Avamere Transitional Care Of Puget Sound
Inspection history, citations, penalties and survey trends for this long-term care facility in Tacoma, Washington.
- Location
- 630 South Pearl Street, Tacoma, Washington 98465
- CMS Provider Number
- 505529
- Inspections on file
- 24
- Latest survey
- March 19, 2026
- Citations (last 12 mo.)
- 56
Citation history
Health deficiencies cited at Avamere Transitional Care Of Puget Sound during CMS and state inspections, most recent first.
A resident admitted with coccyx skin breakdown and moderate Braden risk was initially misclassified as having skin tears rather than Stage II PUs, and the skin integrity care plan lacked resident-centered interventions addressing specific risk factors such as repositioning, offloading, and moisture management. Nursing documentation over time was inconsistent, with notes alternately stating there were no wounds and describing excoriation and open areas, while weekly wound audits and evaluations were missed or incomplete. The WCC eventually identified a large unstageable coccyx PU that progressed to Stage IV, but WCC orders for twice-daily wound care, specific cleansers, and pressure-relieving devices were inaccurately transcribed on the TAR and not fully incorporated into the care plan. Weekly wound assessments were not consistently performed, and the care plan failed to document the presence and stage of the coccyx Stage IV PU or a new heel DTI, contributing to ongoing worsening of the resident’s pressure injuries.
A resident’s PU/PI status was inaccurately assessed and documented across multiple tools and time points, including the admission skin integrity database, daily skilled notes, CAA, and several MDS assessments and modifications. Initial documentation described coccyx wounds as skin tears and later MDS coding alternated between no PU/PI, unstageable PU/PI present on admit, and a Stage IV PU/PI not present on admit, without consistent supporting clinical detail such as stage, location, or measurements. The CAA lacked documented rationale for PU/PI-related care planning, and a new DTI on the heel identified by a WCC was not coded on the discharge MDS because the wound tracker form was not available to the MDS coordinator at the time of completion.
A resident with multiple medical conditions reported rough care by a CNA, resulting in bruising and distress. The incident was documented as a grievance but not reported as an abuse allegation, and there was no evidence of an investigation or required notifications. Staff interviews revealed inconsistent understanding of abuse reporting protocols, and the DNS could not provide documentation of follow-up actions.
A resident with dysphagia and a prescribed minced & moist texture diet was incorrectly served a regular texture hamburger, leading to coughing and hospital evaluation. Staff failed to verify dietary orders and care plans before serving the meal.
The facility failed to investigate an unexpected death and an abuse allegation. A resident with hypertension died unexpectedly after receiving medication against provider orders, and no investigation was conducted. Another resident reported inappropriate behavior by a staff member, but the incident was not logged or reported. The DON and Administrator acknowledged that such incidents should be investigated, but no actions were taken.
The facility failed to ensure accurate MDS assessments for two residents, leading to potential risks for unmet care needs. One resident, with heart conditions, reported pain and received medications, but the MDS inaccurately showed no pain or anticoagulant use. Another resident, with a leg contusion, had dressings applied, yet the MDS did not reflect this. Staff interviews confirmed these discrepancies.
The facility failed to create comprehensive care plans for four residents, leading to potential risks. A resident with anxiety related to toileting had no care plan addressing this issue, while another on narcotic pain medication lacked a pain management plan. A third resident had an indwelling catheter without an order or care plan, and a fourth resident's fear of falling during bed mobility was not addressed in their care plan. Staff interviews revealed communication gaps and inconsistencies in understanding residents' needs.
The facility failed to follow provider orders and ensure safe medication administration for several residents, leading to significant deficiencies in care. A resident with hypertension was given amlodipine despite low blood pressure, resulting in an unexpected death. Another resident experienced lightheadedness due to low blood pressure without proper monitoring or provider notification. Additional issues included improper administration of medications outside prescribed parameters and inadequate documentation of adverse effects and bowel care.
The facility failed to provide a working doorbell for handicap residents in the courtyard, leading to potential risks. A resident reported that the courtyard doors were too heavy to open, and the doorbell did not prompt staff response, leaving them stuck until a staff member came by. The Maintenance Director was aware of the issue but unsure of its duration.
The facility failed to provide nonpharmacological interventions (NPI) before administering PRN pain medications to two residents. One resident with hypertension received oxycodone and acetaminophen without NPI being offered, while another resident with a hip fracture received narcotic pain medication multiple times without NPI being documented. Staff interviews confirmed that the expectation to use NPI prior to PRN medications was not met.
The facility failed to properly store medications in both medication rooms and on two medication carts. Lorazepam, a controlled substance, was not secured in locked compartments in the medication rooms, and refrigerator temperatures were frequently out of range. Additionally, insulins on the medication carts lacked open or expiration dates, with one being expired. Staff interviews indicated a lack of awareness regarding proper procedures for securing medications and monitoring temperatures.
