Alaska Gardens Health And Rehabilitation
Inspection history, citations, penalties and survey trends for this long-term care facility in Tacoma, Washington.
- Location
- 6220 South Alaska Street, Tacoma, Washington 98408
- CMS Provider Number
- 505483
- Inspections on file
- 36
- Latest survey
- May 7, 2026
- Citations (last 12 mo.)
- 21 (1 serious)
Citation history
Health deficiencies cited at Alaska Gardens Health And Rehabilitation during CMS and state inspections, most recent first.
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.
Call Light System Not Functioning in 500 Hall: A facility failed to ensure the call light system worked in the 500 hall bathroom and bathing area. Repeated observations showed the panel light stayed on while the light above the room did not illuminate, and one room's bed B call light did not light at either the door or the panel. The maintenance log also showed repeated call light issues, and the MDS stated the panel was sometimes reset when the error occurred.
Daily nurse staffing postings were not properly displayed in a prominent location and did not include the facility name or the actual total number and actual nursing hours worked. The posting was only on a bulletin board that could be missed from part of the lobby, and staff reported the form showed scheduled rather than actual staffing information; one observation also showed the prior day's posting instead of the current day.
A resident who required CPR did not receive immediate basic life support due to unclear protocols, staff confusion about code status verification, and delays in initiating emergency procedures. Crash carts were found with missing or expired supplies, inconsistent checklists, and incomplete documentation. The system for maintaining and accessing POLST forms was disorganized, with forms missing or filed incorrectly, leading to uncertainty among staff about residents' code status.
Two nursing staff members, an LPN and an RN, were found to have expired CPR certifications and demonstrated insufficient knowledge regarding CPR procedures and required equipment. Facility policy required current CPR certification for all licensed nurses, but interviews and record reviews revealed lapses in compliance and knowledge, placing residents at risk for unmet care needs.
A nurse was employed and worked full time without holding a valid multistate license to practice in the state. The nurse provided care to a resident who experienced a change in condition and required CPR, despite only being licensed in another state. Staff responsible for verifying licensure could not explain how the nurse was allowed to work without proper authorization.
Multiple residents reported disrespectful and unprofessional behavior from staff, including negative interactions, demeaning attire, and lack of communication about medications. Delays in call light response times were also noted, with some residents waiting up to two hours for assistance and feeling ignored or devalued. These issues were acknowledged by facility leadership.
The facility did not timely issue refunds to two residents or their representatives after discharge or death, resulting in significant delays and miscommunication. One resident's refund was delayed due to billing errors and mailing issues, while another resident's trust fund balance was not promptly conveyed after death, contrary to policy and regulatory requirements.
Surveyors found that two medication storage refrigerators containing lorazepam were left unlocked, with narcotic lock boxes either open or inoperable. Additionally, two medication carts contained multiple opened but undated eye medications and an insulin pen, which staff confirmed were being administered to residents. Facility policy requires these medications to be secured and dated upon opening, but these procedures were not followed.
The facility did not identify or investigate multiple allegations of abuse and neglect, including delayed pain medication administration by an LPN, a resident-to-resident incident during activities, and concerns about the administrator's behavior causing residents to feel unsafe or avoidant. These incidents were not documented or reported according to policy, and no investigations were initiated.
A resident with diabetes and dementia, who was assessed as having impaired vision and without corrective lenses, did not have a baseline care plan developed to address their vision needs within 48 hours of admission. The care plan lacked interventions to obtain eyeglasses or arrange for new ones, despite the resident expressing this need.
Three residents did not have care plans that accurately reflected their current medical needs or timely care conferences. One resident with respiratory failure lacked a care plan for their condition, another was not informed about their care and missed a scheduled care conference, and a third had a care plan that did not match the updated fluid restriction order. Staff confirmed these deficiencies and acknowledged that care plans and conferences were not managed as required.
A resident with aphasia and hearing impairment was left without a required whiteboard for communication, as specified in their care plan. Despite staff awareness of the need for the device, it was missing for several days and not replaced, resulting in the resident being unable to effectively communicate with staff.
Two residents dependent on staff for ADL support were not consistently offered shaving or dressed in clean clothing. One resident with upper extremity impairment was repeatedly observed with facial hair and reported not being offered shaving, while another was seen wearing a visibly soiled shirt for several days due to a lack of clean clothes. Staff interviews confirmed these lapses in care and a lack of adherence to facility expectations.
Two residents with renal disease and physician-ordered fluid restrictions received fluids in excess of their prescribed limits due to inconsistent documentation, lack of communication between nursing and dietary staff, and failure to notify the provider when restrictions were exceeded. Staff interviews and record reviews revealed that fluid intake was not accurately tracked, dietary staff were unaware of restrictions, and residents' meal trays did not reflect fluid limitations.
A resident with a history of diabetes, depression, and muscle weakness experienced broken and missing teeth and reported oral pain. Despite referrals from an RDH for dental care, there was no documentation in the EHR of a dental visit or follow-up, and required dental reports were not reviewed or signed by nursing staff. The facility failed to obtain and include dental visit documentation, resulting in unmet dental needs and incomplete records.
A resident with diabetes and renal failure, who was missing upper and lower teeth and requested dental care, was referred by an RDH for dental and denturist services. However, the referral was not promptly acted upon, with no documentation of follow-up or scheduled dental visits, and staff were unaware of the referral until later interviews.
Staff failed to ensure that equipment and surfaces remained cleanable, as evidenced by a resident's wheelchair with a torn armrest exposing uncleanable foam padding and numerous stained shoelaces tied to a bathroom handrail. Both an LPN and the DON acknowledged these items did not meet expectations for cleanable surfaces.
A resident with end stage renal disease and diabetes, who required two-person assistance for bed mobility per their care plan, was assisted by only one CNA during repositioning. This led to the resident falling from the bed and sustaining a fractured arm. Staff and leadership confirmed that the care plan was not followed, resulting in harm.
The facility failed to provide adequate nutrition and hydration, resulting in severe health issues for several residents. One resident was hospitalized with aspiration pneumonia and severe dehydration due to inadequate care planning and monitoring. Another resident experienced repeated hospitalizations for dehydration and uncontrolled blood sugars, with significant delays in addressing critical lab values. A third resident suffered a significant weight loss without proper monitoring or timely intervention. The facility's deficiencies in care planning and monitoring placed residents at risk for further health complications.
The facility failed to implement effective fall prevention measures for three residents, leading to multiple falls and injuries. A resident with a history of falls experienced three falls, resulting in a hip fracture and over-sedation. Another resident fell twice in one night, with incomplete investigations and untimely care plan updates. A third resident fell from their bed, with inadequate post-fall monitoring and communication of interventions to staff.
The facility failed to provide adequate pain management for three residents, leading to significant harm. One resident experienced harm due to delayed pain medication administration and lack of monitoring for opioid use, resulting in hospital transfer and surgical intervention. Another resident's pain complaints were unaddressed, leading to a hospital transfer for a hip fracture. A third resident did not receive scheduled pain medications due to communication failures, and their pain was not adequately assessed or documented.
The facility failed to implement baseline care plans within 48 hours of admission for several residents, leading to unmet care needs and potential health risks. Residents with complex medical conditions, such as heart failure and post-surgical needs, did not receive comprehensive care plans, resulting in inadequate care and communication issues. This deficiency highlights the facility's inability to provide timely and effective care planning.
The facility failed to ensure effective use of resources and maintain compliance due to inadequate administrative oversight in the absence of the DNS and Regional President of Clinicals. The lack of an ADNS and the RCM not being appointed as acting DNS led to the Administrator assuming responsibility for clinical oversight. This resulted in repeated citations for Quality of Care and Significant Medication Errors, and an Immediate Jeopardy related to nutritional care for 11 residents. Additionally, the facility failed to implement a QAPI program and educate staff on its goals.
The facility's QAPI Committee failed to identify and address deficiencies, including medication errors, nutrition monitoring, fall care plan implementation, and training compliance. The committee did not recognize issues in the new resident admission process, leading to medication availability problems. Additionally, the facility did not ensure proper nutrition for tube feeding-dependent residents or track CNA training hours.
