Avamere Rehabilitation At Park West
Inspection history, citations, penalties and survey trends for this long-term care facility in Seattle, Washington.
- Location
- 1703 California Avenue Southwest, Seattle, Washington 98116
- CMS Provider Number
- 505270
- Inspections on file
- 30
- Latest survey
- March 9, 2026
- Citations (last 12 mo.)
- 53
Citation history
Health deficiencies cited at Avamere Rehabilitation At Park West during CMS and state inspections, most recent first.
Two residents with complex medical conditions, including kidney failure, pressure ulcers, infections requiring IV antibiotics, and isolation precautions, were transferred to the ED without the required clinical documentation and notices. Despite facility policies and a discharge checklist requiring a hospital transfer form, MAR, care plan, diagnostic results, advance directives, state transfer/discharge notice, and bed-hold information, an LPN sent only a face sheet and lab results and did not call the ED to provide a report. The ED reported receiving no paperwork for one resident and was unable to reach facility staff for a medication list or status report, and the state-required transfer/discharge and bed-hold notices were not provided to either resident or their representatives.
A resident at high risk for pressure ulcers developed five new PU/PIs due to the facility's failure to implement appropriate interventions and accurately assess and document skin conditions. Despite being dependent on staff for mobility and having multiple risk factors, the care plan lacked specific measures to prevent skin injuries. Upon discharge, the resident had multiple PU/PIs that were not documented or communicated to relevant parties.
The facility failed to ensure a homelike environment for residents on two floors and in one elevator. Observations revealed multiple instances of damage, including gouges and exposed drywall in resident rooms, stained ceiling tiles, and a broken trim in the elevator. Staff confirmed these issues and acknowledged the need for repairs.
The facility failed to transmit the required MDS data to CMS within the required time frames for six residents, resulting in delays in care planning and unmet care needs. The MDS assessments for these residents were transmitted between one and twelve days late, as confirmed by the MDS Coordinators.
The facility failed to update PASRR assessments to reflect changes in the mental health status of four residents. The assessments were outdated or incomplete, missing critical diagnoses such as anxiety, depression, and psychosis. The Social Services Director acknowledged the inaccuracies and the need for revisions.
The facility failed to clarify and follow physician's orders for multiple residents, leading to potential medication errors and adverse outcomes. Issues included duplicate and unclear medication orders, failure to monitor blood pressure as required, and not removing pain patches as scheduled. Additionally, orthostatic blood pressure monitoring was not conducted for a resident on antipsychotic medication, as mandated by facility policy.
The facility failed to provide necessary ADL assistance to several residents, including bathing, grooming, and eating assistance. Residents were observed with long, dirty fingernails, unshaved facial hair, and uncombed hair. Staff acknowledged the lack of required care and assistance.
The facility failed to ensure that three residents received the Restorative Nursing Program (RNP) services they were assessed to require, leading to inconsistencies in providing prescribed splinting and passive/active ROM programs. Observations and interviews revealed that staffing issues and workload prevented the consistent provision of these services, placing residents at risk for a decline in ROM and decreased quality of life.
The facility failed to ensure resident safety by not adequately supervising and storing smoking materials for a resident, and by not securing the Central Supply and soiled utility rooms, which contained hazardous materials accessible to residents.
The facility failed to ensure nursing staff had the appropriate competencies and skill sets to provide safe care, particularly for a resident with a tracheostomy. Staff were not trained in specialized CPR for tracheostomy care, and there was no documentation of skills verification or competency evaluations for current staff. This placed residents at risk for incompetent care and harm.
The facility failed to implement an effective Infection Prevention and Control Program, lacking a water management program, having uncleanable resident equipment, improperly handled urinary catheter bags, and inadequate hand hygiene practices. Staff confirmed these deficiencies, which left residents vulnerable to infections.
The facility failed to revise its infection prevention and control policies and implement an updated Antibiotic (ABO) Stewardship program, lacking protocols to monitor, document, and analyze ABO use. This deficiency, spanning three months, placed residents at risk for adverse outcomes and ABO-resistant organisms.
The facility failed to obtain informed consent for psychotropic medication for a resident with severe memory impairment and did not ensure adequate privacy during care for three other residents. Staff provided care without pulling privacy curtains, exposing residents to potential view from the door or other parts of the room.
The facility failed to provide required written transfer/discharge notifications to three residents, including those with kidney failure, heart failure, and malnourishment, due to a misunderstanding of the requirements. Staff interviews confirmed that no notifications were sent after June 2023.
The facility failed to provide written notice of the bed hold policy to residents and/or their representatives at the time of transfer or within 24 hours, as required by their policy. This deficiency was identified for two residents who were transferred to the hospital. Staff confirmed that the bed hold notifications were not provided as required, placing the residents and their representatives at risk of not being informed of their rights and associated costs.
The facility failed to ensure accurate MDS assessments for six residents, leading to omissions and inaccuracies in documenting refusals of care, medication administration, and resident conditions. Staff interviews confirmed these deficiencies.
The facility failed to develop and implement comprehensive care plans for four residents, leading to inconsistent and inadequate care. One resident's dental health needs were not addressed, another's toileting schedule was omitted, a third's antipsychotic medication details were incomplete, and a fourth lacked necessary CPR equipment in their room.
The facility failed to update CPs for two residents and did not provide a care conference for one resident. One resident had an outdated CP for anticoagulant therapy, another had an outdated CP for meal assistance, and a third resident did not have a care conference for over a year due to staffing issues.
The facility failed to provide consistent feeding tube care for a resident with complex medical needs, including inconsistent formula administration, inadequate documentation of fluid intake, and improper labeling of formula bags. Staff interviews confirmed a lack of adherence to facility policies and physician orders.
The facility failed to timely act on medication-related irregularities identified by the consultant pharmacist for a resident with complex medical diagnoses. Recommendations for a lipid panel blood test and a decrease in a steroid nasal inhaler were delayed by several months, placing the resident at risk for medication-related complications.
A resident with kidney failure and shortness of breath continued to receive an antibiotic medication without proper review or adjustment, despite a nephrologist's recommendation to reduce steroid dosage and a pharmacist's recommendation to clarify the necessity of the antibiotic. The facility failed to schedule a follow-up appointment and clarify the medication order.
A resident with severe memory impairment was administered an antipsychotic medication without an appropriate diagnosis. Despite a consultant pharmacist's concern, the resident continued to receive the medication until a new diagnosis was added without clear documentation of the diagnostic process. Interviews confirmed the medication was given without an adequate diagnosis for several months.
The facility failed to secure and dispose of expired medications and biologicals timely. Expired items were found in the medication room, Pyxis machine, and medication carts. Unsecured medications were also observed in resident rooms and on medication carts. Staff interviews confirmed these findings and acknowledged the lapses in protocol.