The facility failed to maintain an effective infection prevention and control program, lacking analysis of infection data and follow-up activities. Transmission-based precautions were not implemented properly, with staff observed entering rooms without required PPE. Enhanced Barrier Precautions were also not followed during wound care. Interviews confirmed that expected precautions were not consistently implemented.
The facility failed to ensure the infection prevention and control program was managed by a qualified individual. During the absence of the designated infection preventionist, there was confusion about who was responsible for infection control tasks. Staff B and Staff Z had not completed necessary training, and Staff CC, who was expected to cover, was not doing so. This placed residents, family members, and staff at risk.
The facility failed to educate four residents on the benefits and potential side effects of the COVID-19 vaccine before offering it. The residents declined the vaccine, and there was no documentation of education provided. Interviews with staff confirmed the lack of documentation and education, which was expected by the facility's administration.
Failure to Accurately Assess, Care Plan, and Implement Wound Care for Pressure Injuries
Penalty
Summary
The deficiency involves the facility’s failure to provide necessary treatment and services consistent with professional standards of practice to prevent the development and worsening of pressure ulcers/injuries for a resident admitted with coccyx skin breakdown and at moderate risk for pressure injury. On admission, the resident had two coccyx wounds documented as skin tears without detailed wound characteristics, and the Braden Scale score was 14, indicating moderate risk due to moisture, activity, mobility, and friction/shear issues. The initial skin integrity care plan identified actual skin impairment and included general interventions such as keeping skin clean and dry, using lotion, encouraging nutrition, weekly skin assessments, and monitoring/documenting wounds, but it did not include resident-centered interventions addressing specific Braden risk areas or pressure ulcer prevention measures such as repositioning, offloading, or moisture management tailored to the resident’s condition. In the weeks following admission, nursing documentation about the resident’s skin condition was inconsistent and incomplete. Progress notes alternated between stating that the resident had no wounds and describing a pressure ulcer with drainage and slough, excoriation of the buttocks, and open areas on the coccyx, without consistent measurements or staging. Weekly skin audits at times reported no irregularities despite other notes indicating significant skin issues. The contracted wound care clinician (WCC) did not evaluate the coccyx wounds until 14 days after admission, at which time the resident had a large unstageable coccyx pressure injury with extensive eschar. Although the WCC recommended specific treatments, including twice-daily dressing changes, an air mattress, and turning/repositioning every two hours, the care plan was only minimally updated to add an air mattress and did not document the unstageable pressure injury, pressure offloading, repositioning frequency, or other individualized interventions based on the Braden assessment. Over the subsequent weeks, the facility failed to consistently perform and document weekly wound evaluations and did not accurately transcribe or implement physician and WCC wound care orders. Treatment Administration Records showed that orders for twice-daily wound care were entered as once daily, and instructions to leave an acidic wound cleanser on the wound bed for 10 minutes were omitted. Weekly wound evaluations were missing for multiple weeks, and when the WCC documented worsening of the coccyx wound to Stage IV with increasing size and eschar, the care plan still was not updated to reflect the wound stage, detailed interventions, or additional pressure-relieving devices recommended by the WCC. The resident’s coccyx pressure injury continued to worsen in size and depth, and a new deep tissue injury developed on the right heel, despite WCC orders for heel protectors and offloading. The care plan eventually added general instructions to encourage repositioning and elevate heels with pressure-relieving boots, but it still did not document the presence or stage of the coccyx Stage IV pressure ulcer or the heel DTI. Interviews confirmed that wound orders were incorrectly transcribed, weekly wound evaluations were not routinely completed, and the initial coccyx wounds had been misidentified as skin tears rather than Stage II pressure ulcers, contributing to avoidable worsening of the resident’s pressure injuries.
Inaccurate MDS and Wound Documentation for Pressure Ulcers/Injuries
Penalty
Summary
The facility failed to ensure accurate assessment and documentation of a resident’s pressure ulcers/injuries (PU/PIs) from admission through discharge. On admission, the Nursing Database-Skin Integrity dated 12/04/2025 documented two coccyx wounds as skin tears, while the DON later stated the resident actually admitted with two Stage II PU/PIs on the coccyx, indicating the admission documentation was inaccurate. A daily skilled progress note on 12/08/2025 described a PU/PI with drainage and dead tissue but did not include the anatomical location, stage, or measurements. The 12/10/2025 admission MDS coded the resident as at risk for PU/PIs with no unhealed PU/PIs, and the 12/15/2025 PU/PI CAA did not document the rationale for care plan decisions, including complications, risk factors, or resident-centered care needs. Subsequent MDS assessments and modifications contained inconsistent and incomplete coding of the resident’s PU/PIs. A Significant Change MDS dated 01/22/2026 showed one Stage IV PU/PI present on admission, while a 12/10/2025 admission MDS modification dated 01/27/2026 coded one unstageable PU/PI on admission. A later admission MDS modification dated 02/11/2026, submitted after discharge, indicated one unhealed PU/PI but did not include the number or stage of the wound. The MDS coordinator reported there was no supporting documentation for a PU/PI on admission and that the earlier coding of an unstageable PU/PI present on admission was incorrect; the records were then modified to show a Stage IV PU/PI that was not present on admission and had developed at the facility. Additionally, a Wound Care Consultant form dated 02/05/2026 documented a new DTI on the right heel, but the discharge MDS dated 02/10/2026 did not code this DTI, which the MDS coordinator attributed to the wound tracker form not being available in the clinical record at the time of MDS completion.