The facility failed to thoroughly investigate incidents and alleged violations involving three residents, leading to unaddressed falls, neglect allegations, and unreported wounds. A resident with cognitive issues experienced multiple falls without proper documentation or investigation. Another resident faced neglect allegations due to inadequate care and unexpected death, while a third resident was discharged with unreported wounds. The facility's investigations were incomplete, lacking necessary documentation and analysis.
The facility failed to meet professional standards by not holding anti-hypertensive medications when vital signs were outside parameters, delaying lab specimen collection and reporting, and lacking consistent documentation for skilled nursing care. These deficiencies affected multiple residents, potentially impacting their quality of care.
A facility failed to provide adequate care for residents, including not conducting weekly skin checks, failing to monitor surgical wounds, and not following heart failure management protocols. This led to unreported wounds, infections, and multiple rehospitalizations.
A facility failed to ensure residents were free from significant medication errors, affecting 12 residents. Errors included lack of medication reconciliation, incorrect transcription, and untimely administration. Residents experienced missed doses, unavailability of medications, and unreported errors, leading to risks of adverse events and diminished care quality.
The facility failed to provide required annual training for four NACs, as outlined in their Facility Assessment. Missing documentation for trainings in Resident Rights, Change of Condition, Person-Centered Care, and Activities of Daily Living was confirmed by the Staff Development Coordinator and the Regional President of Clinicals. This deficiency placed residents at risk for unmet care needs.
The facility failed to provide mandatory QAPI training to four CNAs, as confirmed by interviews and record reviews. Staff R admitted to not knowing about the QAPI committee, and the Staff Development Coordinator confirmed the lack of training for Staff Q. The facility could not provide documentation for the required annual training for Staff R, S, and T, and no specific QAPI curriculum was available.
A facility failed to notify a resident's court-appointed guardian of a new antibiotic order for a skin infection. The resident, who was moderately cognitively impaired, had a communication deficit and required assistance with personal care. Staff A confirmed the order but did not inform the guardian, while Staff B was unaware of the order, leading to a lack of communication and documentation.
A facility failed to document and monitor a resident's hematoma on their left leg, lacking measurable and descriptive baselines. Despite orders to monitor and notify the provider of changes, records only indicated monitoring without detailed documentation. Staff interviews confirmed no treatments or measurements were performed, and the DON acknowledged the lack of documentation hindered the ability to assess the hematoma's progression.
A resident with COPD did not receive their prescribed respiratory medication, Trelegy, for eight days due to unavailability and lack of communication with the medical provider. The resident experienced distress and shortness of breath during this period. The DNS noted that staff should have taken steps to address the medication's unavailability, including contacting the pharmacy and notifying the doctor.
The facility failed to notify the DPOA for two residents about changes in their medication orders, including morphine for a resident receiving hospice care and an increased dose of Depakote for another resident with dementia. Despite staff expectations to inform and document such changes, there was no record of notification to the residents' representatives.
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.
Call Light System Not Functioning in 500 Hall
Penalty
Summary
The facility failed to ensure the call light system was functioning in the 500 hall bathroom and bathing area. On 05/03/2026, 05/04/2026, and twice on 05/07/2026, observations showed the call light panel in the 500 hall with a room light lit while the call light above the room was not lit. The maintenance log for the 500 hall also documented call light issues on 03/03/2026, 03/06/2026, 04/10/2026, and 05/03/2026 for call lights not turning off. During an observation on 05/07/2026, the call light for room [ROOM NUMBER] bed B did not light above the door or at the call panel. In interview, the Maintenance Director stated the system was checked through periodic audits and review of the maintenance binder, and that the panel was reset when the error occurred. The Administrator stated the light on the call light panel should turn off when the light at the door was turned off, and that observations of them not turning off did not meet expectations.
Daily Nurse Staffing Posting Not Properly Displayed
Penalty
Summary
The facility failed to post the daily nurse staffing data in a prominent place that included the facility name and the total number and actual hours worked for nursing staff for 5 of 5 observed days during the survey period. On 05/03/2026 at 9:00 AM, the front entrance, receptionist desk, and lobby areas had no daily nurse staffing data posted. On 05/04/2026 at 11:00 AM, 05/05/2026 at 6:16 AM, 05/06/2026 at 8:55 AM, and 03/07/2026 at 8:51 AM, the staffing postings were located on a glass-covered bulletin board to the left of a wall picture and grandfather clock after entering the front entrance and turning left toward the 100/200 halls, and could be missed by someone turning right toward the 300 hall. The postings reviewed did not include the facility's name and did not show actual total number or actual nursing staff hours; instead, the form showed "Actual Scheduled Staff" and "Actual Scheduled Hours." On 05/05/2026 at 6:16 AM, the posting displayed staffing information for the previous day, while a later observation at 8:03 AM showed the correct date posted. During interview, the Staffing Coordinator stated the bulletin board was the only location for postings, did not know why the form lacked the facility name, and said the form had been that way since February 2026. The Administrator stated the nurse staffing postings were posted the day before for the next day and typically revised within 24 hours as needed, but could not explain why the form did not have the facility's name or why actuals were not posted.
Failure to Ensure Immediate CPR and Maintain Crash Cart Readiness
Penalty
Summary
The facility failed to ensure that basic life support, including CPR, was initiated immediately and according to policy for a resident who experienced an unexpected death. The facility did not have a clear, written policy or protocol outlining the procedures, documentation expectations, or staff responsibilities during a cardiac or respiratory arrest event. Staff interviews revealed confusion regarding who was responsible for initiating CPR, how to verify code status, and how to call a Code Blue. There were also inconsistencies in staff statements about the sequence of events, with delays in recognizing the resident's unresponsiveness, checking for a pulse, and notifying a nurse. Additionally, some staff members were not current in their CPR certification, and there was uncertainty about whether nursing assistants could initiate CPR if they were certified and knew the resident's code status. The facility's crash carts were not consistently stocked with required, unexpired supplies and equipment necessary for immediate use during a code event. Observations showed missing or expired items such as blood glucose test strips, non-rebreather masks, oral airways, and oxygen tanks that were not full. There were discrepancies between different crash cart checklists, leading to confusion about what items should be present and how equipment should be set up. Some crash carts lacked essential documentation forms, and daily checks were not consistently documented or performed as required. The facility also had an AED that was not readily accessible or in a designated location for emergency use. The system for maintaining and accessing residents' Physician Orders for Life-Sustaining Treatment (POLST) was disorganized and unreliable. POLST forms were missing, filed under incorrect room numbers, or not updated to reflect residents' current locations. There were inconsistencies between posted code status lists and the actual POLST forms in the binders. Staff were unclear about where to find residents' code status information, with some relying on electronic records, binders, or posted lists, and others unsure of the process. These failures placed numerous residents with current POLSTs requesting CPR at serious risk for adverse outcomes.
Removal Plan
- Audited the records of all residents
- Audited the POLST binders
- Audited and stocked the crash carts
- Updated the facility CPR policy
- Educated staff on the facility's CPR Policy and Code Blue Emergency process during CPR
- Audited and ensured licensed staff had current CPR training
- Implemented a plan of correction to sustain ongoing compliance
Expired CPR Certifications and Inadequate Staff Competency
Penalty
Summary
The facility failed to ensure that nursing staff possessed the appropriate knowledge, competencies, and skill sets necessary to provide nursing and related services, including Cardio-Pulmonary Resuscitation (CPR), as required by facility policy and regulatory standards. Specifically, two staff members, an LPN and an RN, were found to have expired CPR certifications upon review. During interviews, the LPN was unable to identify the necessary equipment for responding to respiratory arrest or performing CPR, only mentioning 'hands' and failing to name other required equipment. The RN stated they had received CPR training and claimed to have current certification, but documentation showed their certification was also expired. Additionally, the facility's policy required all licensed nurses to maintain current CPR certification, with routine reviews to validate compliance. However, interviews with administrative staff revealed that while CPR certification was mandatory for nurses, it was only recommended for nursing assistants, and there were ongoing efforts to schedule another CPR class. These findings demonstrate that the facility did not ensure all nursing staff maintained the required competencies and certifications to provide safe and effective care, as evidenced by expired certifications and lack of knowledge regarding emergency procedures.
