Bailey-boushay House
Inspection history, citations, penalties and survey trends for this long-term care facility in Seattle, Washington.
- Location
- 2720 East Madison, Seattle, Washington 98112
- CMS Provider Number
- 505476
- Inspections on file
- 19
- Latest survey
- July 16, 2025
- Citations (last 12 mo.)
- 1
Citation history
Health deficiencies cited at Bailey-boushay House during CMS and state inspections, most recent first.
A resident with severe cognitive impairment and agitation was allowed to leave their unit unaccompanied, contrary to their care plan, and was not monitored by staff or security. As a result, the resident was involved in a verbal altercation and was struck by another individual. Staff interviews and documentation confirmed that the required supervision and care plan protocols were not followed.
The facility did not include required recertification survey results and plans of correction for two years in the Past Survey Results binder, as mandated by policy. The DON and Administrator confirmed the omission, which prevented residents, representatives, and visitors from reviewing these documents as required.
Surveyors found that MDS assessments were not accurately completed for four residents, including failures to document opioid use, incorrectly coding for delusions without supporting EHR documentation, not interviewing a family member for activity preferences when a resident could not communicate, and coding insulin administration without a physician's order. Staff acknowledged these errors and confirmed that the assessments should have been completed accurately.
Multiple residents with serious mental illness or related diagnoses did not have their Level I PASARR assessments accurately completed or updated, and required referrals for Level II evaluations were not made, despite clear indicators. Staff interviews confirmed that the PASARR process was not followed as required, resulting in incomplete documentation and missed referrals.
The facility did not include its name on daily nurse staffing postings for five consecutive days, as required by policy. Both the Charge RN and DON confirmed the omission during interviews and record reviews.
Surveyors found that vaccines were stored in a medication refrigerator with temperatures below the recommended range on multiple occasions, and no required work orders were filed. Additionally, N95 masks in a medication cart were not labeled with expiration dates, and staff could not locate the original packaging to verify shelf life. These failures to follow storage and labeling protocols placed residents at risk for compromised or ineffective medications and supplies.
Surveyors found that staff failed to label and date multiple opened and prepared food items in a reach-in cooler, including milk, a dairy beverage, cooked roast beef, and kielbasa sausage. Staff and leadership confirmed these items should have been labeled and dated according to facility policy.
Staff failed to consistently remove used PPE inside resident rooms and did not perform hand hygiene between glove changes, as required by facility policy and CDC guidelines. These lapses were observed among CNAs, an RN, and housekeeping staff during routine care and cleaning activities, with staff interviews confirming inconsistent understanding and adherence to infection control protocols.
A resident with depression was started on an antidepressant without informed consent being obtained prior to the first dose, as required by facility policy. Staff confirmed that the consent form was completed months after medication administration began, and that informed consent should have been documented in the EHR before starting the medication.
A resident's personal funds were not transferred to their representative or estate within the required timeframe after discharge. Despite facility policy mandating return of funds within one week, the transfer occurred over nine months later, as confirmed by record review and staff interviews.
Two residents prescribed psychotropic medications, including an antianxiety drug and an antidepressant, were not monitored for adverse side effects as required by facility policy. Staff confirmed that monitoring was expected but not documented or ordered for either resident.
A resident who experienced a significant decline, including the need for a feeding tube and increased dependence for mobility and eating, did not have a Significant Change in Status Assessment (SCSA) completed as required. Staff interviews confirmed that an SCSA should have been done following these changes, but it was not documented.
Two residents did not have comprehensive care plans addressing their specific needs: one resident on apixaban lacked a care plan for anticoagulant use and monitoring for side effects, and another resident with PTSD did not have their trauma history or triggers documented or addressed. Staff confirmed these omissions during record reviews and interviews.
The facility did not update care plans for two residents to reflect significant information: one resident's ongoing refusal to wear a safety apron while smoking and another resident's stated activity preferences identified in the MDS. Staff and leadership confirmed these omissions, which were evident in care plan documentation and interviews.
A resident's assessed preferences for activities such as listening to music, going outside, and being around animals were not incorporated into their care plan, resulting in the resident remaining in their room without being offered individualized or group activities. Staff confirmed the lack of personalized activity offerings and documentation showed no activities outside the resident's room were provided.
A resident with a diagnosis of PTSD was not adequately assessed for trauma-informed care or specific triggers, despite facility policy and staff expectations. The resident's care plan did not document their trauma history or identify interventions for PTSD, and staff interviews confirmed that no specific assessment for PTSD triggers was conducted.
A resident receiving apixaban for blood clots was not adequately monitored for adverse side effects, as required by facility policy. Review of medical records and interviews with nursing staff, including an RN, MDS Coordinator, and DON, confirmed that there was no physician's order or documentation for monitoring adverse effects of the anticoagulant, resulting in a failure to ensure proper oversight of high-risk medication use.
The facility did not ensure that residents receiving paid feeding assistance were properly assessed for program appropriateness, nor did it verify that staff providing this assistance had completed required training. A resident with swallowing difficulties received feeding assistance without documented assessment, and another was assisted by a staff member unable to provide proof of training. Facility policy required both assessments and verified training, but these were not documented or completed.
A resident reported an allegation of sexual abuse by a visitor to a social worker, but the facility delayed reporting it to the State Agency for three days, contrary to policy requiring immediate reporting. Staff involved acknowledged the delay, and the Assistant Director of Nursing confirmed the expectation for immediate reporting.
The facility failed to complete admission and annual MDS assessments within the required timelines for four residents, with delays ranging from 54 to 105 days. Staff acknowledged the late completion, which could impact residents' care needs and quality of life.
The facility failed to complete quarterly MDS assessments within the required 14-day timeframe for eight residents, with delays ranging from 14 to 99 days. Staff acknowledged the late completions, which were identified through interviews and record reviews, despite following the RAI manual guidelines.