Failure to Identify and Report Alleged Abuse
Penalty
Summary
The facility failed to identify and report an allegation of abuse involving one resident who was admitted for skilled nursing and rehabilitation following a recent hospitalization. The resident, who had a history of stroke, back surgery, and an implanted nerve stimulator, reported that a CNA was rough during personal care, including yanking the resident up and down and not listening to requests to stop. The resident described feeling like a 'rag doll' and reported bruising as a result of the rough care. The incident was reported by the resident to a provider the following morning, and subsequently discussed with the Director of Nursing Services (DNS). Despite the resident's report and a grievance form documenting the allegation of rough care, the facility did not log the incident as an abuse allegation in the incident logs. There was no documentation in the electronic health record of a provider note, skin assessment, or evaluation following the resident's report. The DNS documented that education would be provided to the CNA and updated the resident's care plan, but there was no evidence of an abuse investigation or required notifications to authorities as outlined in facility policy and state guidelines. Interviews with multiple staff members revealed inconsistent understanding and implementation of abuse reporting protocols. Some staff indicated they would notify supervisors or complete grievance forms, but were unclear about the process for suspending staff or notifying authorities. The DNS stated that further information would be gathered before suspending staff or notifying parties, and could not recall the staff member involved or provide documentation of the education provided. The administrator confirmed that either the administrator or DNS would decide next steps upon being notified of such incidents.
Failure to Serve Correct Therapeutic Diet
Penalty
Summary
The facility failed to ensure that the correct texture of food was served to a resident with a prescribed therapeutic diet. Resident 1, who was moderately cognitively impaired and had a diagnosis of dysphagia, was admitted to the facility with a physician's order for a minced & moist texture diet. Despite this, the resident was served a regular texture hamburger as an alternative meal, which was not in accordance with the prescribed diet. This incident occurred after the resident had been hospitalized for aspiration pneumonia, highlighting the importance of adhering to dietary orders. The incident report revealed that neither the kitchen staff nor the nursing staff verified the resident's dietary orders and care plan before serving the meal. As a result, the resident began coughing after consuming the hamburger, prompting staff to remove the meal and send the resident to the hospital for further evaluation. The failure to check the dietary orders and care plan led to the serving of an incorrect meal texture, which could have posed significant health risks to the resident.
Failure to Investigate Unexpected Death and Abuse Allegation
Penalty
Summary
The facility failed to investigate an unexpected death and an allegation of abuse, leading to deficiencies in care. Resident 52, who had a diagnosis of essential hypertension, unexpectedly died at the facility. The resident was administered amlodipine despite having a low systolic blood pressure, which was against the provider's orders. The resident's condition deteriorated throughout the day, and despite being monitored, the resident became nonresponsive and died. The Director of Nursing Services and the Administrator acknowledged that unexpected deaths should be investigated to rule out abuse, neglect, or mistreatment, but no further investigation was conducted after reviewing the medical records. Resident 114, who was cognitively intact and admitted with multiple fractures of the pelvis, reported an incident involving a staff member to a Charge Nurse. The resident requested that the staff member not return to their room, but the staff member continued to act inappropriately. The incident was not recorded in the facility's incident log, and the Charge Nurse did not report the incident to anyone else. The Director of Nursing Services and the Administrator stated that allegations of abuse should be reported, investigated, and the alleged perpetrator suspended, but these actions were not taken.
Inaccurate MDS Assessments for Two Residents
Penalty
Summary
The facility failed to ensure that the Minimum Data Sets (MDS) accurately reflected the health status and care needs of two residents, leading to potential risks for unidentified and unmet care needs. Resident 107, admitted with congestive heart failure and atrial fibrillation, reported significant pain levels and received both tramadol and heparin sodium during the lookback period. However, the admission MDS inaccurately indicated no pain and no anticoagulant medication. Staff interviews revealed that the MDS Coordinator did not review records for reported pain, and the Director of Nursing Services acknowledged the inaccuracies in the MDS. Similarly, Resident 307, readmitted with heart failure and a leg contusion, was observed with a swollen leg and dressings applied by the facility's nurses. Despite this, the five-day MDS inaccurately showed no dressings. Staff interviews confirmed that the MDS should have reflected the dressing changes. These inaccuracies in the MDS assessments were identified through observations, interviews, and record reviews, highlighting a failure to accurately document residents' conditions.