The facility failed to provide timely dental services for a resident with broken teeth and oral pain. Despite a dental consultation recommending extractions and dentures, no follow-up actions were taken due to staffing shortages, placing the resident at risk for unmet dental needs.
Failure to Provide Required Notices and Clinical Information During Hospital Transfers
Penalty
Summary
The deficiency involves the facility’s failure to develop and implement an effective system for communication and provision of medical records when residents were transferred to the hospital, both for residents expected to return and those not expected to return. Facility policies required that residents transferred for emergency treatment receive a notice of transfer as soon as practicable, that the state agency transfer/discharge notice be completed, and that the facility’s bed-hold policy be provided. Another policy required that specific clinical information be conveyed to the receiving provider, including practitioner and representative contact information, advance directives, care plan, current status and baseline function, diagnoses, allergies, medications, diagnostic tests, and a discharge summary. A facility checklist directed staff to notify the physician, administrator, DON, and resident representative, complete a hospital transfer form, provide the state transfer/discharge notice and bed-hold policy, send a defined packet of clinical documents with the resident, and document all required elements in the medical record. For one resident, the admission MDS showed significant hearing and vision impairment, cognitive impairment, acute kidney failure, history of kidney transplant, pressure ulcers, and other complex diagnoses, with total dependence on staff for personal care and mobility. The comprehensive care plan documented an advance directive with a designated representative, an infected foot wound requiring a mid-line IV antibiotic, and detailed care for the infected pressure ulcer and IV site. The MAR and TAR contained extensive information on medications, including IV antibiotics, isolation requirements, and specific wound care instructions. On the date of transfer, a progress note recorded that the physician evaluated the resident, determined a hospital transfer was necessary, and that the resident was sent by ambulance with no bed hold desired; no additional information was documented. A hospitalist later reported that the ED received no paperwork with the resident, that multiple attempts to obtain a medication list and status report from the facility were unsuccessful, and that the facility did not inform the hospital about the mid-line IV indication or the severe infected foot wound. The hospital pharmacist ultimately had to contact the facility’s pharmacy to obtain the medication and IV information. The LPN assigned to this resident on the day of transfer stated they called the resident representative and arranged transportation, and that they sent only a face sheet and lab results with the resident. The LPN acknowledged they did not call the ED, did not send a hospital transfer sheet, did not complete or provide the state transfer/discharge notice or the bed-hold notice to the resident or representative, and did not use the discharge checklist. The LPN further stated they completed the hospital transfer form after the resident left and did not send it with the resident, and that the MAR, care plan, diagnostic results, advance directives, and change-of-condition form should have been sent but were not. For a second resident, the admission MDS documented cognitive loss, back surgery, bone infection, kidney failure requiring dialysis, and multiple pressure ulcers, with total dependence on staff for personal care and mobility. The comprehensive care plan showed the resident required a specialty mattress, was at high risk for falls, had specific behaviors with defined interventions, required medication monitoring, had an infection, was on IV antibiotics, and required specific isolation precautions. The MAR and TAR contained detailed instructions for routine and IV medications, isolation requirements, and wound care for multiple pressure ulcers. A progress note documented that the resident was sent to the hospital via ambulance for a change in condition, with multiple diagnostic tests and results, vital signs, and contact with the on-call physician who directed transfer to the ED. The LPN reported that, for this transfer, they again did not use the discharge checklist, sent only the face sheet and lab results, did not send a hospital transfer form because it was completed after the resident left, and did not provide the state transfer/discharge notice or bed-hold form to the resident or representative. The resident care manager stated that nurses were expected to follow the discharge checklist, complete the state transfer/discharge notice and bed-hold form when a resident was sent to the hospital, and call the ED to provide a report. The administrator stated that staff did not follow facility policy and that the failure in practice was identified in their system for discharging residents to the hospital. The administrator also stated that nursing staff were expected to complete the hospital transfer form, call the hospital with resident status information, complete all documentation, and send all required documents to the hospital, including the state transfer/discharge notice and bed-hold form to be provided to residents or their representatives and entered into the medical record. These expectations were not met for the two residents reviewed for hospitalization, resulting in noncompliance with WAC 388-97-0120, -0080, and -0140.
Failure to Prevent and Document Pressure Ulcers
Penalty
Summary
The facility failed to implement appropriate interventions to protect a resident's skin from injury, leading to the development of five new pressure ulcers/pressure injuries (PU/PIs) and associated pain. The resident, who was admitted for rehabilitation with multiple diagnoses including a brain disorder, dementia, and diabetes, was assessed at high risk for developing PU/PIs due to factors such as limited mobility, inadequate nutrition, and risk for skin friction and shearing injuries. Despite these risk factors, the facility did not include specific interventions in the care plan to prevent friction and shearing, nor did they accurately assess and document the resident's skin condition. The facility's policy required nursing staff to recognize, assess, and document significant risk factors for developing PUs, as well as to conduct weekly skin assessments. However, the weekly skin assessments for the resident showed no skin impairments, even though the care plan noted redness on the left heel. Additionally, documentation revealed that bed mobility assistance was often provided by only one staff member instead of the required two, and there were instances of incomplete documentation regarding staff assistance with bed mobility. Upon discharge, the resident was found to have multiple PU/PIs, including an unstageable PU/PI on the coccyx and stage two PU/PIs on the buttocks and ankle. The facility failed to document these skin impairments in the discharge notes or communicate them to the resident's representative or the receiving community home. Interviews with facility staff confirmed that the care plan did not address individualized risk factors for PU/PIs, and the nursing staff did not accurately identify, assess, or document the resident's skin injuries, nor did they notify the practitioner or the resident's representative about the PU/PIs.
Failure to Maintain Homelike Environment
Penalty
Summary
The facility failed to ensure a homelike environment for residents on two of its floors and in one of its elevators. Observations revealed multiple instances of damage and disrepair, including deep gouges and exposed drywall in resident rooms, falling and stained ceiling tiles, and scratched paint. Specifically, rooms on the 200 and 300 floors had walls with gouges and missing paint, and ceiling tiles with brown stains. Staff confirmed these observations and acknowledged that the damage should be repaired. Additionally, the elevator had a broken trim with a sharp, jagged edge at thigh level, posing a potential risk to residents, particularly those in wheelchairs. Interviews with staff, including the Director of Nursing, confirmed that the facility's policy was to provide a safe, clean, and homelike environment, and that the observed damages were not in line with this policy. The staff acknowledged the need for repairs and maintenance to ensure the environment met the expected standards. The failure to address these issues left residents at risk for a less-than-homelike environment, contrary to the facility's stated policy and regulatory requirements.