The facility did not discard expired food items in the Kitchen Dry Foods Storage Area, as observed during a survey. Expired tortillas were found, and both the Food Services Manager and Administrator acknowledged that these items should have been discarded by their expiration date, posing a risk to residents.
The facility failed to include a flow diagram in its water management program to monitor Legionella growth and did not follow Enhanced Barrier Precautions (EBP) for a resident with a history of MDRO. The absence of EBP signage and PPE use during high-contact care activities was confirmed by staff.
A resident was not informed of the risks and benefits before using a transfer pole, as required. The resident used the pole daily, but there was no documentation of informed consent. Staff interviews revealed a lack of awareness about the need for consent, and the facility's Assistant Director of Nursing expected such documentation.
The facility failed to report abuse allegations to the State Agency for two residents. One resident reported being hit by a staff member, and another complained of rough care, but neither incident was reported or properly investigated. Staff interviews revealed confusion and miscommunication regarding the reporting process, leading to this deficiency.
A resident reported rough care by nurses, but the facility failed to thoroughly investigate the allegation as required by their policy. The complaint was noted in resident council minutes but not logged in incident or grievance logs. Staff involved were unaware of the need for a formal investigation, leading to an incomplete response and lack of reporting to the State Agency.
A facility failed to provide written notification of hospital transfers to a resident and their representative, as required by regulations. Staff members, including a charge nurse and social worker, confirmed that their practice was to notify by phone only, with no written documentation provided. This deficiency was identified through a review of the resident's clinical records and staff interviews.
A resident was transferred to the hospital without receiving a bed-hold notice, as required by the facility's policy. The absence of documentation in the resident's EHR was confirmed by staff interviews, indicating a failure to inform the resident or their representative about their right to hold their bed during hospitalization.
A resident's MDS assessment inaccurately coded tube feeding and failed to document fall incidents. The resident, with dysphagia, had tube feeding discontinued but was still coded for it in the MDS. Additionally, two near falls were not recorded. The MDS Coordinator acknowledged the errors, and the Assistant DON expected accurate assessments.
A facility failed to ensure a resident's PASRR form accurately reflected their mental health diagnoses, including anxiety and unspecified psychosis. The admissions staff relied on the hospital to complete the PASRRs and were unaware of the inaccuracy, which was not marked for serious mental illness. The Assistant Director of Nursing expected accurate completion and follow-up for incorrect PASRRs.
The facility failed to provide baseline care plans to two residents upon admission, as required by their policy. Although the care plans were reviewed with the residents, there was no documentation that copies were provided. Staff admitted to not offering baseline care plans, only providing comprehensive care plans during care conferences, which contradicted the facility's policy.
A facility failed to create a comprehensive care plan for a resident receiving oxygen therapy. Despite a physician's order for oxygen via nasal cannula, the care plan lacked details on oxygen management. Staff interviews confirmed the expectation for an oxygen care plan, highlighting a risk for unmet care needs.
The facility failed to update care plans for two residents, leading to potential risks for unmet care needs. One resident's care plan inaccurately indicated the use of dentures, which were lost, while another resident's plan did not reflect the discontinuation of tube feeding in favor of oral intake. Staff confirmed the inaccuracies, and the need for care plan revisions was acknowledged by facility coordinators.
A resident used a transfer pole daily to assist with moving in and out of bed, but the facility failed to conduct a safety assessment prior to its use. Observations showed the pole was unstable, and staff interviews confirmed the lack of a formal assessment. The Rehab Manager, responsible for such assessments, admitted that none was conducted, and the Assistant Director of Nursing confirmed the absence of documentation.
A resident with a feeding tube was not provided appropriate care as a registered nurse failed to check gastric residual volumes (GRV) before administering tube feeding, contrary to the facility's policy. The resident's care plan required GRV checks to ensure proper tube placement and feeding tolerance. Both the Charge Nurse and Assistant Director of Nursing confirmed the expectation for staff to perform GRV checks before connecting residents to enteral formula.
The facility failed to conduct timely AIMS assessments for three residents on antipsychotic medications, risking unnecessary medication use and side effects. A resident on Quetiapine lacked an assessment before May 2024, another on Seroquel hadn't been assessed since March 2023, and a third on Olanzapine had no assessments. Staff confirmed these should have been done quarterly.
The facility failed to document that two residents received education on the risks and benefits of the pneumonia vaccine, as required by policy. Despite receiving the vaccine, there was no record in their EHRs indicating they were informed. Staff interviews confirmed the lack of documentation, highlighting a gap in ensuring residents were fully informed before vaccination.
Failure to Provide Required Supervision and Follow Safety Care Plan
Penalty
Summary
The facility failed to provide necessary supervision and follow the safety care plan for a resident with severe cognitive impairment and agitation. The resident's care plan required that staff accompany them when leaving the unit or, if staff were unavailable, that security be notified. Despite these requirements, the resident was allowed access to the elevator and went to the first-floor lobby unaccompanied and without security being informed. During this time, the resident was involved in a verbal exchange and was struck in the face by another individual. Interviews with facility staff, including the Infection Preventionist/Charge Nurse, Assistant Director of Nursing, and Director of Nursing, confirmed that the resident was not accompanied as required and that the care plan was not followed. Documentation and investigation reports also indicated that staff did not provide the necessary supervision or notify security, as outlined in the resident's care plan. This lapse in supervision and failure to adhere to the care plan placed the resident at risk for injury.