Deficiencies in Care Planning for Residents
Penalty
Summary
The facility failed to develop and implement comprehensive person-centered care plans for four residents, leading to potential risks for these individuals. Resident 113, who was admitted with orthopedic surgery complications, expressed anxiety about being left alone in the bathroom, but this was not documented in their care plan. Despite the resident communicating their anxiety to therapy staff, this information was not relayed to nursing staff, resulting in a lack of appropriate interventions. Similarly, Resident 44, who was prescribed narcotic pain medication, did not have a care plan addressing pain management, contrary to the facility's expectations. Resident 108, admitted for post-surgical care, had an indwelling urinary catheter without a corresponding order or care plan, leaving the resident unaware of the catheter's purpose. Additionally, Resident 306, with diagnoses including anxiety and depression, expressed fear of falling during bed mobility, yet their care plan lacked instructions on managing this fear and the required assistance level. Staff interviews revealed inconsistencies in understanding the resident's needs, highlighting a gap in communication and care planning. These deficiencies indicate a failure to ensure that care plans are updated and communicated effectively among staff.
Medication Administration and Monitoring Deficiencies
Penalty
Summary
The facility failed to adhere to provider orders and ensure safe medication administration for several residents, leading to significant deficiencies in care. Resident 52, who had a diagnosis of essential hypertension, was administered amlodipine despite having a systolic blood pressure below the prescribed hold parameter. The resident's low blood pressure was not communicated to the provider in a timely manner, and the resident subsequently died unexpectedly. The Director of Nursing Services acknowledged that the medication should not have been given and that the provider should have been notified immediately of the resident's condition. Resident 8, with a history of chronic respiratory failure and heart conditions, experienced lightheadedness due to low blood pressure, yet there were no hold parameters for their metoprolol medication. Blood pressure readings were not consistently rechecked or documented, and the provider was not informed of low readings. Similarly, Resident 206 received metoprolol despite having a systolic blood pressure below the hold parameter, and Resident 44 was given medications with heart rates below the prescribed limits. These actions were contrary to the facility's expectations and policies. Additional deficiencies were noted with Resident 107, who was on anticoagulant therapy and developed bruising that was not documented or monitored as required. Resident 112, who was receiving morphine, experienced constipation that was not addressed according to the bowel care protocol. The facility failed to document interventions or follow the protocol for residents who had not had a bowel movement for several days. These failures in monitoring and communication placed residents at risk of adverse effects and diminished quality of life.
Non-Functioning Doorbells in Courtyard
Penalty
Summary
The facility failed to provide a working doorbell for handicap residents visiting the courtyard, which was identified as an accident hazard. During an interview, a resident stated that both ends of the courtyard had doors that were too heavy for them to open, and the button intended to call for assistance did not result in a staff response. This left residents stuck in the courtyard until a staff member happened to come by. Observations confirmed that the courtyard doors were heavy and that pressing the doorbells did not prompt a staff response. The Maintenance Director acknowledged awareness of the non-functioning doorbells but was unsure of how long they had been inoperative. This deficiency placed residents at risk for accidents, anxiety, feelings of entrapment, and a diminished quality of life, as the facility did not offer any handicap options for residents in the courtyard.
Failure to Provide Nonpharmacological Interventions Before PRN Pain Medications
Penalty
Summary
The facility failed to provide nonpharmacological interventions (NPI) before administering as-needed (PRN) pain medications to two residents, leading to a deficiency in medication management. Resident 44, who was admitted with a diagnosis of essential hypertension, had orders for oxycodone and acetaminophen to be administered as needed. However, there were no orders for NPI, and the medication administration record showed that Resident 44 received oxycodone four times and acetaminophen three times without any NPI being offered. Interviews with staff confirmed that the expectation was to use NPI prior to administering PRN pain medications, but this was not done for Resident 44. Similarly, Resident 1, admitted with a diagnosis of a fall with a hip fracture, received narcotic pain medication 33 times over a specified period. Documentation showed that NPI was not offered prior to administration for 22 of these instances. Staff interviews revealed that nursing staff should have offered and documented NPI in the medical record, but this was not included in Resident 1's orders. The Director of Nursing Services confirmed that the expectation was to offer NPI before administering narcotic medications, which was not met in this case.
