summary
The facility failed to ensure that medication carts were locked when left unattended, as observed with two staff members, Staff B and Staff C. Staff B, a Registered Nurse, was seen preparing medications at a cart located in the main hallway. After placing medication cards in the cart drawer, Staff B closed the drawers but did not lock the cart before entering a resident's room and closing the door. The cart remained unlocked and unattended for nine minutes while Staff B was inside the room, assisting the resident. Staff B admitted to not locking the cart unless they were gone for longer periods and was unsure about the training received for securing the medication cart. Similarly, Staff C, another Registered Nurse, was observed preparing medications and entering a resident's room without locking the medication cart. The cart was left unlocked and unattended for four minutes while Staff C was inside the room, performing various tasks. Staff C stated that their normal process was to lock the cart when leaving it unattended, especially if they were in a resident's room, and acknowledged being trained by the facility to always lock the cart if it was unattended. The facility's administrator confirmed that leaving the medication cart unlocked was not the expected process and that the cart should always be locked when unattended.
Latest citations in Washington
Inaccurate PASARR screening affected two residents. One resident with vascular dementia, depression, and adjustment disorder had a PASARR level one that did not reflect mental health diagnoses, and staff stated it was inaccurate. Another resident with PTSD had a PASARR level one that did not include the PTSD diagnosis, with no additional PASARR level one or level two found in the EHR; staff stated the screening was not accurate and should have been repeated.
Undated open meds were found on 2 medication carts, including an open insulin vial and multiple open eye drop bottles with no dates. An LPN and an RN both stated the items should have been dated when opened, and the DON stated open multidose vials or bottles found without a date should be discarded immediately.
A resident with respiratory failure, HTN, and anxiety became SOB and diaphoretic, received a breathing tx, and was sent by EMS to the hospital. The facility could not locate the required SNF/NF to Hospital Transfer form or other transfer records showing what information was communicated to the receiving provider.
Care plans for two residents were not updated to match their current status and care needs. One resident had PTSD and generalized anxiety disorder and was receiving a psychotropic medication, but the care plan listed monitoring for antipsychotic and anticonvulsant meds that were not prescribed and did not include the anxiety diagnosis or related behaviors and interventions. Another resident had new upper and lower dentures, but the oral/dental care plan only noted edentulous status and difficulty chewing, with no mention of dentures or denture-related interventions.
Failure to Provide Individualized Activities: A resident with anxiety, depression, and weakness was cognitively intact but said they could not attend group activities because of leg problems and wanted more in-room activities. The resident mostly stayed in bed watching TV, and staff documentation showed only limited room visits with no consistent activity documentation despite a care plan goal for participation two to three times per week.
Failure to maintain heel offloading for a resident with a reopened DFU. A resident with dementia and dependence for mobility had a left heel wound that had healed and then reopened; the wound care provider recommended heel floating and pressure relieving boots at all times, but observations showed the resident in bed with heels on the mattress and later reclined in a wheelchair with the heel resting on the footrest strap and no boots in place. Staff stated the resident had not refused the boots or heel floating, and the care plan was not updated after the wound reopened.
Failure to Address Hearing and Vision Services for a Resident: A resident with dementia, bilateral hearing loss, and impaired vision was observed without eyeglasses or a hearing device, despite records showing admission with eyeglasses and a personal sound amplifier. The care plan addressed vision only and did not include hearing-related interventions, while staff interviews confirmed the resident’s hearing was strained and that the resident’s device use and vision needs were not fully reflected in the plan of care.
Respiratory care was not provided consistently for two residents receiving O2. One resident with COPD and chronic respiratory failure had an O2 order missing the indication for use and Sats parameters, no MAR documentation of O2 therapy, and inconsistent Sats charting. Another resident with respiratory failure was observed on continuous O2 via NC, but provider orders for O2 therapy and tubing changes were not present after readmission, despite the care plan stating the resident was dependent on O2.