Failure to Maintain Accessible Survey Results Binder
Penalty
Summary
The facility failed to ensure that the Past Survey Results binder included the most recent recertification survey results and associated plans of correction for two of the past three years reviewed (2023 and 2024). During a review of the binder, it was found that the recertification survey results and plans of correction dated 03/24/2023 and 06/13/2024 were missing. The facility's policy required that survey reports, certifications, complaint investigations, and plans of correction for the preceding three years be available for review by any individual upon request, and that a copy of the most recent survey report and any plans of correction be kept in a binder in the residents' day room. Interviews with the DON and Administrator confirmed that the responsibility for maintaining and updating the Past Survey Results binder rested with the DON, and that the process involved placing survey results in the binder upon receipt. Both staff members acknowledged that the required documents for 2023 and 2024 were not present in the binder at the time of review. The DON stated that while survey results and plans of correction were accessible online and could be printed upon request, the physical binder did not contain the necessary documents, thereby preventing residents, their representatives, and visitors from exercising their right to review past survey results and the facility's plans of correction.
Inaccurate MDS Assessments for Multiple Residents
Penalty
Summary
The facility failed to ensure accurate completion of the Minimum Data Set (MDS) assessments for four out of thirteen residents reviewed. For one resident, the Medication Administration Record (MAR) showed that an opioid was administered during the MDS look-back period, but this was not documented in Section N of the MDS. The MDS Coordinator acknowledged that the opioid use should have been marked, indicating inaccurate MDS coding. Another resident's quarterly MDS indicated the presence of delusion in Section E, but there was no supporting documentation in the Electronic Health Record (EHR) for this behavior during the observation period. The MDS Coordinator was unable to find any evidence to support the coding of delusion and confirmed it should not have been coded. The Director of Nursing stated that MDS assessments are expected to be coded accurately. For a third resident, the MDS indicated that the resident was rarely or never understood and did not complete the activity preferences interview with the resident's family or significant other, as required when the resident cannot communicate. The MDS Coordinator admitted that no attempt was made to contact the family or significant other. In the fourth case, the MDS showed that a resident received an insulin injection during the observation period, but there was no physician's order for insulin, and the MDS Coordinator confirmed that insulin should not have been coded. The Director of Nursing reiterated the expectation for accurate MDS completion.
Failure to Accurately Complete and Update PASARR Assessments and Referrals
Penalty
Summary
The facility failed to ensure accurate completion and timely updating of Level I Pre-admission Screening and Resident Review (PASARR) assessments for multiple residents with diagnoses or indicators of serious mental illness (SMI), intellectual disabilities (ID), or related conditions (RC). For several residents, including those with documented diagnoses of psychotic and anxiety disorders, the Level I PASARR forms were either not updated to reflect current diagnoses or did not result in appropriate referrals for Level II evaluations, despite SMI indicators being present. In some cases, the original Level I PASARR was completed years prior and had not been revised to account for new or updated mental health diagnoses. Record reviews and interviews with facility staff revealed that residents with marked SMI indicators on their Level I PASARR forms did not have corresponding Level II referrals, as required by facility policy and regulatory standards. Staff interviews confirmed awareness that these residents should have had updated Level I PASARR assessments and referrals for Level II evaluations, but these actions were not completed. For example, one resident with a diagnosis of depression and marked anxiety and psychotic disorders on their PASARR did not have an updated assessment or referral, and another resident's PASARR failed to indicate their known anxiety disorder. The facility's policy states that any indicators of SMI, ID, or RC on the Level I PASARR should prompt a referral for a Level II assessment. However, the review found that for at least five residents, the PASARR process was not followed as required, resulting in incomplete or inaccurate documentation and a lack of necessary referrals. These deficiencies were confirmed through joint record reviews and staff interviews, which consistently indicated that the expected procedures for PASARR completion and referral were not adhered to.
Failure to Include Facility Name on Daily Nurse Staffing Postings
Penalty
Summary
The facility failed to accurately complete and post the daily nurse staffing form to include the facility's name for five consecutive days. Observations and record reviews showed that the posted documents titled 'Licensed and Unlicensed Staff in our Nursing Home Today' did not reflect the facility name on any of the reviewed dates. Staff interviews confirmed that the responsible personnel, including the Charge RN and the DON, acknowledged the omission of the facility name from the posted staffing forms. The facility's own policy, updated in November 2022, requires that the facility name be included on the daily staffing form, but this was not followed during the period reviewed.
Improper Storage and Labeling of Biologicals and Medical Supplies
Penalty
Summary
The facility failed to properly store biologicals and medical supplies according to established protocols and manufacturer recommendations. Specifically, COVID-19 and influenza vaccines were stored in a medication refrigerator on the 2nd floor, where temperature logs showed that the internal temperature fell below the acceptable range of 36-46 degrees Fahrenheit on three separate occasions. Despite facility policy requiring staff to notify the Facilities Manager and file a work order when temperatures are out of range, no work orders were filed for these incidents. Staff interviews confirmed that both the Charge RN and Facilities Manager were not notified as required, and that vaccines were indeed stored in the affected refrigerator during these periods. Additionally, the facility failed to ensure that medical supplies, specifically 3M 1860 N95 masks stored in the West 3 medication cart, were labeled with expiration dates. During an observation, unbagged N95 masks were found in the medication cart without their original packaging, and staff were unable to reference the expiration date as the box could not be located. The Director of Nursing confirmed the expectation that all supplies should have an expiration date available for staff reference, which was not met in this instance. These failures were identified through observation, interview, and record review, and were in direct violation of the facility's own policies and manufacturer guidelines. The lack of proper storage and labeling placed residents at risk for receiving compromised or ineffective biologicals and medical supplies.
Failure to Label and Date Food Items in Refrigerator
Penalty
Summary
Surveyors observed that the facility failed to handle and store food items in accordance with professional standards and its own policy. During a joint observation of the reach-in cooler with a Nutrition Assistant, several food items were found to be either unlabeled or undated, including an opened container of Ultra brand milk, an opened container of Thick & Easy dairy beverage, a resealable plastic bag containing brownish-colored sliced food items identified as cooked roast beef, and a food item wrapped in aluminum foil identified as kielbasa sausage. Staff interviews confirmed that these items should have been labeled and dated upon opening or preparation, as required by facility policy. The facility's policy on Food Receiving and Storage, revised in November 2022, specifies that all foods stored in the refrigerator must be covered, labeled, and dated. Both the Nutrition Assistant and the Executive Chef acknowledged during interviews that the observed food items did not meet these requirements. The Administrator also confirmed the expectation that staff properly label and date food items. The failure to follow these procedures was identified during the survey and documented as a deficiency.