Medication Storage and Labeling Deficiencies
Penalty
Summary
The facility failed to ensure proper storage of medications in both the north and south medication rooms and on two medication carts. In the south medication room, an emergency kit containing Lorazepam, a controlled substance, was not secured in a locked compartment. Similarly, in the north medication room, the refrigerator containing an emergency kit with Lorazepam was not locked, and the medication was not secured. Additionally, the temperature logs for the south medication room showed that the refrigerator temperatures were frequently out of the required range, with instances of both freezing and excessively high temperatures recorded throughout July 2024. On the medication carts, multiple instances of improper labeling were observed. In the south high medication cart, two multi-dose insulins lacked open or expiration dates. Similarly, the south low medication cart contained two multi-dose insulins without open or expiration dates, and one insulin was expired. Staff interviews revealed a lack of awareness and understanding regarding the proper procedures for securing controlled substances and monitoring refrigerator temperatures, contributing to the deficiencies in medication storage and labeling.
Infection Control Deficiencies in LTC Facility
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by the lack of analysis of infection control data, identification of trends, and follow-up activities for the months of April, May, and June 2024. The facility's policy, revised in October 2018, required the infection prevention and control program to be coordinated by an infection preventionist and to follow guidelines from the CDC. However, the facility did not document any analysis or interventions based on infection surveillance data, nor did they map current organisms or infections. Additionally, the facility did not implement transmission-based precautions (TBP) effectively. Observations revealed that rooms with Aerosol Generating Procedure (AGP) precautions had open doors and lacked necessary personal protective equipment (PPE) such as N95 masks. Staff members were observed entering rooms without wearing the required PPE, despite signs indicating the need for gowns, gloves, and masks. Interviews with staff, including the Resident Care Manager and Director of Nursing Services, confirmed that the expected precautions were not followed. The facility also failed to adhere to Enhanced Barrier Precautions (EBP) for residents with multidrug-resistant organisms (MDROs). During wound care for a resident, staff did not wear a gown as required by the CDC guidelines. Interviews with the Director of Nursing Services and the Administrator highlighted the expectation for staff to follow posted precautions, but these were not consistently implemented. The infection preventionist's responsibilities, including tracking and mapping infections and ensuring precautions were in place, were not fulfilled, contributing to the deficiencies observed.
Inadequate Infection Control Oversight
Penalty
Summary
The facility failed to ensure that the infection prevention and control program (IPCP) was managed by a qualified individual with the necessary time and training to effectively oversee the program. This deficiency was identified during interviews and record reviews, revealing that the designated infection preventionist, Staff Z, was on vacation, and there was confusion about who was responsible for infection control tasks in their absence. Staff CC, a Registered Nurse/Resident Care Manager, was expected to cover for Staff Z but stated they were not currently doing so. Additionally, Staff B, who was not aware of their responsibility for infection control tasks, was only managing the antibiotic line list. The report highlights that neither Staff B nor Staff Z had completed infection control training, which is crucial for the effective management of the IPCP. The facility's policy required the infection preventionist to track vaccines, conduct rounds, ensure proper isolation precautions, review electronic health records for new infections, and provide staff education, among other duties. The lack of a qualified and trained infection preventionist to oversee these tasks placed residents, family members, and staff at risk of contracting communicable diseases and experiencing a decreased quality of life.
Failure to Educate Residents on COVID-19 Vaccine
Penalty
Summary
The facility failed to provide education on the benefits and potential side effects of the COVID-19 vaccination to four residents before offering the vaccine. This deficiency was identified during a review of the electronic health records (EHR) for Residents 14, 15, 20, and 34, who all declined the COVID-19 vaccine on various dates in 2024. There was no documentation found indicating that these residents or their representatives received the necessary education prior to being offered the vaccine. Interviews with facility staff further confirmed the deficiency. Staff Z, the Interim Infection Preventionist, acknowledged that residents should have been educated on the benefits and potential side effects of the COVID-19 vaccines when they were offered, but was unable to locate documentation for the four residents in question. Additionally, Staff A, the Administrator, stated that it was their expectation that all residents receive education on the risks and benefits when offered the COVID-19 vaccines. This lack of documentation and education placed residents at risk of not being able to make informed decisions regarding their medical care.
Latest citations in Washington
Inaccurate PASARR screening affected two residents. One resident with vascular dementia, depression, and adjustment disorder had a PASARR level one that did not reflect mental health diagnoses, and staff stated it was inaccurate. Another resident with PTSD had a PASARR level one that did not include the PTSD diagnosis, with no additional PASARR level one or level two found in the EHR; staff stated the screening was not accurate and should have been repeated.
Undated open meds were found on 2 medication carts, including an open insulin vial and multiple open eye drop bottles with no dates. An LPN and an RN both stated the items should have been dated when opened, and the DON stated open multidose vials or bottles found without a date should be discarded immediately.
A resident with respiratory failure, HTN, and anxiety became SOB and diaphoretic, received a breathing tx, and was sent by EMS to the hospital. The facility could not locate the required SNF/NF to Hospital Transfer form or other transfer records showing what information was communicated to the receiving provider.