Failure to Timely Transmit MDS Data
Penalty
Summary
The facility failed to transmit the required Minimum Data Set (MDS) data to the Center for Medicare and Medicaid Services (CMS) within the required time frames for six residents. Specifically, the MDS assessments for Residents 33, 69, 57, 17, 73, and 51 were not completed or transmitted within the mandated 14-day period after the Assessment Reference Date (ARD). This delay in submission was confirmed by the MDS Coordinators, Staff J and Staff Q, during an interview, where they acknowledged the failure to meet the required timelines for MDS completion and transmission. Resident 33 had a Significant Change MDS and a Quarterly MDS that were both transmitted late. Resident 69 and Resident 57 each had a Quarterly MDS that was transmitted 12 and 11 days late, respectively. Resident 17's Annual MDS was transmitted two days late, while Resident 73's Quarterly MDS was also two days late. Resident 51 had two Quarterly MDS assessments that were transmitted one and three days late. These delays in MDS submission placed residents at risk for delays in care planning and unmet care needs.
Failure to Update PASRR Assessments
Penalty
Summary
The facility failed to ensure that Pre-Admission Screening and Resident Review (PASRR) assessments were updated to reflect changes in the mental health status of four residents. Resident 30's Level 1 PASRR, dated 11/28/2023, did not include diagnoses of anxiety or depression, despite these being noted in the resident's medical records. Staff M, the Social Services Director, acknowledged that the PASRR was inaccurate and needed revision. Similarly, Resident 37's PASRR, dated 10/19/2022, did not reflect the resident's diagnoses of psychosis and difficulty adjusting to changes with mixed anxiety and depressed mood, which were documented in the resident's medical records and medication administration records. Staff M confirmed that the PASRR should have been updated to include these diagnoses. Resident 13's PASRR, completed on 02/20/2024, was found to be incomplete, with one of the three required questions left unanswered. Staff M admitted that all questions should have been answered. Lastly, Resident 69's PASRRs, dated 01/06/2023 and 03/25/2024, did not identify the resident's anxiety disorder, despite this being documented in the resident's medical records and medication orders. Staff M acknowledged that the PASRRs should have reflected the anxiety diagnosis. These deficiencies indicate a failure by the facility to ensure that PASRR assessments were accurately and timely updated to reflect residents' current mental health statuses. This oversight could potentially lead to inappropriate placement and inadequate mental health care services for the affected residents. The facility's policy, dated 03/22/2024, mandates periodic reviews of PASRRs to capture any changes in residents' mental health conditions, a responsibility assigned to the Social Services department. However, the policy was not adhered to in these cases, as evidenced by the outdated and incomplete PASRR assessments for Residents 30, 37, 13, and 69.
Failure to Clarify and Follow Physician's Orders
Penalty
Summary
The facility failed to ensure that physician's orders (POs) were clarified as needed for six residents, leading to potential medication errors and adverse outcomes. For instance, Resident 17 had duplicate orders for a powdered laxative medication, and Resident 33 had a high blood pressure medication order without documentation of blood pressure monitoring prior to administration. Additionally, Resident 13's pain medication patch order lacked specific instructions on the location of application, and Resident 57's high blood pressure medication order did not include parameters for when to hold the medication based on blood pressure or heart rate readings. These unclear and duplicate orders were not clarified with the provider by staff, as confirmed by interviews with staff members. The facility also failed to follow physician's orders for two residents. Resident 69 had a pain medication patch that was not removed as scheduled, and Resident 57's insulin medication was not held when blood sugar levels were below the specified threshold. Furthermore, Resident 57 received a pain medication outside the ordered parameters on multiple occasions. Staff interviews revealed that the expectation was for nursing staff to follow, clarify, and document orders as directed, but this was not consistently done. Additionally, the facility did not ensure that orthostatic blood pressure monitoring was conducted as required for Resident 2, who was on antipsychotic medication. The facility's policy mandated monthly orthostatic blood pressure checks for residents on psychoactive medications, but there was no documentation to show that this monitoring was performed for Resident 2. Staff interviews confirmed that the orthostatic blood pressure checks were not completed and documented as required, indicating a lapse in adherence to the facility's policy and physician's orders.
Failure to Provide Necessary ADL Assistance
Penalty
Summary
The facility failed to ensure residents who were dependent on staff for assistance with Activities of Daily Living (ADLs) received the necessary care. Resident 61, who required substantial to maximal assistance with bathing and personal hygiene, was not provided a shower since admission, and their fingernails were observed to be long and dirty on multiple occasions. The care plan did not include specific instructions for bathing preferences, and there was no documentation of refusals. Staff confirmed the lack of showers and nail care for Resident 61 since admission. Resident 51, who had impaired memory and was totally dependent on staff for personal hygiene, was observed with long, dirty fingernails and facial hair on several occasions. Staff acknowledged that ADL assistance, including personal grooming, was not provided as required. Similarly, Resident 58, who had diagnoses including Parkinson's disease and required maximal assistance with transfers and personal hygiene, was observed lying in bed with long facial hair and wearing a hospital gown. The resident expressed a desire to be out of bed and in their wheelchair, but staff did not assist with transfers or grooming as care planned. Resident 73, who had impaired memory and required maximal assistance with personal hygiene, was observed with long fingernails and facial hair. There was no documentation of the resident's preferences or refusals for care. Staff confirmed the lack of ADL assistance. Resident 55, who had severe memory impairment and required assistance with personal hygiene and eating, was observed with long, dirty fingernails, uncombed hair, and a beard. The resident struggled to open food containers without staff assistance. Staff acknowledged that the resident did not receive the required assistance with grooming and eating as documented in their care plan.
Failure to Provide Required Restorative Nursing Program Services
Penalty
Summary
The facility failed to ensure that three residents received the Restorative Nursing Program (RNP) services they were assessed to require. Resident 57, who had multiple medically complex diagnoses including stroke with impairment of functional limitation in range of motion (ROM) to the upper arm and both lower legs, did not receive the prescribed splint and passive ROM to their right hand daily or three to six times per week as per the care plan. Additionally, the active ROM program for Resident 57's lower legs was not provided as frequently as required. Observations confirmed that the resident was not wearing the hand splint, and interviews with staff revealed that the RNP services were not consistently provided due to staffing issues after the departure of another restorative aide in February. Resident 69, who had functional limitations in ROM to both upper arms and lower legs, also did not receive the recommended RNP programs three to six times per week. Observations showed that the resident was not wearing a splint on their left arm, and documentation indicated that the RNP programs were provided less frequently than required. Interviews with staff confirmed the inconsistency in providing the RNP services and the need for a better restorative system. Resident 51, who had paralysis on one side of their body, a contracture to their right hand, and impairment to both legs, did not receive the prescribed splinting and passive ROM programs as required. Observations showed that the resident was not wearing the splint on multiple occasions, and documentation indicated that the RNP programs were provided less frequently than required. Interviews with staff revealed that the workload with other residents' RNPs prevented the consistent provision of the required services. The facility's failure to provide the necessary RNP services as assessed and documented placed the residents at risk for a decline in ROM, increased dependence on staff, and a decreased quality of life.