Nurse Employed Without Valid State License
Penalty
Summary
The facility failed to ensure that a registered nurse (Staff C) employed at the facility held a valid multistate license authorizing practice in the state where the facility is located. Staff C was hired with only a California State RN license, which did not permit practice in the facility's state. Staff C worked full time and was involved in the care of a resident who experienced a change in condition and subsequently coded, requiring CPR and emergency medical intervention. Record review and staff interviews confirmed that Staff C was not authorized to practice in the state, and staff responsible for license verification were unable to explain how this oversight occurred.
Failure to Maintain Resident Dignity and Timely Response to Needs
Penalty
Summary
The facility failed to ensure that care and services were provided in a manner that maintained and promoted dignity and respect for eight of nine residents interviewed. Multiple residents reported negative interactions with staff, including a nursing assistant who responded to a resident's apology by loudly calling for another aide and leaving the resident exposed, as well as wearing attire perceived as demeaning. Residents described staff as disrespectful, belittling, and unprofessional, with one resident sharing that staff wore a shirt with an offensive caption and another stating that staff acted as if they were more important than the residents. Several residents also reported significant delays in call light response times, ranging from 30 minutes to two hours, and described staff as dismissive or unresponsive to their needs, including requests for pain medication. Residents expressed frustration and feelings of being ignored or devalued, with some stating that staff did not inform them about the medications being administered and others noting that their requests were not fulfilled even after long waits. These findings were acknowledged by the facility's administrator and director of nursing services.
Delayed Refunds to Residents and Representatives After Discharge or Death
Penalty
Summary
The facility failed to provide timely refunds to two residents or their representatives following discharge or death, as required by policy and regulation. For one resident who was discharged, the facility overbilled and delayed issuing a refund of $489.72. The refund process was prolonged due to miscommunication, changes in billing services, and errors in mailing the check, resulting in the resident's representative not receiving the funds until several months after discharge. The representative reported inconsistent information from the facility regarding the status of the refund, and the check was ultimately picked up at the facility after multiple reissuances. For another resident who passed away, the facility did not promptly convey the trust fund balance of $530.58 to the appropriate party. Staff waited for direction from the resident's representative regarding the use of the funds for funeral services, and after declining, the facility prepared to send the refund to the Office of Financial Recovery. These delays in refunding owed amounts did not comply with the facility's admission agreement or regulatory requirements, placing resident families and representatives at risk for financial hardship.
Failure to Secure Controlled Substances and Date Opened Medications
Penalty
Summary
Surveyors observed that the facility failed to properly secure controlled substances and to date medications as required by policy and regulation. Specifically, two of three medication storage refrigerators (ASSISI and Long-Term Care) were found unlocked while containing lorazepam, a Schedule IV controlled substance. In both cases, the narcotic lock boxes within the refrigerators were also left open or inoperable, and staff confirmed that these should have been locked and functional whenever controlled substances were present. Additionally, two of three medication carts (ASSISI and Long-Term 2) contained multiple opened but undated medications, including various ophthalmic drops and an insulin injector pen. Staff acknowledged that these medications were being administered to residents and should have been dated upon opening, in accordance with facility policy and manufacturer recommendations. The facility's own policies require that all medications, especially controlled substances, be stored securely and that medications be dated when opened to ensure their integrity and safe administration. During interviews, staff and the Director of Nursing Services confirmed that the observed practices did not meet these requirements. The deficiencies were identified through direct observation, staff interviews, and review of facility policies, with no mention of specific residents affected or adverse outcomes at the time of the survey.
Failure to Identify and Investigate Allegations of Abuse and Neglect
Penalty
Summary
The facility failed to identify and investigate allegations of abuse and neglect for four out of seven sampled residents. For one resident with a history of peritoneal abscess, ovarian cancer, muscle weakness, anxiety, and depression, there were repeated delays or omissions in administering PRN pain medication by an LPN, despite the resident communicating their needs to both CNAs and a nurse supervisor. The medication administration record showed a lack of timely pain medication administration during specific shifts, and the issue was not reported or investigated as required by facility policy. Another resident with bipolar disorder and borderline personality disorder reported being touched by another resident during an activity, which caused distress and led to withdrawal from activities. The incident was reported to the activity director, who spoke to the other resident but did not document the event or report it as required. There was no record of the incident in the grievance or incident logs, and the required investigation was not initiated. Additional concerns involved a resident with adjustment disorder and anxiety who reported fear and perceived retaliation from the administrator after filing a grievance, leading to self-isolation. Another resident with COPD and depression described the administrator as rude and avoided interactions. Multiple residents expressed concerns about the administrator's behavior, but these were not logged or investigated as potential abuse or neglect. The facility's failure to identify, document, and investigate these allegations did not meet the expectations outlined in their abuse and neglect policy.
Failure to Develop Baseline Care Plan for Vision Needs
Penalty
Summary
The facility failed to develop a baseline care plan with specific goals and interventions to address the immediate needs of a newly admitted resident within 48 hours of admission. The resident, who had diagnoses including diabetes and dementia and was able to communicate needs, was assessed as having impaired vision and did not have corrective lenses available at the facility. Despite the resident expressing a desire to have their eyeglasses brought from home, the care plan did not include any interventions or plans to obtain the eyeglasses or arrange for new ones. The omission was confirmed by review of the care plan and by interview with the Director of Nursing Services, who acknowledged that the baseline care plan should have addressed the resident's vision needs.
Failure to Revise and Update Care Plans and Conduct Timely Care Conferences
Penalty
Summary
The facility failed to ensure that care plans were revised and accurately reflected the care needs of three residents, and that care conferences occurred in a timely manner. For one resident with pulmonary fibrosis and chronic respiratory failure with hypoxia, there was no care plan addressing their respiratory conditions, despite the resident requiring oxygen therapy and having recent respiratory symptoms. Both a registered nurse and a care coordinator confirmed that a care plan for these conditions should have been in place upon admission. Another resident with multiple diagnoses, including heart, kidney, and liver disease, as well as diabetes and depression, reported being unaware of their medical plan of care and stated that staff had not discussed their medications, therapy, or treatments for some time. The social services director acknowledged that a scheduled care conference had been missed due to a glitch in the electronic health record system, and the director of nursing services confirmed that care conferences are typically organized by social services in coordination with nursing staff. A third resident, who was dependent on dialysis and had a fluid restriction order, had a care plan that did not reflect the most current provider order for fluid restriction. The care plan listed a 1000 ml per day restriction, while the provider's order had been updated to 1200 ml per day. Staff interviews confirmed that the care plan had not been revised to match the new order, and the director of nursing services stated that the care plan did not meet expectations.
Failure to Provide Communication Device for Resident with Aphasia
Penalty
Summary
The facility failed to maintain a resident's ability to communicate as outlined in their care plan. The resident, who had diagnoses including aphasia and adult failure to thrive, was admitted with the ability to communicate needs and was identified as hard of hearing. The care plan specified the use of a dry erase board to facilitate communication. However, during multiple observations, the resident was found in bed without a whiteboard present, despite signage indicating its use for communication. Staff interviews confirmed that the whiteboard, previously used to communicate with the resident, had been missing for some time and had not been replaced. Further interviews revealed that staff were aware of the care plan intervention but did not report the missing communication device, resulting in the resident being unable to effectively communicate with facility staff. The resident confirmed that staff did not use writing to communicate with them. The Director of Nursing Services acknowledged that communication devices should be kept at the bedside and missing devices should be reported, but this protocol was not followed in this instance.