Failure to Follow Proper PPE Removal and Hand Hygiene Procedures
Penalty
Summary
Multiple staff members failed to follow proper infection prevention and control practices, specifically regarding the removal of personal protective equipment (PPE) and hand hygiene. Observations showed that staff, including CNAs and an RN, exited contact isolation rooms without removing used gowns and gloves inside the room as required. In some cases, used PPE was disposed of in bins located outside the resident rooms, contrary to facility policy and CDC guidelines. Staff interviews revealed a lack of consistent understanding and adherence to the correct procedures for PPE removal, with some staff admitting to habitual non-compliance or being unaware of the proper process. Further deficiencies were observed in hand hygiene practices among staff. Housekeeping and nursing staff were seen changing gloves between tasks or after leaving resident rooms without performing hand hygiene in between glove changes. Staff interviews confirmed that some were unaware of the requirement to clean hands before donning new gloves, while others acknowledged the expectation but failed to comply during observed instances. These lapses occurred during routine care activities, such as meal delivery, medication administration, and cleaning resident rooms. The facility's own policies, updated in June 2024, require adherence to CDC hand hygiene and PPE guidelines, which specify that PPE must be removed and hand hygiene performed before leaving a resident's environment. Despite these policies, observations and staff statements demonstrated inconsistent implementation, resulting in a failure to maintain effective infection prevention and control for residents, staff, and visitors.
Failure to Obtain Informed Consent Prior to Psychotropic Medication Administration
Penalty
Summary
The facility failed to obtain informed consent for the administration of a psychotropic medication prior to starting the medication regimen for one resident diagnosed with depression. According to the facility's policy, informed consent, which includes a discussion of the medication's risks and benefits, must be obtained from the resident or their representative before initiating psychotropic drugs such as antidepressants. Record review showed that the resident was prescribed and began receiving an antidepressant medication, but the informed consent form was not completed until several months after the medication was started. Interviews with facility staff, including a Charge RN and the Director of Nursing, confirmed that the expectation was for informed consent to be obtained and documented in the resident's electronic health record prior to the first dose of the medication. However, staff were unable to locate an informed consent form dated before the start of the antidepressant, and acknowledged that the required consent was not obtained prior to administration. This failure was identified through both record review and staff interviews.
Delayed Transfer of Discharged Resident's Personal Funds
Penalty
Summary
The facility failed to ensure that a discharged resident's personal funds were transferred to the resident or their representative/estate within the required timeframe. According to the facility's own Resident Trust Procedures, the balance in a resident's personal fund should be returned within one week of discharge. However, review of records showed that a resident who was discharged had a trust account balance of $622.23, which was not transferred until 283 days after discharge. The check to the resident's representative was dated significantly later than the discharge date, indicating a substantial delay in returning the funds. Interviews with the Finance Manager and the Administrator confirmed that the facility's process requires transferring trust balances within a week after discharge, and both acknowledged that the transfer in this case was late. The deficiency was identified through review of the trust account ledger, discharge records, and interviews, all of which confirmed that the resident's funds were not handled in accordance with facility policy or regulatory requirements.
Failure to Monitor for Adverse Side Effects of Psychotropic Medications
Penalty
Summary
The facility failed to ensure adequate monitoring for adverse side effects of psychotropic medications for two residents. One resident with an anxiety disorder was prescribed clonazepam, an antianxiety medication, but there was no documentation in the clinical record of monitoring for adverse side effects as required by facility policy. Multiple staff interviews confirmed that there was no order or documentation for monitoring, and staff acknowledged that such monitoring should have been in place. Another resident with a diagnosis of depression was prescribed and administered an antidepressant daily, but there was no evidence of monitoring for adverse side effects in the medication administration record or physician's orders. Staff interviews confirmed that monitoring for adverse side effects was expected to begin with the initial dose, but this was not documented or ordered. The lack of monitoring for both residents was contrary to the facility's policy on high-risk medication monitoring.
Failure to Complete SCSA After Resident's Significant Decline
Penalty
Summary
The facility failed to complete a Significant Change in Status Assessment (SCSA) Minimum Data Set (MDS) for a resident who experienced a major decline in condition. The resident was initially admitted without a feeding tube and required substantial to moderate assistance with eating and mobility. Following an aspiration event, the resident was hospitalized, failed a swallow evaluation, and had a feeding tube placed, resulting in a transition to NPO status. Upon return to the facility, the resident's condition had changed significantly, including increased dependence for mobility and receiving the majority of nutrition via tube feeding. Despite these changes, review of the resident's records showed that no SCSA was completed after the decline, as required by the RAI Manual when a significant change in status occurs that is not expected to resolve within two weeks. Interviews with the MDS Coordinator and the Director of Nursing confirmed that an SCSA should have been completed for this resident's decline in condition, but it was not documented in the electronic health record.
Failure to Develop Comprehensive Care Plans for Anticoagulant Use and PTSD
Penalty
Summary
The facility failed to develop and implement comprehensive care plans for two residents with specific clinical needs. For one resident who was prescribed apixaban, an anticoagulant, the Medication Administration Record confirmed the medication was started, but the resident’s care plan did not include any reference to anticoagulant use or monitoring for its adverse side effects. Multiple staff interviews and joint record reviews confirmed that the care plan lacked this essential information, despite staff acknowledging that monitoring for side effects should have been included. Another resident with a diagnosis of Post Traumatic Stress Disorder (PTSD) did not have their history of trauma or identified triggers addressed in their care plan. The resident reported discomfort with certain situations due to past traumatic events, but the care plan did not document the PTSD diagnosis or specific interventions related to trauma-informed care. Staff interviews confirmed that the care plan did not reference triggers or trauma history, and staff stated that such information would be a relevant and expected addition.