Failure to Ensure Safety and Supervision
Penalty
Summary
The facility failed to ensure the safety of its residents by not adequately supervising and storing smoking materials for a resident who smoked, and by not securing the Central Supply and soiled utility rooms. Resident 83, who had impaired vision, used a wheelchair, and required substantial assistance with daily activities, was found to be storing cigarettes in their pocket despite the facility's policy requiring such materials to be stored with the facility. This discrepancy was observed during an interview where the resident admitted to smoking outside the designated smoking times and areas, contrary to the facility's smoking policy and their signed agreement. The facility's staff, including the Director of Nursing and the Administrator, acknowledged the need for better organization and supervision of the smoking process but had not effectively enforced the policy with Resident 83. Additionally, the facility's Central Supply room was observed to be unlocked and unsupervised on multiple occasions, containing potentially hazardous materials such as medical supplies, over-the-counter medications, and chemicals. Staff acknowledged the importance of keeping the room secured but failed to do so consistently. Similarly, the soiled utility rooms on the 1st and 3rd floors were found unsecured, with dangerous chemicals accessible to residents. Staff confirmed that these rooms should be locked at all times to prevent access to hazardous materials, but observations showed that the doors did not secure properly, posing a risk to resident safety.
Failure to Ensure Nursing Staff Competency in Tracheostomy and Stoma Care
Penalty
Summary
The facility failed to ensure that nursing staff had the appropriate competencies and skill sets to provide nursing care and related services that assured resident safety and attained or maintained the resident's highest practicable physical, mental, and psychosocial well-being. This deficiency was identified through observation, interview, and record review, revealing that the facility did not verify skills competency for five Certified Nursing Assistants (CNAs) and one Registered Nurse (RN) interviewed for special focused training for tracheostomy and stoma care. Specifically, the facility did not provide specialized CPR training for staff working with Resident 91, who had a tracheostomy, and staff were unable to explain the specific CPR requirements for this resident. The Director of Nursing acknowledged that the facility policy did not include emergency care for choking or CPR for residents with a tracheostomy and that specialized CPR training should have been provided before staff worked with Resident 91. Additionally, the Staff Development Coordinator, who had been in the position for two months, stated that there was no documentation for skills verification or competency evaluations for any current staff, and no process for staff skills evaluations on hire or annually. The Human Resources staff confirmed that there were no skills verification documents on file for a sample of five staff. The Resident Care Manager also stated that no special focus training was performed for staff on how to care for a tracheostomy or stoma routinely or in an emergency. The facility's failure to validate their nursing staff's knowledge, skills, abilities, behaviors, and other characteristics necessary to perform job-related functions safely and successfully placed residents at risk for incompetent care and harm, specifically placing Resident 91 at risk for injury, harm, and death.
Infection Control Deficiencies
Penalty
Summary
The facility failed to implement an effective Infection Prevention and Control Program, as evidenced by the lack of a water management program, uncleanable resident equipment, improperly handled urinary catheter bags, and inadequate hand hygiene practices. During an interview, the Environmental Director and Administrator confirmed that there was no current water management program to monitor and prevent waterborne pathogens like Legionella. Observations revealed multiple instances of resident equipment, such as mattresses, wheelchairs, walkers, and dining room chairs, with damaged surfaces that were uncleanable, posing a risk for infection spread. Staff interviews corroborated that these items should be intact and cleanable to reduce infection risks. Specific observations included a CNA handling Resident 66's morning hygiene care without changing gloves or performing hand hygiene between dirty and clean tasks, and another CNA providing care to Resident 51 without changing gloves or washing hands between different care activities. These lapses in hand hygiene were acknowledged by the staff involved, who admitted to not following proper hand hygiene protocols. Additionally, Resident 61's catheter bag was observed lying on the floor and dragging on the hall carpet, which was confirmed by staff to be improper handling that could compromise the catheter's integrity and contaminate the environment. The facility's failure to maintain cleanable surfaces on resident equipment and ensure proper hand hygiene practices, along with the absence of a water management program, left residents vulnerable to infections and other negative health outcomes. Staff interviews consistently highlighted the importance of these measures in preventing the spread of infections, yet the observations indicated a significant lapse in adherence to these protocols.
Failure to Implement Updated Antibiotic Stewardship Program
Penalty
Summary
The facility failed to revise its infection prevention and control policies and develop and implement an updated Antibiotic (ABO) Stewardship program to comply with the 10/24/2023 federal requirements. Specifically, the facility did not implement protocols and a system to monitor, document, and analyze the appropriate use of ABOs. This failure included the lack of leadership support and accountability for three months (January, February, and March 2024). The facility did not have an infection surveillance process that gathered data on residents' symptoms, the type of infectious organism, assessment of infections to meet specific criteria for ABO treatment, and tracking the spread of infection through tracing similar organisms. This placed residents at risk for potential adverse outcomes associated with the inappropriate or unnecessary use of ABOs and an increased risk for ABO-resistant organisms. The facility's policies on Surveillance for Infections and Antibiotic Stewardship were outdated and not revised to meet the new federal requirements. The Infection Control Preventionist (ICP), who started in February 2024, was unable to provide infection control surveillance, analysis, data reports, or Quality Assurance Policy Improvement leadership review for January and February 2024. During an interview, the ICP and other staff members acknowledged that the ABO stewardship program was not intact and did not meet the required standards. The surveillance log provided by the ICP lacked documentation on the organism, symptoms, and criteria for ABO use, further indicating the deficiency in the facility's infection control and ABO stewardship program.
Failure to Obtain Consent and Ensure Privacy
Penalty
Summary
The facility failed to obtain informed consent prior to administering psychotropic medication to Resident 37. The resident, who had severe memory impairment and exhibited verbal behaviors, was given an antipsychotic medication without proper consent. The consent form in the resident's record was not correctly filled out, as it did not specify which medication the resident was consenting to. The Director of Nursing confirmed that the form should have been properly completed to indicate the specific medication, but it was not, resulting in a lack of informed consent for the treatment provided to Resident 37. Additionally, the facility did not ensure adequate privacy during the provision of care for Residents 3, 76, and 69. Observations showed that staff members provided care without pulling privacy curtains, exposing the residents to potential view from the door or other parts of the room. This lack of privacy was noted during various care activities, including dressing and incontinence care. Staff interviews revealed a lack of awareness about the importance of using privacy curtains to protect residents' dignity and privacy during care. The Resident Care Manager acknowledged the importance of privacy and stated that curtains should be used to ensure residents' rights are protected.