Failure to Provide ADL Support: Residents Not Shaved or Dressed in Clean Clothing
Penalty
Summary
The facility failed to provide necessary care and services to ensure that two residents dependent on staff for activities of daily living (ADLs) were properly groomed and dressed in clean clothing. One resident, who had upper extremity impairment and required assistance with personal hygiene, was observed on multiple occasions with long facial hair around the chin area. The resident reported not always being offered shaving and expressed a desire to have facial hair removed, stating they had never refused when offered. Staff interviews revealed uncertainty about whether they could shave the resident, and the Director of Nursing Services was unaware that the resident had not been offered shaving, which did not meet facility expectations. Another resident, dependent on staff for personal hygiene and dressing due to conditions including COPD, dementia, and muscle weakness, was observed over several days wearing the same visibly soiled shirt. Staff confirmed that the resident received a bed bath but was not changed into clean clothes because their shirts had not returned from the laundry. Staff stated that the expectation was for residents to wear clean clothing at all times, and if clean clothes were unavailable, items from donations should be used. These findings were based on observations, interviews, and record reviews.
Failure to Monitor and Document Fluid Restrictions for Residents with Renal Disease
Penalty
Summary
The facility failed to monitor and accurately document fluid intake for two residents with physician-ordered fluid restrictions, resulting in the residents receiving fluids in excess of their prescribed limits. One resident, with a history of diabetes, renal failure, and dependence on dialysis, had a fluid restriction order of 1200 ml per 24 hours. However, documentation showed that on multiple occasions, the resident was provided with fluids exceeding this limit, with totals ranging from 1312 ml to 1672 ml in a 24-hour period. The provider was not notified when the fluid restriction was exceeded, and documentation was inconsistent or missing in several records, including the medication administration record (MAR), treatment administration record (TAR), and electronic health record (EHR). Staff interviews confirmed that the fluid restriction orders did not clearly specify the amount of fluid to be provided by dietary services, and that documentation of fluid intake was not consistently accurate or complete. Another resident, also dependent on dialysis and diagnosed with end stage renal disease, had a fluid restriction order of 1500 ml per 24 hours, with specific amounts to be provided by dietary and nursing staff. Review of records showed discrepancies between the fluids documented by nursing and those recorded by nursing assistants, with intake amounts documented as high as 1280 ml in a single shift. Additionally, the resident's meal tray ticket did not indicate a fluid restriction, and the dietary supervisor was unaware of the restriction, resulting in the kitchen not being informed of the need to limit fluids. Observations confirmed that the resident had access to multiple cups of fluid at the bedside, and staff interviews revealed a lack of awareness and communication regarding the fluid restriction. The deficiency was further evidenced by the lack of coordination between nursing and dietary departments, incomplete or inaccurate documentation of fluid intake, and failure to notify the provider when fluid restrictions were exceeded. Staff acknowledged that the orders were not followed as written, and that the documentation and communication processes did not meet expectations for ensuring compliance with physician-ordered fluid restrictions.
Failure to Provide Prompt Dental Care and Documentation
Penalty
Summary
The facility failed to provide prompt dental care and obtain post-visit dental documentation for one resident. The resident, who had a history of diabetes, depression, and muscle weakness, was observed to have broken and missing teeth and reported occasional oral pain. The resident had been referred by a Registered Dental Hygienist (RDH) for dental care on two separate occasions due to pain, but there was no documentation in the electronic health record (EHR) that the resident had been seen by a dentist or that a follow-up appointment was scheduled. The care plan indicated the need for dental care coordination, but this was not effectively carried out. Staff interviews revealed that the RDH's referrals were not properly communicated or documented, and the dental reports were not reviewed or signed by nursing staff as required. Although a dental appointment was scheduled and later confirmed to have occurred, the facility failed to obtain and include the dental visit documentation in the resident's EHR. The Social Services Director and Administrator both acknowledged that the expected documentation and follow-up were not present, and the dental summary report obtained later was unclear regarding the care provided. This lack of timely dental care and documentation did not meet facility expectations and requirements.
Failure to Provide Prompt Dental Services Following Referral
Penalty
Summary
A deficiency occurred when the facility failed to provide prompt dental services for a resident who was readmitted with diagnoses including diabetes and renal failure. The resident, who was able to communicate needs, was observed to have missing upper and lower teeth and expressed a desire to see a dentist for extractions and to obtain dentures or partial dentures. The resident's care plan included an intervention to refer to a facility dentist or dental hygienist as needed. Documentation showed that the resident was seen by a Registered Dental Hygienist (RDH), who referred the resident to a dentist and denturist after the resident requested dental care. Despite the RDH's referral, there was no evidence that the referral was acted upon in a timely manner. Staff interviews revealed that the RDH's report and referral were not noted by nursing staff or a provider, and there was no documentation explaining why the resident had not seen a dentist. The Social Services Director reported submitting a referral through a dental portal but could not provide documentation of the submission or any follow-up. The administrator confirmed the lack of documentation and was unable to explain the delay in dental care, noting that this did not meet expectations.
Failure to Maintain Cleanable Equipment and Surfaces
Penalty
Summary
Facility staff failed to maintain essential equipment in a manner that allowed for proper disinfection on one of five sampled halls. Observations revealed that a resident was using a wheelchair with a torn left-hand armrest, where the vinyl covering had worn away, exposing the underlying foam padding. This exposed foam was not a cleanable surface. The resident confirmed that the armrest had been damaged for some time, and subsequent observations showed the damage persisted over several days. Additionally, in another room, approximately 25 shoelaces were found tied to the handrail next to the toilet. These shoelaces were stained with brown material and were not cleanable. The shoelaces remained in place over multiple days. Interviews with staff, including an LPN/Care Coordinator and the DON, confirmed that both the damaged wheelchair armrest and the stained shoelaces did not meet facility expectations for cleanable surfaces and should have been reported for repair or removal.
Failure to Provide Two-Person Assistance for Bed Mobility Resulting in Resident Injury
Penalty
Summary
A deficiency occurred when a resident, admitted with end stage renal disease and diabetes and receiving dialysis, did not receive the required level of assistance for bed mobility as specified in their care plan. The care plan, updated on 11/20/2024, indicated that the resident required two-person extensive assistance for repositioning and turning in bed. However, on 04/12/2025, the resident was assisted by only one CNA during bed mobility, contrary to the care plan instructions. As a result of this deviation from the care plan, the resident slid from the bed while being changed, fell to the floor, and sustained a fractured right humerus. Interviews with staff and facility leadership confirmed that staff are expected to follow the care plan and use the Kardex to determine the required number of staff for such tasks. The incident investigation determined that the CNA performed bed mobility alone, which was not in accordance with the resident's documented needs.
Failure to Provide Adequate Nutrition and Hydration
Penalty
Summary
The facility failed to ensure residents received adequate nutrition and hydration, leading to significant health issues for multiple residents. Resident 20 was admitted to the hospital with aspiration pneumonia, sepsis, severe dehydration, severe malnutrition, and acute kidney injury. The facility did not accurately assess and develop a care plan to prevent aspiration pneumonia, failed to monitor and document nutritional status, and did not provide physician-ordered oral care. Additionally, the facility did not maintain the head of the bed elevation as required, contributing to the resident's condition. Resident 22 experienced repeated hospitalizations due to dehydration and uncontrolled blood sugars. The facility failed to assess the resident's feeding tube status, did not develop care plan interventions to prevent dehydration, and delayed implementing physician orders to correct electrolyte imbalances. The resident's tube feeding was not documented for 18 days, and there was a significant delay in addressing critical lab values, leading to further deterioration of the resident's health. Resident 40 suffered a significant unplanned weight loss of 20 pounds in two weeks. The facility did not develop a person-centered nutrition care plan, failed to monitor weights consistently, and did not evaluate oral intake. The resident's responsible party was not informed of the weight loss, and there was a delay in starting ordered IV fluids for rehydration. The facility's lack of timely intervention and monitoring placed the resident at risk for further health complications.