Failure to Revise Care Plans for Resident Safety and Activity Preferences
Penalty
Summary
The facility failed to revise and update comprehensive care plans for two residents as required. For one resident, repeated refusals to wear a safety apron while smoking were observed and documented by staff, but this behavior was not reflected in the resident's care plan. Staff interviews confirmed that the refusal was ongoing and known to the care team, yet the care plan was not updated to address this behavior, despite expectations from nursing leadership that it should have been included. For another resident, the quarterly Minimum Data Set (MDS) assessment identified specific activity preferences, including being around animals, doing favorite activities, and going outside for fresh air. These preferences were marked as very important by the resident's representative. However, a review of the resident's activity care plan showed that these preferences were not incorporated. Staff involved in care planning acknowledged that the care plan did not reflect the resident's identified interests, and facility leadership confirmed that such preferences should be included.
Failure to Provide Individualized Activity Program Based on Resident Preferences
Penalty
Summary
The facility failed to provide an individualized and ongoing activity program that met the needs and preferences of a resident, as identified through comprehensive assessments and care planning. The resident's Minimum Data Set (MDS) assessments indicated several daily preferences, including listening to preferred music, keeping up with the news, going outside for fresh air, being around animals, and participating in favorite activities. However, these preferences were not incorporated into the resident's activity care plan. Observations over several days showed the resident remained in their room, primarily in bed with the TV on, and was not offered activities outside of their room. Interviews with staff confirmed that the resident was not escorted to group activities or provided with opportunities to participate in activities aligned with their stated preferences. Staff acknowledged that the resident could have been safely transported outside their room using a Geri-chair, but this was not done. Documentation also revealed that no activities outside the resident's room were provided during the month reviewed, and the activity care plan was not personalized to reflect the resident's interests and preferences as identified in the MDS assessments.
Failure to Assess and Care Plan for PTSD Triggers in Resident
Penalty
Summary
The facility failed to adequately assess and provide trauma-informed care for a resident diagnosed with Post Traumatic Stress Disorder (PTSD). Despite the facility's policy requiring staff to provide trauma-informed and culturally competent care, including working with residents and families to identify strengths and minimize triggers, the resident's comprehensive care plan did not document their history of trauma or identify specific triggers. The resident, who had experienced two separate traumatic events, reported discomfort with certain situations, but this information was not reflected in their care plan. Interviews with facility staff revealed that there was no specific assessment process in place to identify PTSD triggers for residents. The social worker confirmed that the initial social services assessment did not include discussions about triggers or PTSD-related concerns, and the care plan lacked any reference to PTSD or associated interventions. The Director of Nursing stated that residents with PTSD should receive trauma-informed care and have their triggers identified and included in their care plans, but this was not done for the resident in question.
Failure to Monitor for Adverse Effects of Anticoagulant Medication
Penalty
Summary
The facility failed to ensure adequate monitoring for a resident receiving an anticoagulant medication, apixaban, which was prescribed for pulmonary embolism and deep vein thrombosis. According to the facility's High-Alert Medication Monitoring Policy, residents on high-risk medications are to be routinely assessed for adverse side effects, with observations documented in the clinical record. However, review of the physician's order summary and the Medication Administration Records (MARs) for April and May 2025 showed that there was no order for monitoring adverse side effects related to anticoagulant use, nor was there documentation of such monitoring for the resident in question. Interviews with nursing staff, including a Registered Nurse, the Minimum Data Set Coordinator, and the Director of Nursing, confirmed that the resident had not been adequately monitored for adverse side effects from anticoagulant use. Staff acknowledged that there was no physician's order for monitoring, and the required monitoring was not performed or documented. This lack of monitoring was contrary to facility policy and was confirmed through both record review and staff interviews.
Failure to Assess Residents and Verify Staff Training in Paid Feeding Assistance Program
Penalty
Summary
The facility failed to ensure that residents receiving paid feeding assistance were properly assessed for appropriateness and that staff providing this assistance were adequately trained. One resident required one-person total assistance with eating and was observed being assisted by a recreation therapist, who claimed to have received paid feeding assistant training. However, the staff member was unable to provide a valid training certificate, and the facility could not locate documentation confirming completion of the required training. Another resident, who had documented swallowing difficulties and required thickened liquids, was also receiving paid feeding assistance. Review of the resident's records showed no documentation of an assessment to determine if they were appropriate for the paid feeding assistance program, despite facility policy requiring such an assessment for residents with complicated feeding problems, including swallowing difficulties. Interviews with facility staff revealed a lack of awareness regarding responsibility for completing these assessments, and the Director of Nursing confirmed that the resident did not meet the criteria for the program and that no assessment documentation existed. Facility policy stated that only residents without complicated feeding problems should be considered for the paid feeding assistant program and that only appropriately trained staff should provide this assistance. The lack of assessment and training documentation for both residents and staff led to the deficiency, as residents with special dietary needs and risks were assisted by staff whose qualifications could not be verified.
Delayed Reporting of Abuse Allegation
Penalty
Summary
The facility failed to report an allegation of abuse in a timely manner to the State Agency, as required by their policy and federal law. A cognitively intact resident reported an allegation of sexual abuse by a visitor to a social worker, Staff B, on February 7, 2025. However, the facility did not report this allegation to the State Agency until February 10, 2025, three days after the initial report was made by the resident. This delay in reporting was contrary to the facility's policy, which mandates immediate reporting of such incidents. During interviews, Staff B acknowledged that the resident had informed them of the incident on February 7, 2025, and admitted that they should have reported it to the State Agency on the same day. The Assistant Director of Nursing, Staff A, also confirmed that they expected allegations of sexual abuse to be reported immediately. The failure to report the allegation promptly placed residents at risk for potential unidentified abuse and lack of protection from abuse.