A resident with dementia, hearing loss, and missing lower teeth had an MDS showing obvious or likely cavities or broken natural teeth, and the care plan identified oral/dental health problems with an intervention to coordinate dental care and transportation. Staff stated the resident’s dental needs were captured on the MDS, but no referral was made for dental services or follow-up with the dentist, and the DON said the lack of referral did not meet expectations.
Inaccurate Meal Intake Documentation: A resident with DM, dysphagia, and protein-calorie malnutrition was observed eating less than 25% of a meal, but the POC documented 76-100% intake. The CNA said the resident usually ate only 25-50% of meals and that intake was sometimes documented based on what a coworker reported. The LPN/RCM and DON stated meal intake should be documented accurately.
Inaccurate PASARR Screening for Two Residents
Penalty
Summary
The facility failed to ensure that two residents were screened for additional mental health supports through the PASARR process. Resident 97 was admitted with diagnoses including vascular dementia, depression, and adjustment disorder, and was able to make needs known. Review of the PASARR level one dated 04/10/2026 showed no mental health diagnoses and no need for a PASARR level two, even though the resident’s record included mental health diagnoses. During interview, the Regional Social Services staff and the Administrator stated the PASARR was inaccurate, needed modifications, and did not meet expectations. Resident 6 was admitted with diagnoses including heart failure, respiratory failure, and PTSD, and was able to make needs known. Review of the PASARR level one dated 03/30/2026 showed no serious mental illness indicators marked and no PASARR level two indicated, and the EHR contained no other documented PASARR level one or level two. The Social Services Director stated the hospital-provided PASARR was reviewed for accuracy and, if inaccurate, another level one would be completed, and stated this resident’s PASARR did not include PTSD and should have had another level one completed. The Administrator also stated the PASARR was not accurate and another level one needed to be conducted, but none could be located in the EHR.
Undated Open Medications on Medication Carts
Penalty
Summary
The facility failed to ensure proper storage and labeling of medications for 2 of 3 sampled medication carts reviewed for medication storage and labeling, including carts on the 400 and 500 halls. On the 500 hall medication cart, an open vial of insulin and an open bottle of eye drops were observed with no dates. During interview, an LPN stated that when an insulin vial or bottle of eye drops is opened, it should be dated immediately and said both items should have been dated upon opening; the LPN stated they would dispose of the undated vial and bottle. On the 400 hall medication cart, two open bottles of eye drops were observed with no dates. During interview, an RN stated both bottles should have been dated as soon as they were opened and said they would get new eye drops and dispose of the undated bottles. The DNS/RN stated that if an eye drop was opened it should have been dated immediately and that any open multidose vial or bottle found without a date should be discarded immediately.
Missing Hospital Transfer Documentation
Penalty
Summary
The facility failed to ensure hospital transfer documentation was completed for one resident who was transferred to the hospital after complaining of not being able to breathe and appearing diaphoretic. The resident had diagnoses of respiratory failure, high blood pressure, and anxiety disorder, and was able to make needs known. A breathing treatment was provided, and the provider agreed to send the resident out for further evaluation, after which emergency transportation took the resident to the hospital. Record review found no documentation showing what information was provided or communicated to the receiving facility for the transfer. Staff stated that transfer documentation should have included a SNF/NF to Hospital Transfer form, the resident's face sheet, and the medication and treatment administration records, but they were unable to locate documentation showing these items were completed or sent for the resident's hospital transfer.