Failure to Implement Effective Fall Prevention Measures
Penalty
Summary
The facility failed to develop and implement a resident-centered fall prevention care plan for three residents, leading to multiple falls and injuries. Resident 1, who had a history of falls and was at high risk due to conditions such as Parkinson's disease and atrial fibrillation, experienced three falls. The facility did not consistently monitor Resident 1 for post-fall injuries, update their care plan in a timely manner, or ensure that interventions were communicated to staff. After the third fall, Resident 1 was found to have a hip fracture and was over-sedated due to psychotropic medications. Resident 8, who had moderate cognition problems and required assistance for activities of daily living, experienced two falls in one night. The facility's investigation into these falls was incomplete, lacking details about the circumstances and necessary interventions. The care plan was not updated with timely interventions, and there was no consistent post-fall monitoring or documentation of physician notification. Resident 11, who had cognition problems and required assistance with activities of daily living, fell from their bed. The facility did not document consistent post-fall monitoring or notify the physician and responsible party. The care plan interventions were not effectively communicated to staff, as evidenced by the lack of implementation of specific interventions such as placing the bed in the lowest position and against the wall.
Inadequate Pain Management Leads to Harm in Residents
Penalty
Summary
The facility failed to provide adequate pain management for three residents, leading to significant harm. Resident 2 experienced harm due to the facility's failure to accurately transcribe and clarify admission orders for pain medications, resulting in delayed administration of scheduled pain medications. The facility also failed to evaluate the underlying cause of Resident 2's sudden onset of severe chest pain and shortness of breath after open-heart surgery. This resident was not monitored for adverse effects of opioid use and was transferred to the hospital in acute respiratory failure, where it was discovered that they had broken chest wires requiring surgical intervention. Resident 1 suffered harm when their complaints of pain were not addressed, and their behavioral signs of pain were not evaluated. The facility did not monitor Resident 1 for post-fall injuries, and they were transferred to the hospital, where a new hip fracture requiring surgical intervention was discovered. The facility's pain care plan for Resident 1 lacked person-centered interventions, and there was no evidence of non-medication interventions or PRN pain medications being provided. Resident 13, who was non-English speaking and required an interpreter, did not receive their scheduled pain medications due to a failure in communication with the pharmacy. The facility did not implement non-medication pain interventions, and Resident 13's pain was not adequately assessed or documented. The lack of translation services further hindered the staff's ability to assess and manage Resident 13's pain effectively.
Failure to Implement Baseline Care Plans
Penalty
Summary
The facility failed to develop and implement baseline care plans within 48 hours of admission for five residents, which is a requirement to address their immediate health and safety needs. This deficiency was observed in the cases of Residents 1, 2, 8, 19, and 13, where the facility did not provide written summaries of the baseline care plans to the residents or their responsible parties in a language they understood. The absence of these care plans led to a lack of clear instructions for direct care staff, resulting in unmet care needs and potential risks to the residents' health and safety. Resident 2, who was admitted with chronic heart failure and post-surgical needs, did not receive a comprehensive care plan that included necessary instructions for diet, heart failure management, and other critical care needs. The resident reported not receiving expected care, such as proper wound care and blood sugar monitoring, which contributed to their rehospitalization. Similarly, Resident 8, who had specific needs related to a stroke and tube feeding, did not have these needs addressed in their care plan, and their responsible party confirmed the absence of a baseline care plan. Resident 19's care plan was incomplete, lacking instructions for their immediate healthcare needs, and Resident 1's care plan did not address essential health and safety instructions related to their medical conditions. Resident 13, who required communication assistance due to a language barrier, did not have a care plan that included communication strategies or tools, leaving staff without guidance on how to meet their needs. These deficiencies highlight the facility's failure to ensure timely and effective care planning, placing residents at risk for adverse outcomes.
Inadequate Administrative Oversight and QAPI Program
Penalty
Summary
The facility failed to ensure effective and efficient use of resources to maintain residents' highest practical physical, mental, and psychosocial well-being, as well as compliance with state and federal regulations. This deficiency was primarily due to inadequate clinical administrative oversight in the absence of both the Director of Nursing (DNS) and the Regional President of Clinicals. The facility did not have an Assistant Director of Nursing (ADNS) to fill in, and the Resident Care Manager (RCM), who was the only Registered Nurse (RN) available, was not appointed as the acting DNS. Consequently, the Administrator assumed responsibility for ensuring physician orders were implemented, which contributed to the facility's inability to maintain substantial compliance with regulatory requirements. The facility's historical surveys revealed ongoing non-compliance, with repeated citations for Quality of Care and Significant Medication Errors. An Immediate Jeopardy was identified related to the facility's failure to ensure 11 residents received care to maintain acceptable nutritional status. Additionally, the administration failed to develop, implement, and monitor a Quality Assurance Process Improvement (QAPI) program, and staff were not educated on the QAPI goals. These deficiencies placed residents at risk for adverse events, substandard quality of care, rehospitalization, and diminished quality of life.
Ineffective QAPI Committee and Deficient Practices
Penalty
Summary
The facility failed to maintain an effective Quality Assurance/Performance Improvement (QAPI) Committee, which did not self-identify deficient practices or implement corrective actions for identified deficiencies. The QAPI committee did not recognize issues in the new resident admission process, specifically the failure to ensure that newly admitted residents' medications were available in a timely manner and that orders were accurate, complete, and reconciled. This oversight led to a citation for significant medication errors, as the facility did not have medications available for residents. Additionally, the facility did not identify failures in ensuring residents received necessary nutrition and monitoring their response to interventions, particularly for tube feeding-dependent residents. The facility also failed to consistently implement fall care plans, initiate incident reports, or document monitoring following resident falls. Furthermore, the facility did not comply with training requirements, as they did not track annual in-service hours for CNAs, which was not self-identified by the QAPI committee.
Inadequate Investigation of Incidents and Alleged Violations
Penalty
Summary
The facility failed to conduct thorough investigations into incidents, accidents, and alleged violations involving three residents, which placed them at risk for abuse, neglect, and diminished quality of care. Resident 1, who had moderate cognitive problems and a history of falls, experienced multiple falls during their stay. The facility did not document or investigate these falls adequately, failing to identify root causes or unmet care needs. Additionally, an allegation of neglect was made by Resident 1's family member, but the facility's investigation lacked interviews, witness statements, and a thorough clinical chart review. Resident 8, who had moderate cognitive problems and required assistance with activities of daily living, experienced falls and an allegation of neglect was reported. The facility's investigation into these incidents was incomplete, lacking documentation to rule out neglect. The resident's responsible party reported issues with call light accessibility, long wait times, and inadequate care, including unaddressed urinary problems and insufficient nutrition despite a feeding tube. The facility failed to provide a thorough investigation into the circumstances leading to Resident 8's unexpected death. Resident 38, who had severe cognitive problems and was at risk for pressure injuries, was discharged with unreported wounds. The facility did not conduct a thorough investigation into the allegation of neglect reported by the resident's caregiver at the receiving facility. The caregiver discovered multiple wounds upon admission, which were not documented or treated by the facility. The lack of a comprehensive investigation into these incidents highlights the facility's failure to ensure resident safety and proper care.
Deficiencies in Medication Management, Lab Processing, and Documentation
Penalty
Summary
The facility failed to ensure that care and services provided met professional standards of practice for eight out of twelve sample residents. Specifically, the facility did not hold anti-hypertensive medications when vital signs were outside the ordered parameters for three residents. This oversight occurred despite clear physician orders to withhold medication if the systolic blood pressure was below 110 or the heart rate was below 60. The medications were administered to residents even when their vital signs indicated that the medication should have been withheld, potentially placing them at risk for adverse events. Additionally, the facility did not ensure timely collection and reporting of lab specimens for four residents. There were significant delays in collecting STAT lab orders, and in some cases, lab results were not communicated to the physician in a timely manner. For instance, one resident's critical lab result was not reported to the physician until two days after it was obtained, and another resident's urine specimen was not collected until 15 hours after the order was updated. These delays in lab processing and communication could have contributed to inadequate medical management and delayed treatment. Furthermore, the facility failed to provide consistent monitoring and documentation for residents requiring skilled nursing care. The documentation for four residents did not consistently reflect the need for skilled nursing services, nor did it adequately document changes in condition or events that occurred. This lack of thorough and timely documentation did not meet the Medicare requirements for skilled nursing care and could have impacted the quality of care provided to these residents.