Failure to Complete Timely MDS Assessments
Penalty
Summary
The facility failed to complete admission Minimum Data Set (MDS) assessments within the required 14 days of admission for two residents and did not complete annual MDS assessments within 14 days from the Assessment Reference Date (ARD) for another two residents. Specifically, Resident 1's admission MDS was completed 54 days late, and Resident 25's admission MDS was completed 105 days late. Additionally, Resident 27's annual MDS was completed 69 days late, and Resident 3's annual MDS was completed 88 days late. These delays were confirmed through interviews and record reviews with facility staff, who acknowledged the late completion of the assessments. The Resident Assessment Instrument (RAI) 3.0 User's Manual mandates that comprehensive assessments be completed within 14 days of admission and annually within 14 days from the ARD. The facility's failure to adhere to these timelines placed residents at risk for delayed and/or unmet care needs, potentially affecting their quality of life. Staff members, including the MDS Coordinator and the Assistant Director of Nursing, were aware of the expectations for timely MDS completion but did not meet these requirements for the residents in question.
Late Completion of MDS Assessments
Penalty
Summary
The facility failed to ensure that quarterly Minimum Data Set (MDS) assessments were conducted within the required timeframe of 14 days from the Assessment Reference Date (ARD) for eight residents. This deficiency was identified through interviews and record reviews, revealing that the MDS assessments for Residents 2, 5, 19, 6, 3, 22, 25, and 18 were completed late, ranging from 14 to 99 days past the ARD. Staff D, the MDS Coordinator, acknowledged during interviews that the assessments were not completed on time, despite following the Resident Assessment Instrument (RAI) manual guidelines. The report highlights specific instances of late MDS assessments for each resident. For example, Resident 2's quarterly MDS with an ARD of 01/02/2024 was completed 86 days late, and another with an ARD of 04/03/2024 was 21 days late. Similarly, Resident 5's assessments were 99 and 33 days late, respectively. Staff B, the Assistant Director of Nursing, confirmed the expectation for timely completion of MDS assessments, aligning with the RAI manual. The failure to complete these assessments on time placed residents at risk for delayed or unidentified care needs.
Expired Food Items Not Discarded
Penalty
Summary
The facility failed to adhere to professional standards of food safety by not discarding expired food items in the Kitchen Dry Foods Storage Area. During an observation and interview, it was found that there were four packages of small size tortillas and six packages of large size tortillas with expiration dates that had passed. The Food Services Manager, Staff L, acknowledged that these tortillas were expired and should have been discarded by their expiration date. Additionally, the Administrator, Staff A, confirmed the expectation that food items should be discarded by their expiration date and recognized that the expired tortillas should have been removed from the kitchen. This oversight placed residents at risk for foodborne illness, cross-contamination, and a diminished quality of life.
Deficiencies in Water Management and Infection Control Practices
Penalty
Summary
The facility failed to ensure its water management program included a flow diagram to assess or monitor the potential growth of Legionella or other waterborne pathogens. The facility's Water Management Policy, revised in November 2021, aimed to reduce the risk of healthcare-associated infections from water sources. However, the facility's Water Quality Management Plan, revised in March 2018, did not include a flow diagram of their building water systems. Staff R, the Facilities Manager, confirmed that the water management plan lacked a flow diagram, and Staff A, the Administrator, acknowledged not having seen one. Additionally, the facility did not adhere to Enhanced Barrier Precautions (EBP) for a resident with a history of Multidrug-Resistant Organism (MDRO). Resident 23's physician orders required EBP for high-contact care activities, including the use of gloves and gowns. However, multiple observations revealed the absence of EBP signage on Resident 23's door. Staff G, a Certified Nursing Assistant, and Staff F, a Registered Nurse, both confirmed the lack of EBP signage and the failure to use PPE during high-contact care. Staff B, the Assistant Director of Nursing, stated that residents on EBP should have signage and that staff should follow EBP protocols.
Failure to Inform Resident of Risks and Benefits of Transfer Pole
Penalty
Summary
The facility failed to inform a resident and/or their representative of the risks and benefits before the installation and use of a transfer pole. This deficiency was identified for one of the two residents reviewed for accidents, specifically Resident 27. The resident was admitted to the facility and was noted to be independent in certain movements according to the Minimum Data Set assessment. However, the care plan included the use of a transfer pole as a safety device, and there was no documentation in the electronic health record indicating that the resident had been informed of the risks and benefits associated with its use. Observations and interviews revealed that Resident 27 used the transfer pole daily for mobility purposes. Staff members, including a Certified Nursing Assistant, a Registered Nurse, and a Charge Nurse, confirmed the resident's use of the pole but indicated a lack of awareness or documentation regarding the need for consent. The Rehab Manager stated that verbal consent was obtained, but there was no written documentation to support this. The Assistant Director of Nursing acknowledged that the transfer pole was considered an assistive device and expected documentation of informed consent to be present.
Failure to Report Abuse Allegations
Penalty
Summary
The facility failed to report allegations of abuse to the State Agency for two residents, which is a violation of federal law requiring all allegations of abuse or neglect to be reported. Resident 3 reported being hit by an unknown female staff member, but the investigation report did not show that this allegation was reported to the State Agency. Similarly, Resident 25's complaint of rough care by nurses was documented in the Resident Council Minutes, but there was no evidence that this was reported to the State Agency or investigated. The facility's policy on the prevention of abuse and neglect requires the Administrator On Call to investigate all alleged incidents and report them according to the State's Nursing Home Guidelines. However, the facility did not adhere to these guidelines, as evidenced by the lack of reporting for both Resident 3 and Resident 25's allegations. Staff members involved in the process, including the Administrator and the Director of Nursing, failed to report these incidents, citing reasons such as not considering the rough care as abuse or believing that the situation was being handled internally. Interviews with staff revealed a lack of clarity and consistency in the reporting process. Staff A, the Administrator, acknowledged that the allegations should have been reported to the State Agency. Staff B, the Assistant DON, stated that they did not report the allegations because they believed it was the Administrator's responsibility. This miscommunication and failure to follow established protocols resulted in the deficiency of not reporting potential abuse incidents to the appropriate authorities.