Care plans did not reflect current diagnoses, medications, or denture status
Penalty
Summary
The facility failed to ensure that care plans were revised and accurately reflected residents’ current status and care needs for 2 of 21 sampled residents. Resident 6 was admitted with diagnoses including heart failure, respiratory failure, and PTSD, and was able to make needs known. The EHR showed Resident 6 also had generalized anxiety disorder and was receiving a psychotropic medication, but the current care plan dated 05/05/2026 documented monitoring for side effects of antipsychotic and anticonvulsant medications even though Resident 6 was not prescribed those medications. The care plan also identified PTSD but did not include generalized anxiety disorder or behaviors to monitor and interventions related to PTSD or anxiety disorder. Staff F, LPN/CC, stated the care plan did not accurately reflect the resident’s current status or prescribed medications, and Staff B, DNS, stated it did not meet expectations because it did not address the anxiety disorder or target behaviors and interventions. Resident 71 was admitted with diagnoses including PTSD, high blood pressure, and depression and was able to make needs known. Observation on 05/06/2026 showed a denture cup by the sink with the resident’s name on the lid and new upper and lower dentures dated 01/12/26. The resident stated the lower dentures did not fit well and that denture adhesive had been provided, but the dentures still did not fit right and the resident had not told staff yet. The focused oral/dental care plan, initiated on 06/23/2026, identified the resident as edentulous and having difficulty chewing, but did not show that the resident had dentures or include interventions related to denture use or maintenance. Staff E, CNA, stated they had not seen the resident wear dentures and were unaware of the new dentures, Staff C, LPN/CC, stated the care plan should have been updated when the dentures were obtained, and Staff B, DNS, stated the care plan should have reflected the dentures and interventions.
Failure to Provide Individualized Activities
Penalty
Summary
The facility failed to provide individualized activities for Resident 5, who was admitted with diagnoses including anxiety disorder, depression, and weakness. The admission MDS dated 01/14/2026 showed the resident was cognitively intact. During interviews on 05/03/2026 and 05/06/2026, Resident 5 stated they could not attend in-person activities because of their legs, wanted more activities to occupy them, mostly stayed in bed watching TV, and did not remember the last time activities staff visited to offer activities. The resident also stated activities staff would need to offer something they were able to do because they had difficulty doing some activities. The activities care plan dated 12/26/2026 showed a goal for Resident 5 to participate in activities two to three times per week. Progress notes documented one visit on 12/22/2026 to provide a welcome packet and encourage participation in daily activities, but no further activity documentation was found in the progress notes. Staff H stated room visits should include puzzles, arts and crafts, visiting, and chatting, and that documentation was placed in tasks, but the task record showed no documentation of activities for the past 30 days. Staff J stated paper documentation existed for room visits and that Resident 5 was on a list for room visits every Monday and Wednesday, while the room visit documentation showed only four visits on 01/26/2026, 02/06/2026, 03/10/2026, and 04/08/2026.
Failure to Maintain Heel Offloading for Reopened DFU
Penalty
Summary
The facility failed to consistently implement pressure reducing strategies for a resident with a left heel diabetic foot ulcer that had reopened. The resident was admitted with diagnoses including left hip fracture with surgical repair, a blood clot of the left lower leg, and dementia, and was dependent on staff for mobility and unable to make needs known. The baseline care plan and care plan both included heel offloading interventions, and the wound care provider initially recommended heel floating with pillows or wedge and pressure relieving boots. The wound later resolved, but a weekly skin assessment documented that the left heel wound reopened and was very painful to touch. After the wound reopened, the contracted wound care provider documented that the DFU to the left heel had reopened and recommended the resident wear pressure relieving boots at all times. The current care plan reviewed after the wound reopened did not include new interventions related to the reopened wound. Observations showed the resident seated in a reclined wheelchair with the left foot/heel resting on the footrest strap and no pressure relieving boots in place, and later lying in bed with both heels directly on the mattress without being floated and without boots. Staff interviews indicated the resident had not refused the boots or heel floating, and the LPN/CC and DON stated the resident should have been assessed and the plan of care updated when the wound reopened.
Failure to Address Resident Hearing and Vision Needs
Penalty
Summary
The facility failed to address one resident’s hearing and vision needs. Resident 112 was admitted with diagnoses including a leg fracture, dementia, and hearing loss in both ears, and was able to make needs known. The record showed the resident lost their glasses and was given readers, but the resident did not wear them because they were concerned that wearing glasses that were not their prescription would further degrade their vision. Observation did not show glasses in the resident’s room, and the resident stated they did not use a hearing aid. The resident was observed to be hard of hearing, requiring an elevated voice and repeated questions to understand. The admission MDS dated [DATE] documented adequate hearing with hearing aid and adequate vision with corrective lenses, while the significant change MDS dated [DATE] documented moderate difficulty hearing without a hearing aid and impaired vision without corrective lenses. The care plan initiated 02/24/2026 addressed impaired vision with interventions to arrange consultation with eye care practitioners as needed and remind the resident to wear glasses, but it did not include a focus area or interventions for hearing loss or use of hearing aids. A resident clothing list showed the resident admitted with one pair of eyeglasses and one Super Ear headset personal sound amplifier, yet observation and interview showed the resident in bed without eyeglasses or a hearing device, with the amplifier stored in the bedside table drawer. Staff interviews confirmed the resident’s hearing was strained, that the hearing device and glasses were not being used, and that the resident’s hearing device use should have been included in the plan of care and the resident should have been referred for eye care assessment.