Deficiencies in Wound and Heart Failure Care
Penalty
Summary
The facility failed to provide care and services in accordance with professional standards of practice and quality care to meet the physical, mental, and psychosocial needs of several residents. For Resident 38, the facility did not conduct weekly skin checks as ordered, failed to document a new skin impairment, and did not perform a skin check upon discharge. This resulted in the resident being discharged with multiple unreported wounds, including a Stage II pressure ulcer and deep tissue injuries, which were only discovered after the resident returned home. Resident 2 experienced a lack of consistent monitoring and care for a surgical wound on their left leg. Despite having a surgical wound with staples, there were no directives for care or monitoring in the care plan, and the dressing was not changed for several days, leading to an infection. The resident reported pain and drainage, but the facility did not address these concerns promptly, resulting in delayed healing and ongoing wound care needs. For Resident 10, the facility did not follow hospital discharge orders for heart failure management, including daily weights and monitoring for edema. The resident was not weighed daily, and their care plan did not include instructions for managing their heart and respiratory conditions. This lack of monitoring and adherence to care protocols contributed to multiple rehospitalizations for respiratory failure and heart failure exacerbations.
Significant Medication Errors in LTC Facility
Penalty
Summary
The facility failed to ensure that 12 sampled residents were free from significant medication errors. These errors included the failure to conduct thorough medication reconciliations upon admission, verify allergies before administering medications, clarify duplicate or questionable orders, and correctly transcribe orders into the electronic Medication Administration Record (MAR). Additionally, medications were not administered timely in accordance with professional standards of practice, and identified medication errors were not reported or investigated. This placed residents at risk for adverse events, rehospitalization, poorly managed health conditions, and diminished quality of care and life. Resident 26, who had a history of stroke and heart attack, was not given their prescribed blood thinner, dabigatran, after admission, leading to a hospital transfer for neurologic changes. Resident 2, who was allergic to Lantus insulin, was administered the medication despite the allergy, and their pain medications were not accurately transcribed or administered timely. Resident 22 did not receive their prescribed insulin and blood sugar checks due to a lack of medication reconciliation on readmission. Resident 13 did not receive any of their ordered medications upon admission due to unavailability, and the physician was not notified. Other residents, such as Resident 10, experienced missed doses of critical medications like diuretics and pain patches due to unavailability, with no physician notification. Resident 38 continued to receive medications that were ordered to be stopped, and Resident 14's insulin orders were not clarified, leading to poorly controlled blood sugars. Resident 8's insulin and oxygen orders were not properly reconciled, and Resident 17's inhalant medication was unavailable without provider notification. Late medication administration was a recurring issue for Residents 23, 34, 10, and 15, with medications often given hours after the scheduled time, compromising their treatment efficacy.
Deficiency in Staff Training Documentation
Penalty
Summary
The facility failed to ensure that staff were educated on all required topics as specified in their Facility Assessment. This deficiency was identified for four sampled staff members, all of whom were Nursing Assistant Certified (NAC). The facility's assessment, dated February 27, 2025, outlined mandatory annual trainings, including Resident Rights and Facility Responsibilities, Change of Condition, Person-Centered Care Competencies, and Activities of Daily Living Competencies. However, upon review of employee files and interviews, it was found that Staff Q, who was hired on January 24, 2024, did not receive training in Resident Rights, Change of Condition, Person-Centered Care, or Activities of Daily Living. The Staff Development Coordinator, Staff P, confirmed the absence of documentation for these trainings. Further investigation revealed that training records for Staff R, Staff S, and Staff T, all NACs hired between March 2022 and December 2023, were also missing. During interviews, the Administrator and the Regional President of Clinicals acknowledged the existence of an in-service calendar intended to ensure mandatory trainings were conducted, but the calendar was not provided upon request. The Regional President of Clinicals also confirmed that competencies for the requested staff could not be found. This lack of training documentation placed residents at risk for unmet care needs and inadequate quality of care.
Failure to Provide Mandatory QAPI Training to CNAs
Penalty
Summary
The facility failed to provide mandatory Quality Assurance and Performance Improvement (QAPI) training to four Certified Nursing Assistants (CNAs), identified as Staff Q, R, S, and T. During an interview, Staff R, a CNA, admitted to not knowing what the QAPI committee was or the meaning of QAPI, indicating a lack of training. Staff R mentioned that they would report concerns to their nurse. The Staff Development Coordinator, Staff P, confirmed through a review of training records that Staff Q had not received QAPI training. Additionally, the facility could not provide documentation proving that Staff R, S, and T had received the required annual QAPI training. The facility's training program included a component called 'Stop and Watch,' which instructed staff to report observations and document them in the computer, but no specific QAPI curriculum was available.
Failure to Notify Guardian of New Medication Order
Penalty
Summary
The facility failed to notify the responsible party of a new medication order for a resident, identified as Resident 2, who was moderately cognitively impaired and had a court-appointed guardian. The resident was admitted with diagnoses including a communication deficit and a genetic-related intellectual disability, requiring assistance with personal care. On December 30, 2024, a physician ordered an antibiotic to treat a skin infection on the resident's leg, which was confirmed by Staff A, a Resident Care Manager (RCM). However, there was no documentation in the progress notes indicating that the resident's guardian was informed of this new medication order. Interviews with staff revealed a lack of communication and understanding of responsibilities regarding notification of new orders. Staff A stated that they confirmed pending orders each morning but did not notify the resident or their responsible party unless they were under their care management. Staff B, another RCM, was unaware of Staff A's actions and believed that whoever received or confirmed an order should inform the resident and their responsible party, documenting it in a progress note. This miscommunication and lack of notification prevented the guardian from being involved in the care planning process and being informed about the resident's medications.
Failure to Monitor and Document Skin Impairment
Penalty
Summary
The facility failed to document a measurable and descriptive baseline and routinely monitor the progression of a skin impairment for a resident with a hematoma on their left lower leg. Upon admission, the resident was noted to have a large hematoma on the left lateral calf, but there were no documented measurements or additional details describing the hematoma. Subsequent weekly skin checks also lacked documented measurements or detailed descriptions, and there was no indication of whether the hematoma was improving or worsening. Despite physician orders to monitor the hematoma and notify the provider of any delayed healing or worsening, the treatment administration record only showed that the hematoma was being monitored each shift without corresponding documentation in the electronic medical record. Interviews with staff revealed that no treatments, observations, or measurements were performed on the hematoma, and the Director of Nursing Services acknowledged that the lack of documentation meant staff would not have known if the hematoma was worsening or improving.
Failure to Administer Prescribed Respiratory Medication
Penalty
Summary
The facility failed to ensure the administration of a prescribed respiratory medication, Trelegy, for a resident diagnosed with chronic obstructive pulmonary disease (COPD) and respiratory failure. The medication was not administered on eight occasions over a period spanning late December 2024 to early January 2025. The medication administration records indicated that there should have been progress notes explaining the missed doses, but the notes revealed issues such as the medication not being located, waiting for a pharmacy refill, and the pharmacy stating it was too early for a refill. On two occasions, no progress notes were written. There was no documented communication with the resident's medical provider regarding the unavailability of the medication during this period. The resident experienced shortness of breath and was in obvious distress during the time the medication was unavailable. A collateral contact observed the resident struggling to breathe, describing the resident as "like a fish out of water." The Director of Nursing Services (DNS) stated that staff should have contacted the pharmacy, notified the doctor, requested alternative treatment orders if necessary, and informed the DNS when the medication was unavailable. The DNS also mentioned that the facility could have paid for an early refill if insurance coverage was an issue, but this step was not taken.