Failure to Investigate Allegation of Rough Care
Penalty
Summary
The facility failed to thoroughly investigate an allegation of abuse involving a resident, identified as Resident 25, who reported that nurses were rough during care. The facility's policy mandates that all allegations of abuse, neglect, or mistreatment must be thoroughly investigated, yet there was no documentation of an investigation or report to the State Agency regarding Resident 25's complaint. The incident was noted in the Resident Council Minutes, but it was not logged in the facility's incident reporting or grievance logs. Staff E, who facilitated the resident council meetings, reported the concern to Staff O, the Director of Nursing, but no further action was documented. Staff B, the Assistant Director of Nursing, was unaware of the allegation until informed by the administrator on a later date. The investigation report for Resident 25, dated several months after the initial complaint, lacked interviews with other residents and staff, and was described by Staff A as an abbreviated investigation. Staff B treated the complaint as a care issue rather than abuse, leading to a lack of thorough investigation and reporting. This oversight placed Resident 25 at risk for repeated incidents and diminished quality of life.
Failure to Provide Written Notification of Hospital Transfer
Penalty
Summary
The facility failed to provide a written notice of transfer or discharge to a resident and their representative, which is a requirement under the regulations. Specifically, Resident 10 was transferred to the hospital on two occasions, but there was no documentation indicating that written notification was provided to the resident or their representative. This lack of documentation was confirmed through interviews with various staff members, including a charge nurse, a social worker, the assistant director of nursing, and the administrator. Each of these staff members acknowledged that their practice was to notify residents and their representatives by phone, and they did not provide written documentation for hospital transfers. The deficiency was identified during a review of Resident 10's clinical records, which showed no evidence of written notification for hospitalizations on two specific dates. Staff members interviewed during the investigation consistently stated that it was not their policy to provide written notifications, and the administrator was uncertain about the requirement for written notices. This failure to provide written notification placed Resident 10 at risk of not being able to make an informed decision about their transfers or discharges.
Failure to Provide Bed-Hold Notice During Hospital Transfer
Penalty
Summary
The facility failed to provide a bed-hold notice to a resident, identified as Resident 10, at the time of their transfer to the hospital. According to the facility's policy, updated in January 2018, clinical staff are required to ask the resident to sign a copy of the bed-hold policy and provide them with a copy at the time of hospitalization. However, a review of Resident 10's electronic health record (EHR) revealed no documentation indicating that a bed-hold notice was given to the resident or their representative during their transfer to the hospital on 05/04/2024. Interviews with facility staff, including a charge nurse, a social worker, and the assistant director of nursing, confirmed the absence of the required documentation. Staff members acknowledged that a bed-hold notice should have been provided to Resident 10 and/or their representative at the time of hospitalization, as per the facility's policy. This oversight placed the resident at risk of not being informed about their right to hold their bed while hospitalized.
Inaccurate MDS Assessment for Tube Feeding and Falls
Penalty
Summary
The facility failed to accurately assess a resident's condition in their Minimum Data Set (MDS) assessment, specifically regarding tube feeding and fall incidents. The resident, who was admitted with multiple diagnoses including dysphagia, had their tube feeding discontinued in February 2024, yet the quarterly MDS with an Assessment Reference Date (ARD) of March 23, 2024, incorrectly coded the resident as receiving tube feeding. Observations and interviews confirmed that the resident was receiving nutrition and hydration orally, using adaptive utensils, and was assisted by staff during mealtimes. Additionally, the facility did not code fall incidents in the resident's quarterly MDS, despite records showing two near falls from a wheelchair on March 18, 2024. The MDS Coordinator acknowledged the errors, stating that the tube feeding should not have been coded and the falls should have been included. The Assistant Director of Nursing expressed an expectation for staff to complete MDS assessments accurately, highlighting the oversight in the resident's assessment.
Inaccurate PASRR Form for Resident with Mental Health Diagnoses
Penalty
Summary
The facility failed to ensure the Level 1 Pre-Admission Screening and Resident Review (PASRR) accurately reflected the current diagnosis for a resident, which placed the resident at risk for inappropriate placement and/or not receiving timely and necessary services to meet mental health care needs. The resident was admitted with diagnoses including anxiety and unspecified psychosis, yet the PASRR form did not mark any mental disorders. This discrepancy was identified during an interview and record review. Staff H, responsible for admissions, stated that the hospital was responsible for completing the PASRRs and that they would request the PASRR from the hospital social worker. If a PASRR was incorrect, Staff H would contact the social worker to correct it. However, in this case, Staff H was unaware of the inaccuracy in the PASRR form for the resident. The Assistant Director of Nursing expected the PASRR form to be completed accurately and for Admissions to follow up with the hospital for any incorrect PASRRs.
Failure to Provide Baseline Care Plans to Residents
Penalty
Summary
The facility failed to provide a copy of the baseline care plan to two residents, which is a requirement according to their policy. Resident 230 was admitted to the facility, and although the baseline care plan was reviewed with the resident and their representative by Staff K, there was no documentation in the Electronic Health Record (EHR) that a copy was provided. Staff K admitted to not offering or providing baseline care plans to residents or their representatives, only providing comprehensive care plans during care conference meetings. Similarly, Resident 29 was admitted to the facility, and the baseline care plan was reviewed with the resident by Staff V. However, there was no documentation in the EHR that a copy of the baseline care plan was offered or provided to Resident 29. Staff K confirmed the practice of not providing baseline care plans, which was contrary to the facility's policy as stated by Staff B, the Assistant Director of Nursing. This failure resulted in the residents not being informed of their initial plan for delivery of care services.