Care plans for two residents were not updated to match their current status and care needs. One resident had PTSD and generalized anxiety disorder and was receiving a psychotropic medication, but the care plan listed monitoring for antipsychotic and anticonvulsant meds that were not prescribed and did not include the anxiety diagnosis or related behaviors and interventions. Another resident had new upper and lower dentures, but the oral/dental care plan only noted edentulous status and difficulty chewing, with no mention of dentures or denture-related interventions.
Failure to Provide Individualized Activities: A resident with anxiety, depression, and weakness was cognitively intact but said they could not attend group activities because of leg problems and wanted more in-room activities. The resident mostly stayed in bed watching TV, and staff documentation showed only limited room visits with no consistent activity documentation despite a care plan goal for participation two to three times per week.
Failure to maintain heel offloading for a resident with a reopened DFU. A resident with dementia and dependence for mobility had a left heel wound that had healed and then reopened; the wound care provider recommended heel floating and pressure relieving boots at all times, but observations showed the resident in bed with heels on the mattress and later reclined in a wheelchair with the heel resting on the footrest strap and no boots in place. Staff stated the resident had not refused the boots or heel floating, and the care plan was not updated after the wound reopened.
Failure to Address Hearing and Vision Services for a Resident: A resident with dementia, bilateral hearing loss, and impaired vision was observed without eyeglasses or a hearing device, despite records showing admission with eyeglasses and a personal sound amplifier. The care plan addressed vision only and did not include hearing-related interventions, while staff interviews confirmed the resident’s hearing was strained and that the resident’s device use and vision needs were not fully reflected in the plan of care.
Respiratory care was not provided consistently for two residents receiving O2. One resident with COPD and chronic respiratory failure had an O2 order missing the indication for use and Sats parameters, no MAR documentation of O2 therapy, and inconsistent Sats charting. Another resident with respiratory failure was observed on continuous O2 via NC, but provider orders for O2 therapy and tubing changes were not present after readmission, despite the care plan stating the resident was dependent on O2.
A resident with dementia, hearing loss, and missing lower teeth had an MDS showing obvious or likely cavities or broken natural teeth, and the care plan identified oral/dental health problems with an intervention to coordinate dental care and transportation. Staff stated the resident’s dental needs were captured on the MDS, but no referral was made for dental services or follow-up with the dentist, and the DON said the lack of referral did not meet expectations.
Inaccurate Meal Intake Documentation: A resident with DM, dysphagia, and protein-calorie malnutrition was observed eating less than 25% of a meal, but the POC documented 76-100% intake. The CNA said the resident usually ate only 25-50% of meals and that intake was sometimes documented based on what a coworker reported. The LPN/RCM and DON stated meal intake should be documented accurately.
Inaccurate PASARR Screening for Two Residents
Penalty
Summary
The facility failed to ensure that two residents were screened for additional mental health supports through the PASARR process. Resident 97 was admitted with diagnoses including vascular dementia, depression, and adjustment disorder, and was able to make needs known. Review of the PASARR level one dated 04/10/2026 showed no mental health diagnoses and no need for a PASARR level two, even though the resident’s record included mental health diagnoses. During interview, the Regional Social Services staff and the Administrator stated the PASARR was inaccurate, needed modifications, and did not meet expectations. Resident 6 was admitted with diagnoses including heart failure, respiratory failure, and PTSD, and was able to make needs known. Review of the PASARR level one dated 03/30/2026 showed no serious mental illness indicators marked and no PASARR level two indicated, and the EHR contained no other documented PASARR level one or level two. The Social Services Director stated the hospital-provided PASARR was reviewed for accuracy and, if inaccurate, another level one would be completed, and stated this resident’s PASARR did not include PTSD and should have had another level one completed. The Administrator also stated the PASARR was not accurate and another level one needed to be conducted, but none could be located in the EHR.
Undated Open Medications on Medication Carts
Penalty
Summary
The facility failed to ensure proper storage and labeling of medications for 2 of 3 sampled medication carts reviewed for medication storage and labeling, including carts on the 400 and 500 halls. On the 500 hall medication cart, an open vial of insulin and an open bottle of eye drops were observed with no dates. During interview, an LPN stated that when an insulin vial or bottle of eye drops is opened, it should be dated immediately and said both items should have been dated upon opening; the LPN stated they would dispose of the undated vial and bottle. On the 400 hall medication cart, two open bottles of eye drops were observed with no dates. During interview, an RN stated both bottles should have been dated as soon as they were opened and said they would get new eye drops and dispose of the undated bottles. The DNS/RN stated that if an eye drop was opened it should have been dated immediately and that any open multidose vial or bottle found without a date should be discarded immediately.