Failure to Notify DPOA of Medication Changes
Penalty
Summary
The facility failed to notify the designated Durable Power of Attorney (DPOA) for two residents regarding changes in their medication orders, which is a requirement for ensuring that residents' representatives are included in the plan of care. Resident 1, who was admitted to the facility and had a diagnosis of Alzheimer's dementia, began receiving hospice care and was prescribed morphine, an opioid pain medication, on 07/27/2024. Despite the administration of morphine on multiple occasions, there was no documentation indicating that Resident 1's DPOA was informed of this new medication order. Similarly, Resident 2, who also had a diagnosis of dementia, experienced a change in their medication regimen with an increased dose of Depakote, a medication for seizures, on 07/18/2024. The medical record showed that the increased dose was administered starting that evening, but there was no documentation that Resident 2's DPOA was notified of this change. Interviews with facility staff, including LPNs and the Director of Nursing Services, confirmed that the expectation was to notify the resident and their responsible party of medication changes and document these communications, which was not done in these cases.
Latest citations in Washington
Inaccurate PASARR screening affected two residents. One resident with vascular dementia, depression, and adjustment disorder had a PASARR level one that did not reflect mental health diagnoses, and staff stated it was inaccurate. Another resident with PTSD had a PASARR level one that did not include the PTSD diagnosis, with no additional PASARR level one or level two found in the EHR; staff stated the screening was not accurate and should have been repeated.
Undated open meds were found on 2 medication carts, including an open insulin vial and multiple open eye drop bottles with no dates. An LPN and an RN both stated the items should have been dated when opened, and the DON stated open multidose vials or bottles found without a date should be discarded immediately.
A resident with respiratory failure, HTN, and anxiety became SOB and diaphoretic, received a breathing tx, and was sent by EMS to the hospital. The facility could not locate the required SNF/NF to Hospital Transfer form or other transfer records showing what information was communicated to the receiving provider.
Care plans for two residents were not updated to match their current status and care needs. One resident had PTSD and generalized anxiety disorder and was receiving a psychotropic medication, but the care plan listed monitoring for antipsychotic and anticonvulsant meds that were not prescribed and did not include the anxiety diagnosis or related behaviors and interventions. Another resident had new upper and lower dentures, but the oral/dental care plan only noted edentulous status and difficulty chewing, with no mention of dentures or denture-related interventions.
Failure to Provide Individualized Activities: A resident with anxiety, depression, and weakness was cognitively intact but said they could not attend group activities because of leg problems and wanted more in-room activities. The resident mostly stayed in bed watching TV, and staff documentation showed only limited room visits with no consistent activity documentation despite a care plan goal for participation two to three times per week.
Failure to maintain heel offloading for a resident with a reopened DFU. A resident with dementia and dependence for mobility had a left heel wound that had healed and then reopened; the wound care provider recommended heel floating and pressure relieving boots at all times, but observations showed the resident in bed with heels on the mattress and later reclined in a wheelchair with the heel resting on the footrest strap and no boots in place. Staff stated the resident had not refused the boots or heel floating, and the care plan was not updated after the wound reopened.
Failure to Address Hearing and Vision Services for a Resident: A resident with dementia, bilateral hearing loss, and impaired vision was observed without eyeglasses or a hearing device, despite records showing admission with eyeglasses and a personal sound amplifier. The care plan addressed vision only and did not include hearing-related interventions, while staff interviews confirmed the resident’s hearing was strained and that the resident’s device use and vision needs were not fully reflected in the plan of care.
Respiratory care was not provided consistently for two residents receiving O2. One resident with COPD and chronic respiratory failure had an O2 order missing the indication for use and Sats parameters, no MAR documentation of O2 therapy, and inconsistent Sats charting. Another resident with respiratory failure was observed on continuous O2 via NC, but provider orders for O2 therapy and tubing changes were not present after readmission, despite the care plan stating the resident was dependent on O2.
A resident with dementia, hearing loss, and missing lower teeth had an MDS showing obvious or likely cavities or broken natural teeth, and the care plan identified oral/dental health problems with an intervention to coordinate dental care and transportation. Staff stated the resident’s dental needs were captured on the MDS, but no referral was made for dental services or follow-up with the dentist, and the DON said the lack of referral did not meet expectations.
Inaccurate Meal Intake Documentation: A resident with DM, dysphagia, and protein-calorie malnutrition was observed eating less than 25% of a meal, but the POC documented 76-100% intake. The CNA said the resident usually ate only 25-50% of meals and that intake was sometimes documented based on what a coworker reported. The LPN/RCM and DON stated meal intake should be documented accurately.
Inaccurate PASARR Screening for Two Residents
Penalty
Summary
The facility failed to ensure that two residents were screened for additional mental health supports through the PASARR process. Resident 97 was admitted with diagnoses including vascular dementia, depression, and adjustment disorder, and was able to make needs known. Review of the PASARR level one dated 04/10/2026 showed no mental health diagnoses and no need for a PASARR level two, even though the resident’s record included mental health diagnoses. During interview, the Regional Social Services staff and the Administrator stated the PASARR was inaccurate, needed modifications, and did not meet expectations. Resident 6 was admitted with diagnoses including heart failure, respiratory failure, and PTSD, and was able to make needs known. Review of the PASARR level one dated 03/30/2026 showed no serious mental illness indicators marked and no PASARR level two indicated, and the EHR contained no other documented PASARR level one or level two. The Social Services Director stated the hospital-provided PASARR was reviewed for accuracy and, if inaccurate, another level one would be completed, and stated this resident’s PASARR did not include PTSD and should have had another level one completed. The Administrator also stated the PASARR was not accurate and another level one needed to be conducted, but none could be located in the EHR.
Undated Open Medications on Medication Carts
Penalty
Summary
The facility failed to ensure proper storage and labeling of medications for 2 of 3 sampled medication carts reviewed for medication storage and labeling, including carts on the 400 and 500 halls. On the 500 hall medication cart, an open vial of insulin and an open bottle of eye drops were observed with no dates. During interview, an LPN stated that when an insulin vial or bottle of eye drops is opened, it should be dated immediately and said both items should have been dated upon opening; the LPN stated they would dispose of the undated vial and bottle. On the 400 hall medication cart, two open bottles of eye drops were observed with no dates. During interview, an RN stated both bottles should have been dated as soon as they were opened and said they would get new eye drops and dispose of the undated bottles. The DNS/RN stated that if an eye drop was opened it should have been dated immediately and that any open multidose vial or bottle found without a date should be discarded immediately.
Missing Hospital Transfer Documentation
Penalty
Summary
The facility failed to ensure hospital transfer documentation was completed for one resident who was transferred to the hospital after complaining of not being able to breathe and appearing diaphoretic. The resident had diagnoses of respiratory failure, high blood pressure, and anxiety disorder, and was able to make needs known. A breathing treatment was provided, and the provider agreed to send the resident out for further evaluation, after which emergency transportation took the resident to the hospital. Record review found no documentation showing what information was provided or communicated to the receiving facility for the transfer. Staff stated that transfer documentation should have included a SNF/NF to Hospital Transfer form, the resident's face sheet, and the medication and treatment administration records, but they were unable to locate documentation showing these items were completed or sent for the resident's hospital transfer.
Care plans did not reflect current diagnoses, medications, or denture status
Penalty
Summary
The facility failed to ensure that care plans were revised and accurately reflected residents’ current status and care needs for 2 of 21 sampled residents. Resident 6 was admitted with diagnoses including heart failure, respiratory failure, and PTSD, and was able to make needs known. The EHR showed Resident 6 also had generalized anxiety disorder and was receiving a psychotropic medication, but the current care plan dated 05/05/2026 documented monitoring for side effects of antipsychotic and anticonvulsant medications even though Resident 6 was not prescribed those medications. The care plan also identified PTSD but did not include generalized anxiety disorder or behaviors to monitor and interventions related to PTSD or anxiety disorder. Staff F, LPN/CC, stated the care plan did not accurately reflect the resident’s current status or prescribed medications, and Staff B, DNS, stated it did not meet expectations because it did not address the anxiety disorder or target behaviors and interventions. Resident 71 was admitted with diagnoses including PTSD, high blood pressure, and depression and was able to make needs known. Observation on 05/06/2026 showed a denture cup by the sink with the resident’s name on the lid and new upper and lower dentures dated 01/12/26. The resident stated the lower dentures did not fit well and that denture adhesive had been provided, but the dentures still did not fit right and the resident had not told staff yet. The focused oral/dental care plan, initiated on 06/23/2026, identified the resident as edentulous and having difficulty chewing, but did not show that the resident had dentures or include interventions related to denture use or maintenance. Staff E, CNA, stated they had not seen the resident wear dentures and were unaware of the new dentures, Staff C, LPN/CC, stated the care plan should have been updated when the dentures were obtained, and Staff B, DNS, stated the care plan should have reflected the dentures and interventions.