Failure to Provide Required Transfer/Discharge Notifications
Penalty
Summary
The facility failed to ensure that residents received the required written notices at the time of transfer or discharge, or as soon as practicable, for three residents reviewed for hospitalization. Resident 66, who had kidney failure and was on dialysis, was transferred to the hospital from the Kidney Center without receiving a written notification regarding the reason for the transfer. Staff interviews revealed that the Medical Records Assistant stopped sending these notifications after June 2023, mistakenly believing they were no longer required. The Social Services Director acknowledged that the required written notices were not provided to Resident 66 or their representative, nor was the Long-Term Care Ombudsman notified as required. Similarly, Resident 30, who had complex medical diagnoses including heart failure and a vertebrae infection, was transferred to the hospital twice for blood transfusions without receiving written notifications. Resident 97, who had diagnoses including malnourishment, gout, and nausea, was also transferred to the hospital without receiving the required written notification. Staff interviews confirmed that no transfer notifications were sent after June 2023 due to a misunderstanding of the requirements. The facility's failure to provide these notifications was not in alignment with the residents' stated goals for care and preferences.
Failure to Provide Bed Hold Notification
Penalty
Summary
The facility failed to provide written notice of the bed hold policy to residents and/or their representatives at the time of transfer or within 24 hours, as required by their policy. This deficiency was identified for two residents, Resident 66 and Resident 97, who were transferred to the hospital. Resident 66, who had kidney failure and was undergoing dialysis, was transferred to the hospital from the Kidney Center due to a change in condition. The medical record did not show any evidence that the bed hold policy was discussed or offered to Resident 66 or their representative during the transfer. Staff K, responsible for offering bed holds, confirmed that the bed hold was not provided as required. Resident 97, who had diagnoses including malnourishment, gout, and nausea, was transferred to the hospital after experiencing a sudden headache and nausea. The facility did not provide a bed hold due to the resident's altered mental state at the time of transfer. Resident 97 returned to the facility eight days later. Staff M from Social Services stated that nursing typically handled the bed hold process and confirmed that Resident 97 should have received a bed hold, but the resident's record did not show that it was provided. This failure to provide the required bed hold notification placed the residents and their representatives at risk of not being informed of their rights and the cost associated with holding the resident's bed while hospitalized.
Inaccurate MDS Assessments for Multiple Residents
Penalty
Summary
The facility failed to ensure that the Minimum Data Set (MDS) assessments for six residents accurately reflected their conditions. For Resident 7, the MDS did not capture the resident's refusal of a knee brace program on two occasions. Similarly, Resident 57's MDS did not reflect the resident's refusal of a Range of Motion (ROM) program and bathing assistance. Staff interviews confirmed that these refusals should have been documented accurately in the MDS assessments. Resident 69's MDS inaccurately indicated that the resident did not receive antianxiety medications, despite the Medication Administration Record (MAR) showing regular administration of such medication. Resident 81's MDS was incomplete and inaccurate, failing to include a resident interview for mood and pain assessment, and incorrectly noting the presence of natural teeth when the resident had none. Staff interviews revealed that the MDS was completed remotely by a corporate nurse, which may have contributed to these inaccuracies. Resident 37's MDS did not include an active psychotic disorder diagnosis, despite the resident receiving antipsychotic medication. Similarly, Resident 2's MDS failed to document the administration of antipsychotic medication for Obsessive-Compulsive Disorder (OCD) and did not include the resident's weight, as staff failed to weigh the resident during the assessment period. Staff interviews confirmed these omissions and inaccuracies in the MDS assessments.
Failure to Develop and Implement Comprehensive Care Plans
Penalty
Summary
The facility failed to ensure a person-centered comprehensive care plan (CP) was developed and implemented for four residents, leading to inconsistent and inadequate care. Resident 66, who had kidney and heart failure, and high blood pressure, was observed to have missing teeth and required staff assistance for oral care. However, no CP was developed to address the resident's dental health needs. Staff K confirmed that an oral/dental CP should have been initiated but was not. Resident 73, who had impaired memory and was frequently incontinent, was observed to smell like urine. Despite being a candidate for a scheduled toileting program, no bowel and bladder CP was developed to instruct staff on the toileting schedule. Staff K confirmed the omission of the necessary CP for Resident 73's incontinent care needs. Resident 37, who had severely impaired memory and took antipsychotic medication, had a CP that did not specify which antipsychotic medication was prescribed or the behaviors it was meant to treat. Staff B emphasized the importance of comprehensive and accurate CPs. Resident 91, who had a tracheostomy and required specialized CPR equipment, did not have the necessary Ambu bag or pediatric CPR mask available in their room as directed by their CP. Staff O confirmed the absence of these critical items, which were eventually found on the medical crash cart. Staff B stated that the required suction machine and supplies should have been in the room per the CP directions.
Failure to Update Care Plans and Schedule Care Conferences
Penalty
Summary
The facility failed to ensure Care Plans (CP) were updated and/or revised as needed for two residents and did not provide an opportunity for a care conference for one resident. Resident 83 had a CP that inaccurately included an intervention for anticoagulant therapy, despite not receiving any anticoagulant medication. This discrepancy was confirmed by the Resident Care Manager (RCM) during an interview. Resident 51's CP indicated a need for one-to-one assistance during meals, but observations showed the resident eating without staff assistance. The RCM acknowledged that the CP was outdated and needed revision. Additionally, Resident 59 did not have a care conference for over a year, despite the facility's policy to hold such conferences quarterly and annually. The resident confirmed not having a care conference in a long time, and the Social Services Director admitted to being behind in scheduling due to staffing issues. The last documented care conference for Resident 59 was over a year ago, which was confirmed by staff during interviews and record reviews.
Failure to Implement Proper Feeding Tube Care
Penalty
Summary
The facility failed to implement proper care for a resident with a feeding tube, leading to several deficiencies. The resident, who had multiple medically complex diagnoses including malnutrition, required the use of a feeding tube for more than 51% of their total caloric and fluid intake. The facility did not provide a consistent formula or rate of administration, failed to document the total intake provided over 24 hours, did not clarify and administer the correct amount of water flushing required, and did not label and date the feeding tube formula as required by the facility's policy. These actions were observed over several days, with inconsistencies in the type of formula used, the rate of administration, and the labeling of the formula bags. The resident's physician orders included specific instructions for water flushing and formula administration, but these were not consistently followed. For example, the orders directed staff to flush the feeding tube with 300 mL of water three times a day and to provide a 300 mL bolus feeding four times a day of Isosource formula. However, observations showed that the formula bags were sometimes unlabeled or incorrectly labeled, and the administration rates varied. Additionally, during a medication pass, a nurse administered a total of 238 mL of water, which was not in accordance with the physician's orders. Interviews with staff revealed a lack of adherence to the facility's policies and physician orders. The Resident Care Manager acknowledged that there should be an order identifying the nutritional intake needs for the resident and that the total amount of fluid intake should be documented every 24 hours. The Director of Nursing also stated that feeding tube orders should be followed consistently, with formula bags labeled and dated as required. The failure to follow these protocols placed the resident at risk for complications related to their feeding tube and hydration status.