Missing Hospital Transfer Documentation
Penalty
Summary
The facility failed to ensure hospital transfer documentation was completed for one resident who was transferred to the hospital after complaining of not being able to breathe and appearing diaphoretic. The resident had diagnoses of respiratory failure, high blood pressure, and anxiety disorder, and was able to make needs known. A breathing treatment was provided, and the provider agreed to send the resident out for further evaluation, after which emergency transportation took the resident to the hospital. Record review found no documentation showing what information was provided or communicated to the receiving facility for the transfer. Staff stated that transfer documentation should have included a SNF/NF to Hospital Transfer form, the resident's face sheet, and the medication and treatment administration records, but they were unable to locate documentation showing these items were completed or sent for the resident's hospital transfer.
Care plans did not reflect current diagnoses, medications, or denture status
Penalty
Summary
The facility failed to ensure that care plans were revised and accurately reflected residents’ current status and care needs for 2 of 21 sampled residents. Resident 6 was admitted with diagnoses including heart failure, respiratory failure, and PTSD, and was able to make needs known. The EHR showed Resident 6 also had generalized anxiety disorder and was receiving a psychotropic medication, but the current care plan dated 05/05/2026 documented monitoring for side effects of antipsychotic and anticonvulsant medications even though Resident 6 was not prescribed those medications. The care plan also identified PTSD but did not include generalized anxiety disorder or behaviors to monitor and interventions related to PTSD or anxiety disorder. Staff F, LPN/CC, stated the care plan did not accurately reflect the resident’s current status or prescribed medications, and Staff B, DNS, stated it did not meet expectations because it did not address the anxiety disorder or target behaviors and interventions. Resident 71 was admitted with diagnoses including PTSD, high blood pressure, and depression and was able to make needs known. Observation on 05/06/2026 showed a denture cup by the sink with the resident’s name on the lid and new upper and lower dentures dated 01/12/26. The resident stated the lower dentures did not fit well and that denture adhesive had been provided, but the dentures still did not fit right and the resident had not told staff yet. The focused oral/dental care plan, initiated on 06/23/2026, identified the resident as edentulous and having difficulty chewing, but did not show that the resident had dentures or include interventions related to denture use or maintenance. Staff E, CNA, stated they had not seen the resident wear dentures and were unaware of the new dentures, Staff C, LPN/CC, stated the care plan should have been updated when the dentures were obtained, and Staff B, DNS, stated the care plan should have reflected the dentures and interventions.
Failure to Provide Individualized Activities
Penalty
Summary
The facility failed to provide individualized activities for Resident 5, who was admitted with diagnoses including anxiety disorder, depression, and weakness. The admission MDS dated 01/14/2026 showed the resident was cognitively intact. During interviews on 05/03/2026 and 05/06/2026, Resident 5 stated they could not attend in-person activities because of their legs, wanted more activities to occupy them, mostly stayed in bed watching TV, and did not remember the last time activities staff visited to offer activities. The resident also stated activities staff would need to offer something they were able to do because they had difficulty doing some activities. The activities care plan dated 12/26/2026 showed a goal for Resident 5 to participate in activities two to three times per week. Progress notes documented one visit on 12/22/2026 to provide a welcome packet and encourage participation in daily activities, but no further activity documentation was found in the progress notes. Staff H stated room visits should include puzzles, arts and crafts, visiting, and chatting, and that documentation was placed in tasks, but the task record showed no documentation of activities for the past 30 days. Staff J stated paper documentation existed for room visits and that Resident 5 was on a list for room visits every Monday and Wednesday, while the room visit documentation showed only four visits on 01/26/2026, 02/06/2026, 03/10/2026, and 04/08/2026.
Failure to Maintain Heel Offloading for Reopened DFU
Penalty
Summary
The facility failed to consistently implement pressure reducing strategies for a resident with a left heel diabetic foot ulcer that had reopened. The resident was admitted with diagnoses including left hip fracture with surgical repair, a blood clot of the left lower leg, and dementia, and was dependent on staff for mobility and unable to make needs known. The baseline care plan and care plan both included heel offloading interventions, and the wound care provider initially recommended heel floating with pillows or wedge and pressure relieving boots. The wound later resolved, but a weekly skin assessment documented that the left heel wound reopened and was very painful to touch. After the wound reopened, the contracted wound care provider documented that the DFU to the left heel had reopened and recommended the resident wear pressure relieving boots at all times. The current care plan reviewed after the wound reopened did not include new interventions related to the reopened wound. Observations showed the resident seated in a reclined wheelchair with the left foot/heel resting on the footrest strap and no pressure relieving boots in place, and later lying in bed with both heels directly on the mattress without being floated and without boots. Staff interviews indicated the resident had not refused the boots or heel floating, and the LPN/CC and DON stated the resident should have been assessed and the plan of care updated when the wound reopened.