Respiratory Care Orders and Documentation Not Maintained
Penalty
Summary
The facility failed to provide respiratory care consistent with professional standards of practice for two residents receiving oxygen therapy. One resident with COPD and chronic respiratory failure with hypoxia was observed multiple times lying in bed receiving oxygen at 2 L via nasal cannula. The resident’s oxygen order, dated 02/15/2026, allowed 1 to 4 L per minute continuously via nasal cannula, but it did not include an indication for use or oxygen saturation parameters. The April and May 2026 MARs did not show documentation of oxygen therapy being provided, and the TARs showed only an order to change oxygen tubing if damaged or visibly soiled, not an order for oxygen therapy. Oxygen saturations were not documented consistently daily from 04/01/2026 through 05/04/2026. A second resident with respiratory failure, high blood pressure, and anxiety disorder was observed in the room receiving oxygen at 6 L via nasal cannula on multiple occasions. The resident stated they needed oxygen therapy to breathe, and the care plan identified the resident as dependent on oxygen and to receive oxygen per provider orders. However, provider orders reviewed on 05/04/2026 showed no orders for oxygen therapy or for changing oxygen tubing. Staff stated the oxygen and tubing-change orders had been discontinued when the resident went to the hospital and were not added back to the MAR or TAR when the resident readmitted to the facility.
Failure to Refer Resident With Identified Dental Needs
Penalty
Summary
The facility failed to ensure that Resident 112 received needed dental care. Resident 112 was admitted with diagnoses including a leg fracture, dementia, and hearing loss in both ears. Observation on 05/03/2026 showed the resident had missing lower teeth. The admission MDS, dated [DATE], documented obvious or likely cavities or broken natural teeth, and the care plan dated 02/24/2026 identified oral/dental health problems related to likely cavities or broken teeth with an intervention to coordinate dental care and provide transportation. During interviews, Staff G, Regional Social Services, stated Resident 112's dental needs were captured on the 02/24/2026 MDS and the resident was not referred for dental services. Staff M, Social Services Director, stated residents with dental needs should be referred to social services to be scheduled for assessment by a dental care practitioner, and that Resident 112 should have been referred after the MDS assessment. Staff B, DON, stated residents with identified dental needs should be referred for follow-up with a dentist and that Resident 112 should have been referred to the in-house dental provider; Staff B stated the lack of referral did not meet expectations.
Inaccurate Meal Intake Documentation
Penalty
Summary
The facility failed to accurately document the amount of food eaten for Resident 13, who was admitted with diagnoses including diabetes mellitus, dysphagia, and protein-calorie malnutrition. The quarterly MDS dated 02/12/2026 showed the resident was moderately cognitively impaired. During observation on 05/05/2026 at 12:09 PM, a meal tray was delivered to the resident’s room, set up on a bedside table, and the resident was observed eating slowly, eating less than 25% of the meal, then laying back in bed and closing their eyes while the tray remained in the room. Staff later removed the tray, but the POC documentation for lunch on 05/05/2026 recorded that Resident 13 ate 76-100% of the meal. During interview, the CNA stated the resident typically ate 25-50% of meals and never ate all of the food, and that if they did not pick up a tray they would ask a coworker what the resident ate before documenting it. The CNA stated they were told the resident ate 75-100% of lunch, so that is what was entered. The LPN/RCM stated staff should document meal intake accurately in POC, and the RN/DNS stated it was their expectation that all staff document meal intake accurately.
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