Failure to Act on Pharmacist Recommendations
Penalty
Summary
The facility failed to ensure timely action on medication-related irregularities identified by the consultant pharmacist for one resident. Resident 33, who had complex medical diagnoses including high blood pressure and hyperlipidemia, had a medication order for hyperlipidemia that required periodic monitoring through a lipid panel blood test. Although the consultant pharmacist recommended this test in October 2023 and the provider agreed, the lipid panel was not obtained until January 2024, three months later. Additionally, a recommendation to decrease a steroid nasal inhaler due to lack of symptoms was made in November 2023 but was not addressed until March 2024, after repeated recommendations and delays in provider approval. The Director of Nursing (Staff B) acknowledged that pharmacy recommendations should be completed and implemented by the end of the month they are made and should be readily available in the resident's records. However, the facility's failure to act on these recommendations in a timely manner placed Resident 33 at risk for medication-related complications. The pharmacy's pending response lists for November and December 2023 showed that the facility had not addressed the recommendations, and the records confirmed the delays in obtaining necessary lab tests and adjusting medication orders.
Failure to Review and Adjust Medication Regimen
Penalty
Summary
The facility failed to ensure that Resident 58's drug regimen was free from unnecessary medications. Resident 58, who had diagnoses including kidney failure and shortness of breath, was receiving an antibiotic (ABO) medication every 48 hours for long-term use of systemic steroids since November 2023. Despite a nephrologist's recommendation in January 2024 to reduce the steroid dosage and follow up in eight weeks, the facility did not schedule the follow-up appointment or clarify the necessity of the ABO medication with the nephrologist. Additionally, a pharmacist's recommendation in February 2024 to clarify the ABO medication with the nephrologist was not followed by the staff. Staff K, the Resident Care Manager, acknowledged that they were responsible for following up with the nephrologist's recommendations but admitted to missing the follow-up appointment and failing to clarify the ABO medication order. This oversight resulted in Resident 58 continuing to receive the ABO medication without proper review or adjustment, contrary to the nephrologist's instructions and the pharmacist's recommendations.
Failure to Ensure Appropriate Diagnosis for Antipsychotic Medication
Penalty
Summary
The facility failed to ensure residents were free of unnecessary medications, specifically for one resident who was administered an antipsychotic (AP) medication without an appropriate diagnosis. The resident, who had severe memory impairment and verbal behaviors, was given an AP medication for vascular dementia with behavioral disturbance and psychosis. However, the facility's consultant pharmacist noted that dementia was not an appropriate indication for the use of an AP medication and that the resident did not have a documented psychosis diagnosis. Despite this, the resident continued to receive the medication until a new diagnosis of unspecified psychosis was added by the facility's medical supply clerk, without clear documentation of who diagnosed the resident or the diagnostic process followed. Interviews with the Director of Nursing and the Regional Nurse Consultant confirmed that the resident received the AP medication without an adequate diagnosis from September 2022 until February 2024. The facility's policy required that psychoactive medications be provided at the lowest effective dose and only with supporting diagnoses. The lack of proper documentation and adherence to this policy left the resident at risk for adverse side effects and unnecessary medication use.
Failure to Secure and Dispose of Expired Medications
Penalty
Summary
The facility failed to ensure drugs and biologicals were secured and expired medications and biologicals were disposed of timely in accordance with professional standards. In the first floor medication room, expired ostomy pouches, IV tubing, and IV fluid were found, along with expired IV antibiotic medication and liquid antacid medication in the refrigerator. Additionally, the refrigerator contained medications for discharged residents that had not been removed. The Pyxis machine also contained expired IV fluid and electrolyte solution. Medication carts on the third and first floors had loose pills and an opened nasal spray with no open date or resident name. Staff interviews confirmed these findings and acknowledged that expired medications should not be kept and that medications for discharged residents should be destroyed within one to two days after discharge, but this was not done. Unsecured medications were also observed in resident rooms and on medication carts. A steroid inhaler, analgesic lotion, and antifungal powder were found unsecured on a resident's bedside table, and a pain patch was left unsecured on another resident's bedside table. Additionally, an unsecured, opened pain patch was observed on top of a medication cart without staff present. Staff interviews confirmed that medications should not be left unsecured at a resident's bedside or on top of medication carts without staff present.
Failure to Provide Timely Dental Services
Penalty
Summary
The facility failed to ensure prompt dental services were provided for Resident 57, who was cognitively intact and had obvious dental issues, including broken teeth and oral pain. Despite a dental consultation in June 2023 recommending x-rays, evaluation, and extraction of all upper and lower teeth, followed by the provision of dentures, no follow-up actions were taken. The resident expressed interest in obtaining dentures, but the necessary dental services were not coordinated or provided in a timely manner. Interviews with staff revealed that the Medical Records Director, responsible for coordinating dental appointments, cited staffing shortages as a reason for the delay in scheduling these appointments. The Director of Nursing stated that referrals should be followed up within a week, but this did not occur for Resident 57. The lack of timely follow-up placed the resident at risk for unmet dental needs and diminished quality of life.
Latest citations in Washington
Inaccurate PASARR screening affected two residents. One resident with vascular dementia, depression, and adjustment disorder had a PASARR level one that did not reflect mental health diagnoses, and staff stated it was inaccurate. Another resident with PTSD had a PASARR level one that did not include the PTSD diagnosis, with no additional PASARR level one or level two found in the EHR; staff stated the screening was not accurate and should have been repeated.
Undated open meds were found on 2 medication carts, including an open insulin vial and multiple open eye drop bottles with no dates. An LPN and an RN both stated the items should have been dated when opened, and the DON stated open multidose vials or bottles found without a date should be discarded immediately.
A resident with respiratory failure, HTN, and anxiety became SOB and diaphoretic, received a breathing tx, and was sent by EMS to the hospital. The facility could not locate the required SNF/NF to Hospital Transfer form or other transfer records showing what information was communicated to the receiving provider.
Care plans for two residents were not updated to match their current status and care needs. One resident had PTSD and generalized anxiety disorder and was receiving a psychotropic medication, but the care plan listed monitoring for antipsychotic and anticonvulsant meds that were not prescribed and did not include the anxiety diagnosis or related behaviors and interventions. Another resident had new upper and lower dentures, but the oral/dental care plan only noted edentulous status and difficulty chewing, with no mention of dentures or denture-related interventions.
Failure to Provide Individualized Activities: A resident with anxiety, depression, and weakness was cognitively intact but said they could not attend group activities because of leg problems and wanted more in-room activities. The resident mostly stayed in bed watching TV, and staff documentation showed only limited room visits with no consistent activity documentation despite a care plan goal for participation two to three times per week.