Failure to Develop Oxygen Care Plan for Resident
Penalty
Summary
The facility failed to develop a comprehensive care plan for a resident who was receiving oxygen therapy, which was identified during a survey. The resident, admitted to the facility, had a physician's order for oxygen administration via nasal cannula as needed for comfort, starting on 04/06/2024. However, a review of the resident's care plan, printed on 05/14/2024, revealed the absence of a care plan addressing oxygen care and management. Interviews with facility staff, including a Registered Nurse, Charge Nurse, and the Assistant Director of Nursing, confirmed that the resident should have had an oxygen care plan in place when the oxygen treatment began. This oversight placed the resident at risk for unmet care needs and a diminished quality of life.
Failure to Revise Care Plans for Two Residents
Penalty
Summary
The facility failed to revise comprehensive care plans for two residents, leading to potential risks for unmet care needs. Resident 15, who was admitted to the facility, had a care plan indicating the use of full upper and lower dentures, with assistance required for placement and care. However, observations and interviews revealed that Resident 15 was not wearing dentures and had lost them. Staff members, including a Recreational Therapist and a Certified Nursing Assistant, confirmed that Resident 15 did not have dentures, and the care plan was incorrect. The Minimum Data Set Coordinator and the Assistant Director of Nursing acknowledged that the care plan should have been revised to reflect the resident's current status. Resident 25, also admitted to the facility, had a care plan indicating the use of enteral nutrition with a goal to tolerate a certain percentage of intake via tube feeding. However, physician orders and nursing progress notes showed that tube feeding was discontinued, and the tube was maintained only for medication administration. Observations and interviews confirmed that Resident 25 received food and water orally and used adaptive utensils with staff assistance during meals. The Minimum Data Set Coordinator confirmed that the care plan should have been updated to reflect the change from tube feeding to oral intake.
Failure to Assess Resident for Safe Use of Transfer Pole
Penalty
Summary
The facility failed to ensure an assessment was completed prior to the use of a transfer pole for a resident, which placed the resident at risk for accidents and injury. The resident, who was independent in certain movements according to their Minimum Data Set, used a transfer pole daily to assist with moving in and out of bed. However, there was no documentation in the resident's electronic health record indicating that an assessment for the safe use of the transfer pole had been conducted. Observations revealed that the transfer pole was unstable, and staff interviews confirmed that no formal assessment had been performed. Staff members, including a Certified Nursing Assistant and a Physical Medicine Aide, acknowledged the use of the transfer pole by the resident and noted its instability. The Rehab Manager, responsible for assessing residents for safety prior to the use of assistive devices, admitted that no formal assessment was conducted for the transfer pole. The Assistant Director of Nursing expected the Rehab department to perform such assessments and confirmed that there was no documentation of an assessment for the resident's use of the transfer pole.
Failure to Check Gastric Residual Volumes Before Tube Feeding
Penalty
Summary
The facility failed to ensure appropriate treatment and services related to tube feeding for a resident, identified as Resident 10, who was reviewed for tube feeding management. The deficiency was observed when a registered nurse, Staff U, connected Resident 10's feeding tube to their enteral formula without checking the gastric residual volumes (GRV) prior to the administration of the tube feeding. This action was contrary to the facility's policy, which requires checking the GRV to verify the appropriate placement of the feeding tube and to assess the resident's tolerance to the feeding. Resident 10 had a feeding tube as indicated in their significant change in status Minimum Data Set dated 04/16/2024, and their care plan, revised on 05/04/2024, included instructions to check the GRV. During interviews, both the Charge Nurse, Staff N, and the Assistant Director of Nursing, Staff B, confirmed that staff were expected to check the GRV each time before connecting residents to their enteral formula. The failure to adhere to this protocol placed Resident 10 at risk for medical complications and a diminished quality of life.
Failure to Conduct Timely AIMS Assessments for Residents on Antipsychotics
Penalty
Summary
The facility failed to conduct timely Abnormal Involuntary Movement Scale (AIMS) assessments for three residents receiving antipsychotic medications, which are necessary to monitor for tardive dyskinesia and other side effects. Resident 20, who was prescribed Quetiapine for restlessness and agitation, did not have an AIMS assessment completed prior to May 16, 2024, despite being admitted earlier. Staff acknowledged that the assessment should have been conducted quarterly, but it was not done. Similarly, Resident 6, who was taking Seroquel for anxiety related to dementia with behavioral disturbances, had not received an AIMS assessment since March 2023. The resident's records lacked documentation of monitoring for side effects related to tardive dyskinesia or Extrapyramidal Symptoms (EPS). Resident 3, prescribed Olanzapine for unspecified psychosis and neurocognitive disorder with Lewy Bodies, also did not have any AIMS assessments completed. Staff confirmed that these assessments were expected to be done quarterly but were not performed.
Failure to Document Pneumonia Vaccine Education
Penalty
Summary
The facility failed to ensure that residents received education regarding the potential risks and benefits of the pneumonia vaccine, specifically for two residents reviewed for immunizations. The facility's policy, reviewed in March 2023, mandates that each resident or their legal representative be provided with education about the benefits, potential side effects, and possible medical contraindications of the pneumococcal immunization. However, for Residents 3 and 20, there was no documentation in their Electronic Health Records (EHR) indicating that they were informed of these risks and benefits before receiving the pneumococcal vaccine on April 13, 2023. Interviews with facility staff revealed a lack of documentation regarding the provision of this information. On May 17, 2024, the Infection Preventionist, Staff C, confirmed the absence of documentation for Residents 3 and 20. Additionally, on May 20, 2024, the Assistant Director of Nursing, Staff B, stated that it was expected that residents be informed of the risks and benefits of pneumonia vaccinations and that there should be documentation of whether a resident received the vaccination or declined it. This oversight placed the residents and/or their representatives at risk of not being fully informed before making decisions about their pneumonia immunizations.
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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