Failure to Address Resident Hearing and Vision Needs
Penalty
Summary
The facility failed to address one resident’s hearing and vision needs. Resident 112 was admitted with diagnoses including a leg fracture, dementia, and hearing loss in both ears, and was able to make needs known. The record showed the resident lost their glasses and was given readers, but the resident did not wear them because they were concerned that wearing glasses that were not their prescription would further degrade their vision. Observation did not show glasses in the resident’s room, and the resident stated they did not use a hearing aid. The resident was observed to be hard of hearing, requiring an elevated voice and repeated questions to understand. The admission MDS dated [DATE] documented adequate hearing with hearing aid and adequate vision with corrective lenses, while the significant change MDS dated [DATE] documented moderate difficulty hearing without a hearing aid and impaired vision without corrective lenses. The care plan initiated 02/24/2026 addressed impaired vision with interventions to arrange consultation with eye care practitioners as needed and remind the resident to wear glasses, but it did not include a focus area or interventions for hearing loss or use of hearing aids. A resident clothing list showed the resident admitted with one pair of eyeglasses and one Super Ear headset personal sound amplifier, yet observation and interview showed the resident in bed without eyeglasses or a hearing device, with the amplifier stored in the bedside table drawer. Staff interviews confirmed the resident’s hearing was strained, that the hearing device and glasses were not being used, and that the resident’s hearing device use should have been included in the plan of care and the resident should have been referred for eye care assessment.
Respiratory Care Orders and Documentation Not Maintained
Penalty
Summary
The facility failed to provide respiratory care consistent with professional standards of practice for two residents receiving oxygen therapy. One resident with COPD and chronic respiratory failure with hypoxia was observed multiple times lying in bed receiving oxygen at 2 L via nasal cannula. The resident’s oxygen order, dated 02/15/2026, allowed 1 to 4 L per minute continuously via nasal cannula, but it did not include an indication for use or oxygen saturation parameters. The April and May 2026 MARs did not show documentation of oxygen therapy being provided, and the TARs showed only an order to change oxygen tubing if damaged or visibly soiled, not an order for oxygen therapy. Oxygen saturations were not documented consistently daily from 04/01/2026 through 05/04/2026. A second resident with respiratory failure, high blood pressure, and anxiety disorder was observed in the room receiving oxygen at 6 L via nasal cannula on multiple occasions. The resident stated they needed oxygen therapy to breathe, and the care plan identified the resident as dependent on oxygen and to receive oxygen per provider orders. However, provider orders reviewed on 05/04/2026 showed no orders for oxygen therapy or for changing oxygen tubing. Staff stated the oxygen and tubing-change orders had been discontinued when the resident went to the hospital and were not added back to the MAR or TAR when the resident readmitted to the facility.
Failure to Refer Resident With Identified Dental Needs
Penalty
Summary
The facility failed to ensure that Resident 112 received needed dental care. Resident 112 was admitted with diagnoses including a leg fracture, dementia, and hearing loss in both ears. Observation on 05/03/2026 showed the resident had missing lower teeth. The admission MDS, dated [DATE], documented obvious or likely cavities or broken natural teeth, and the care plan dated 02/24/2026 identified oral/dental health problems related to likely cavities or broken teeth with an intervention to coordinate dental care and provide transportation. During interviews, Staff G, Regional Social Services, stated Resident 112's dental needs were captured on the 02/24/2026 MDS and the resident was not referred for dental services. Staff M, Social Services Director, stated residents with dental needs should be referred to social services to be scheduled for assessment by a dental care practitioner, and that Resident 112 should have been referred after the MDS assessment. Staff B, DON, stated residents with identified dental needs should be referred for follow-up with a dentist and that Resident 112 should have been referred to the in-house dental provider; Staff B stated the lack of referral did not meet expectations.
Inaccurate Meal Intake Documentation
Penalty
Summary
The facility failed to accurately document the amount of food eaten for Resident 13, who was admitted with diagnoses including diabetes mellitus, dysphagia, and protein-calorie malnutrition. The quarterly MDS dated 02/12/2026 showed the resident was moderately cognitively impaired. During observation on 05/05/2026 at 12:09 PM, a meal tray was delivered to the resident’s room, set up on a bedside table, and the resident was observed eating slowly, eating less than 25% of the meal, then laying back in bed and closing their eyes while the tray remained in the room. Staff later removed the tray, but the POC documentation for lunch on 05/05/2026 recorded that Resident 13 ate 76-100% of the meal. During interview, the CNA stated the resident typically ate 25-50% of meals and never ate all of the food, and that if they did not pick up a tray they would ask a coworker what the resident ate before documenting it. The CNA stated they were told the resident ate 75-100% of lunch, so that is what was entered. The LPN/RCM stated staff should document meal intake accurately in POC, and the RN/DNS stated it was their expectation that all staff document meal intake accurately.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release June 24, 2026) and official state health department websites — never guesswork.
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