Failure to maintain heel offloading for a resident with a reopened DFU. A resident with dementia and dependence for mobility had a left heel wound that had healed and then reopened; the wound care provider recommended heel floating and pressure relieving boots at all times, but observations showed the resident in bed with heels on the mattress and later reclined in a wheelchair with the heel resting on the footrest strap and no boots in place. Staff stated the resident had not refused the boots or heel floating, and the care plan was not updated after the wound reopened.
Failure to Address Hearing and Vision Services for a Resident: A resident with dementia, bilateral hearing loss, and impaired vision was observed without eyeglasses or a hearing device, despite records showing admission with eyeglasses and a personal sound amplifier. The care plan addressed vision only and did not include hearing-related interventions, while staff interviews confirmed the resident’s hearing was strained and that the resident’s device use and vision needs were not fully reflected in the plan of care.
Respiratory care was not provided consistently for two residents receiving O2. One resident with COPD and chronic respiratory failure had an O2 order missing the indication for use and Sats parameters, no MAR documentation of O2 therapy, and inconsistent Sats charting. Another resident with respiratory failure was observed on continuous O2 via NC, but provider orders for O2 therapy and tubing changes were not present after readmission, despite the care plan stating the resident was dependent on O2.
A resident with dementia, hearing loss, and missing lower teeth had an MDS showing obvious or likely cavities or broken natural teeth, and the care plan identified oral/dental health problems with an intervention to coordinate dental care and transportation. Staff stated the resident’s dental needs were captured on the MDS, but no referral was made for dental services or follow-up with the dentist, and the DON said the lack of referral did not meet expectations.
Inaccurate Meal Intake Documentation: A resident with DM, dysphagia, and protein-calorie malnutrition was observed eating less than 25% of a meal, but the POC documented 76-100% intake. The CNA said the resident usually ate only 25-50% of meals and that intake was sometimes documented based on what a coworker reported. The LPN/RCM and DON stated meal intake should be documented accurately.
Inaccurate PASARR Screening for Two Residents
Penalty
Summary
The facility failed to ensure that two residents were screened for additional mental health supports through the PASARR process. Resident 97 was admitted with diagnoses including vascular dementia, depression, and adjustment disorder, and was able to make needs known. Review of the PASARR level one dated 04/10/2026 showed no mental health diagnoses and no need for a PASARR level two, even though the resident’s record included mental health diagnoses. During interview, the Regional Social Services staff and the Administrator stated the PASARR was inaccurate, needed modifications, and did not meet expectations. Resident 6 was admitted with diagnoses including heart failure, respiratory failure, and PTSD, and was able to make needs known. Review of the PASARR level one dated 03/30/2026 showed no serious mental illness indicators marked and no PASARR level two indicated, and the EHR contained no other documented PASARR level one or level two. The Social Services Director stated the hospital-provided PASARR was reviewed for accuracy and, if inaccurate, another level one would be completed, and stated this resident’s PASARR did not include PTSD and should have had another level one completed. The Administrator also stated the PASARR was not accurate and another level one needed to be conducted, but none could be located in the EHR.
Undated Open Medications on Medication Carts
Penalty
Summary
The facility failed to ensure proper storage and labeling of medications for 2 of 3 sampled medication carts reviewed for medication storage and labeling, including carts on the 400 and 500 halls. On the 500 hall medication cart, an open vial of insulin and an open bottle of eye drops were observed with no dates. During interview, an LPN stated that when an insulin vial or bottle of eye drops is opened, it should be dated immediately and said both items should have been dated upon opening; the LPN stated they would dispose of the undated vial and bottle. On the 400 hall medication cart, two open bottles of eye drops were observed with no dates. During interview, an RN stated both bottles should have been dated as soon as they were opened and said they would get new eye drops and dispose of the undated bottles. The DNS/RN stated that if an eye drop was opened it should have been dated immediately and that any open multidose vial or bottle found without a date should be discarded immediately.
Missing Hospital Transfer Documentation
Penalty
Summary
The facility failed to ensure hospital transfer documentation was completed for one resident who was transferred to the hospital after complaining of not being able to breathe and appearing diaphoretic. The resident had diagnoses of respiratory failure, high blood pressure, and anxiety disorder, and was able to make needs known. A breathing treatment was provided, and the provider agreed to send the resident out for further evaluation, after which emergency transportation took the resident to the hospital. Record review found no documentation showing what information was provided or communicated to the receiving facility for the transfer. Staff stated that transfer documentation should have included a SNF/NF to Hospital Transfer form, the resident's face sheet, and the medication and treatment administration records, but they were unable to locate documentation showing these items were completed or sent for the resident's hospital transfer.
Care plans did not reflect current diagnoses, medications, or denture status
Penalty
Summary
The facility failed to ensure that care plans were revised and accurately reflected residents’ current status and care needs for 2 of 21 sampled residents. Resident 6 was admitted with diagnoses including heart failure, respiratory failure, and PTSD, and was able to make needs known. The EHR showed Resident 6 also had generalized anxiety disorder and was receiving a psychotropic medication, but the current care plan dated 05/05/2026 documented monitoring for side effects of antipsychotic and anticonvulsant medications even though Resident 6 was not prescribed those medications. The care plan also identified PTSD but did not include generalized anxiety disorder or behaviors to monitor and interventions related to PTSD or anxiety disorder. Staff F, LPN/CC, stated the care plan did not accurately reflect the resident’s current status or prescribed medications, and Staff B, DNS, stated it did not meet expectations because it did not address the anxiety disorder or target behaviors and interventions. Resident 71 was admitted with diagnoses including PTSD, high blood pressure, and depression and was able to make needs known. Observation on 05/06/2026 showed a denture cup by the sink with the resident’s name on the lid and new upper and lower dentures dated 01/12/26. The resident stated the lower dentures did not fit well and that denture adhesive had been provided, but the dentures still did not fit right and the resident had not told staff yet. The focused oral/dental care plan, initiated on 06/23/2026, identified the resident as edentulous and having difficulty chewing, but did not show that the resident had dentures or include interventions related to denture use or maintenance. Staff E, CNA, stated they had not seen the resident wear dentures and were unaware of the new dentures, Staff C, LPN/CC, stated the care plan should have been updated when the dentures were obtained, and Staff B, DNS, stated the care plan should have reflected the dentures and interventions.