Failure to Provide Individualized Activities
Penalty
Summary
The facility failed to provide individualized activities for Resident 5, who was admitted with diagnoses including anxiety disorder, depression, and weakness. The admission MDS dated 01/14/2026 showed the resident was cognitively intact. During interviews on 05/03/2026 and 05/06/2026, Resident 5 stated they could not attend in-person activities because of their legs, wanted more activities to occupy them, mostly stayed in bed watching TV, and did not remember the last time activities staff visited to offer activities. The resident also stated activities staff would need to offer something they were able to do because they had difficulty doing some activities. The activities care plan dated 12/26/2026 showed a goal for Resident 5 to participate in activities two to three times per week. Progress notes documented one visit on 12/22/2026 to provide a welcome packet and encourage participation in daily activities, but no further activity documentation was found in the progress notes. Staff H stated room visits should include puzzles, arts and crafts, visiting, and chatting, and that documentation was placed in tasks, but the task record showed no documentation of activities for the past 30 days. Staff J stated paper documentation existed for room visits and that Resident 5 was on a list for room visits every Monday and Wednesday, while the room visit documentation showed only four visits on 01/26/2026, 02/06/2026, 03/10/2026, and 04/08/2026.
Failure to Maintain Heel Offloading for Reopened DFU
Penalty
Summary
The facility failed to consistently implement pressure reducing strategies for a resident with a left heel diabetic foot ulcer that had reopened. The resident was admitted with diagnoses including left hip fracture with surgical repair, a blood clot of the left lower leg, and dementia, and was dependent on staff for mobility and unable to make needs known. The baseline care plan and care plan both included heel offloading interventions, and the wound care provider initially recommended heel floating with pillows or wedge and pressure relieving boots. The wound later resolved, but a weekly skin assessment documented that the left heel wound reopened and was very painful to touch. After the wound reopened, the contracted wound care provider documented that the DFU to the left heel had reopened and recommended the resident wear pressure relieving boots at all times. The current care plan reviewed after the wound reopened did not include new interventions related to the reopened wound. Observations showed the resident seated in a reclined wheelchair with the left foot/heel resting on the footrest strap and no pressure relieving boots in place, and later lying in bed with both heels directly on the mattress without being floated and without boots. Staff interviews indicated the resident had not refused the boots or heel floating, and the LPN/CC and DON stated the resident should have been assessed and the plan of care updated when the wound reopened.
Failure to Address Resident Hearing and Vision Needs
Penalty
Summary
The facility failed to address one resident’s hearing and vision needs. Resident 112 was admitted with diagnoses including a leg fracture, dementia, and hearing loss in both ears, and was able to make needs known. The record showed the resident lost their glasses and was given readers, but the resident did not wear them because they were concerned that wearing glasses that were not their prescription would further degrade their vision. Observation did not show glasses in the resident’s room, and the resident stated they did not use a hearing aid. The resident was observed to be hard of hearing, requiring an elevated voice and repeated questions to understand. The admission MDS dated [DATE] documented adequate hearing with hearing aid and adequate vision with corrective lenses, while the significant change MDS dated [DATE] documented moderate difficulty hearing without a hearing aid and impaired vision without corrective lenses. The care plan initiated 02/24/2026 addressed impaired vision with interventions to arrange consultation with eye care practitioners as needed and remind the resident to wear glasses, but it did not include a focus area or interventions for hearing loss or use of hearing aids. A resident clothing list showed the resident admitted with one pair of eyeglasses and one Super Ear headset personal sound amplifier, yet observation and interview showed the resident in bed without eyeglasses or a hearing device, with the amplifier stored in the bedside table drawer. Staff interviews confirmed the resident’s hearing was strained, that the hearing device and glasses were not being used, and that the resident’s hearing device use should have been included in the plan of care and the resident should have been referred for eye care assessment.
Respiratory Care Orders and Documentation Not Maintained
Penalty
Summary
The facility failed to provide respiratory care consistent with professional standards of practice for two residents receiving oxygen therapy. One resident with COPD and chronic respiratory failure with hypoxia was observed multiple times lying in bed receiving oxygen at 2 L via nasal cannula. The resident’s oxygen order, dated 02/15/2026, allowed 1 to 4 L per minute continuously via nasal cannula, but it did not include an indication for use or oxygen saturation parameters. The April and May 2026 MARs did not show documentation of oxygen therapy being provided, and the TARs showed only an order to change oxygen tubing if damaged or visibly soiled, not an order for oxygen therapy. Oxygen saturations were not documented consistently daily from 04/01/2026 through 05/04/2026. A second resident with respiratory failure, high blood pressure, and anxiety disorder was observed in the room receiving oxygen at 6 L via nasal cannula on multiple occasions. The resident stated they needed oxygen therapy to breathe, and the care plan identified the resident as dependent on oxygen and to receive oxygen per provider orders. However, provider orders reviewed on 05/04/2026 showed no orders for oxygen therapy or for changing oxygen tubing. Staff stated the oxygen and tubing-change orders had been discontinued when the resident went to the hospital and were not added back to the MAR or TAR when the resident readmitted to the facility.
Failure to Refer Resident With Identified Dental Needs
Penalty
Summary
The facility failed to ensure that Resident 112 received needed dental care. Resident 112 was admitted with diagnoses including a leg fracture, dementia, and hearing loss in both ears. Observation on 05/03/2026 showed the resident had missing lower teeth. The admission MDS, dated [DATE], documented obvious or likely cavities or broken natural teeth, and the care plan dated 02/24/2026 identified oral/dental health problems related to likely cavities or broken teeth with an intervention to coordinate dental care and provide transportation. During interviews, Staff G, Regional Social Services, stated Resident 112's dental needs were captured on the 02/24/2026 MDS and the resident was not referred for dental services. Staff M, Social Services Director, stated residents with dental needs should be referred to social services to be scheduled for assessment by a dental care practitioner, and that Resident 112 should have been referred after the MDS assessment. Staff B, DON, stated residents with identified dental needs should be referred for follow-up with a dentist and that Resident 112 should have been referred to the in-house dental provider; Staff B stated the lack of referral did not meet expectations.
Inaccurate Meal Intake Documentation
Penalty
Summary
The facility failed to accurately document the amount of food eaten for Resident 13, who was admitted with diagnoses including diabetes mellitus, dysphagia, and protein-calorie malnutrition. The quarterly MDS dated 02/12/2026 showed the resident was moderately cognitively impaired. During observation on 05/05/2026 at 12:09 PM, a meal tray was delivered to the resident’s room, set up on a bedside table, and the resident was observed eating slowly, eating less than 25% of the meal, then laying back in bed and closing their eyes while the tray remained in the room. Staff later removed the tray, but the POC documentation for lunch on 05/05/2026 recorded that Resident 13 ate 76-100% of the meal. During interview, the CNA stated the resident typically ate 25-50% of meals and never ate all of the food, and that if they did not pick up a tray they would ask a coworker what the resident ate before documenting it. The CNA stated they were told the resident ate 75-100% of lunch, so that is what was entered. The LPN/RCM stated staff should document meal intake accurately in POC, and the RN/DNS stated it was their expectation that all staff document meal intake accurately.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release June 24, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