Failure to Provide Individualized Activities
Penalty
Summary
The facility failed to provide individualized activities for Resident 5, who was admitted with diagnoses including anxiety disorder, depression, and weakness. The admission MDS dated 01/14/2026 showed the resident was cognitively intact. During interviews on 05/03/2026 and 05/06/2026, Resident 5 stated they could not attend in-person activities because of their legs, wanted more activities to occupy them, mostly stayed in bed watching TV, and did not remember the last time activities staff visited to offer activities. The resident also stated activities staff would need to offer something they were able to do because they had difficulty doing some activities. The activities care plan dated 12/26/2026 showed a goal for Resident 5 to participate in activities two to three times per week. Progress notes documented one visit on 12/22/2026 to provide a welcome packet and encourage participation in daily activities, but no further activity documentation was found in the progress notes. Staff H stated room visits should include puzzles, arts and crafts, visiting, and chatting, and that documentation was placed in tasks, but the task record showed no documentation of activities for the past 30 days. Staff J stated paper documentation existed for room visits and that Resident 5 was on a list for room visits every Monday and Wednesday, while the room visit documentation showed only four visits on 01/26/2026, 02/06/2026, 03/10/2026, and 04/08/2026.
Failure to Maintain Heel Offloading for Reopened DFU
Penalty
Summary
The facility failed to consistently implement pressure reducing strategies for a resident with a left heel diabetic foot ulcer that had reopened. The resident was admitted with diagnoses including left hip fracture with surgical repair, a blood clot of the left lower leg, and dementia, and was dependent on staff for mobility and unable to make needs known. The baseline care plan and care plan both included heel offloading interventions, and the wound care provider initially recommended heel floating with pillows or wedge and pressure relieving boots. The wound later resolved, but a weekly skin assessment documented that the left heel wound reopened and was very painful to touch. After the wound reopened, the contracted wound care provider documented that the DFU to the left heel had reopened and recommended the resident wear pressure relieving boots at all times. The current care plan reviewed after the wound reopened did not include new interventions related to the reopened wound. Observations showed the resident seated in a reclined wheelchair with the left foot/heel resting on the footrest strap and no pressure relieving boots in place, and later lying in bed with both heels directly on the mattress without being floated and without boots. Staff interviews indicated the resident had not refused the boots or heel floating, and the LPN/CC and DON stated the resident should have been assessed and the plan of care updated when the wound reopened.
Failure to Address Resident Hearing and Vision Needs
Penalty
Summary
The facility failed to address one resident’s hearing and vision needs. Resident 112 was admitted with diagnoses including a leg fracture, dementia, and hearing loss in both ears, and was able to make needs known. The record showed the resident lost their glasses and was given readers, but the resident did not wear them because they were concerned that wearing glasses that were not their prescription would further degrade their vision. Observation did not show glasses in the resident’s room, and the resident stated they did not use a hearing aid. The resident was observed to be hard of hearing, requiring an elevated voice and repeated questions to understand. The admission MDS dated [DATE] documented adequate hearing with hearing aid and adequate vision with corrective lenses, while the significant change MDS dated [DATE] documented moderate difficulty hearing without a hearing aid and impaired vision without corrective lenses. The care plan initiated 02/24/2026 addressed impaired vision with interventions to arrange consultation with eye care practitioners as needed and remind the resident to wear glasses, but it did not include a focus area or interventions for hearing loss or use of hearing aids. A resident clothing list showed the resident admitted with one pair of eyeglasses and one Super Ear headset personal sound amplifier, yet observation and interview showed the resident in bed without eyeglasses or a hearing device, with the amplifier stored in the bedside table drawer. Staff interviews confirmed the resident’s hearing was strained, that the hearing device and glasses were not being used, and that the resident’s hearing device use should have been included in the plan of care and the resident should have been referred for eye care assessment.
Respiratory Care Orders and Documentation Not Maintained
Penalty
Summary
The facility failed to provide respiratory care consistent with professional standards of practice for two residents receiving oxygen therapy. One resident with COPD and chronic respiratory failure with hypoxia was observed multiple times lying in bed receiving oxygen at 2 L via nasal cannula. The resident’s oxygen order, dated 02/15/2026, allowed 1 to 4 L per minute continuously via nasal cannula, but it did not include an indication for use or oxygen saturation parameters. The April and May 2026 MARs did not show documentation of oxygen therapy being provided, and the TARs showed only an order to change oxygen tubing if damaged or visibly soiled, not an order for oxygen therapy. Oxygen saturations were not documented consistently daily from 04/01/2026 through 05/04/2026. A second resident with respiratory failure, high blood pressure, and anxiety disorder was observed in the room receiving oxygen at 6 L via nasal cannula on multiple occasions. The resident stated they needed oxygen therapy to breathe, and the care plan identified the resident as dependent on oxygen and to receive oxygen per provider orders. However, provider orders reviewed on 05/04/2026 showed no orders for oxygen therapy or for changing oxygen tubing. Staff stated the oxygen and tubing-change orders had been discontinued when the resident went to the hospital and were not added back to the MAR or TAR when the resident readmitted to the facility.
Failure to Refer Resident With Identified Dental Needs
Penalty
Summary
The facility failed to ensure that Resident 112 received needed dental care. Resident 112 was admitted with diagnoses including a leg fracture, dementia, and hearing loss in both ears. Observation on 05/03/2026 showed the resident had missing lower teeth. The admission MDS, dated [DATE], documented obvious or likely cavities or broken natural teeth, and the care plan dated 02/24/2026 identified oral/dental health problems related to likely cavities or broken teeth with an intervention to coordinate dental care and provide transportation. During interviews, Staff G, Regional Social Services, stated Resident 112's dental needs were captured on the 02/24/2026 MDS and the resident was not referred for dental services. Staff M, Social Services Director, stated residents with dental needs should be referred to social services to be scheduled for assessment by a dental care practitioner, and that Resident 112 should have been referred after the MDS assessment. Staff B, DON, stated residents with identified dental needs should be referred for follow-up with a dentist and that Resident 112 should have been referred to the in-house dental provider; Staff B stated the lack of referral did not meet expectations.
Inaccurate Meal Intake Documentation
Penalty
Summary
The facility failed to accurately document the amount of food eaten for Resident 13, who was admitted with diagnoses including diabetes mellitus, dysphagia, and protein-calorie malnutrition. The quarterly MDS dated 02/12/2026 showed the resident was moderately cognitively impaired. During observation on 05/05/2026 at 12:09 PM, a meal tray was delivered to the resident’s room, set up on a bedside table, and the resident was observed eating slowly, eating less than 25% of the meal, then laying back in bed and closing their eyes while the tray remained in the room. Staff later removed the tray, but the POC documentation for lunch on 05/05/2026 recorded that Resident 13 ate 76-100% of the meal. During interview, the CNA stated the resident typically ate 25-50% of meals and never ate all of the food, and that if they did not pick up a tray they would ask a coworker what the resident ate before documenting it. The CNA stated they were told the resident ate 75-100% of lunch, so that is what was entered. The LPN/RCM stated staff should document meal intake accurately in POC, and the RN/DNS stated it was their expectation that all staff document meal intake accurately.
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