Bellevue Post Acute
Inspection history, citations, penalties and survey trends for this long-term care facility in Bellevue, Washington.
- Location
- 2424 156th Avenue Northeast, Bellevue, Washington 98007
- CMS Provider Number
- 505500
- Inspections on file
- 33
- Latest survey
- January 10, 2026
- Citations (last 12 mo.)
- 65
Citation history
Health deficiencies cited at Bellevue Post Acute during CMS and state inspections, most recent first.
A resident with orders for PT/OT and a PT plan of care specifying treatment twice weekly did not receive PT services for an 18‑day period. The resident reported not having PT for about two weeks, and review of therapy notes confirmed no PT during that time and no documentation of refusals or missed visits. The PT stated residents are to be seen per their treatment plan and that missed visits should be documented, but no such documentation existed. The rehab director acknowledged the gap in services was due to staffing shortages that prevented scheduling, and the administrator confirmed the expectation that residents receive therapy as ordered.
A resident was discharged without receiving the required written notice of transfer/discharge, and neither the resident's representative nor the Office of the State Long Term Care Ombudsman were notified as mandated by facility policy and regulation. Staff interviews confirmed a lack of awareness and documentation regarding the notification process.
Surveyors found that the facility did not ensure an area was free from accident hazards and failed to provide adequate supervision to prevent accidents, resulting in a deficiency.
A resident reported feeling threatened by a staff member described as the head of nurses. Despite facility policy requiring immediate suspension of any accused staff pending investigation, the DON—who matched the initial description—was not suspended and instead conducted the follow-up interview, ultimately ruling themselves out as the alleged perpetrator. Staff interviews confirmed knowledge of the suspension policy, but it was not followed in this case.
A facility failed to notify law enforcement of suspected abuse involving a CNA and a resident. The resident reported feeling powerless and vulnerable after the CNA did not respect her request to stop touching her during a shower. Despite the facility's policy requiring such incidents to be reported, law enforcement was not contacted, as confirmed by interviews with the DON and Executive Administrator.
The facility did not post nurse staffing information on the second floor, as required by policy. Observations showed postings were only on the first floor, and interviews with staff and a resident confirmed the deficiency. Staff G admitted the posting was not in a prominent place accessible to all, and a resident suggested it should be posted on the second floor as well.
The facility failed to maintain food safety standards, with improper labeling and storage of food items, inconsistent hand hygiene and glove use by kitchen staff, and lack of hair coverings. Observations showed food past use-by dates, staff not washing hands after glove removal, and uncovered desserts being delivered to residents' rooms. Staff acknowledged these issues, which were against facility policies.
The facility did not include 2021 recertification and complaint survey results in the survey result binder and failed to post notices about the availability of these reports. This prevented residents and visitors from accessing important information. Two residents were unaware of the survey reports' availability, and observations confirmed the lack of postings. The Executive Director acknowledged the missing documents.
The facility failed to provide baseline care plans and written summaries to several residents within 48 hours of admission, as required by policy. Staff interviews and record reviews revealed that written summaries were not consistently provided, and in one case, a baseline care plan was missing entirely. This placed residents at risk for unmet care needs.
The facility failed to develop and implement comprehensive care plans for four residents, including those using assistive devices and self-administering medications. A resident with dementia used a tilt-in-space wheelchair without a care plan, while another had a Ventolin inhaler at their bedside without a self-administration plan. Additionally, a resident with dysphagia was left unsupervised during meals, contrary to their care plan, risking aspiration.
The facility failed to maintain a safe environment and provide adequate supervision, leading to potential hazards. Bubbling in the first-floor hallway carpet posed a tripping risk, while a resident with dysphagia was left unsupervised with food and fluids, contrary to their care plan. Staff acknowledged these issues, highlighting delays in addressing the carpet problem and the need for strict adherence to supervision protocols.
Expired medications and improperly labeled liquid medications were found in two medication carts at the facility. Observations revealed expired drugs such as Senna plus, Iron, Bisacodyl, Aspirin, Vitamin D3, Fish oil, Fexofenadine hydrochloride, and Melatonin. Additionally, Tylenol and Lactulose solutions lacked proper labeling. Staff acknowledged the oversight, and the DON confirmed the facility's expectations for medication management.
The facility failed to manage its resources effectively, resulting in hazardous carpet conditions in the hallways. Observations showed bubbling in the carpet, posing a risk to residents using mobility aids. Staff confirmed the issue, and the Executive Director acknowledged awareness but cited delays in corporate response to repair requests.
The facility failed to ensure proper hand hygiene and glove use by staff during resident care and meal delivery, as observed with an LPN and a scheduler. Additionally, Enhanced Barrier Precautions (EBP) were not implemented for residents with indwelling catheters, increasing infection risk. Observations showed catheter tubing touching the floor and staff not wearing gowns during high-contact care. Interviews revealed a lack of awareness and policy for EBP, leading to increased infection risk.
A facility failed to obtain informed consent before administering psychotropic medications to a resident with moderately impaired cognition. Despite the facility's policy requiring consent, the resident's EHR lacked documentation of consent for antidepressant and antianxiety medications. Staff confirmed that consent should have been obtained and documented.
Two residents were found with medications at their bedside without completed assessments or physician orders for self-administration. One resident had an incomplete assessment for a Ventolin inhaler and no order for a Stiolto Respimat inhaler, while another had home medications without any documented clearance. Staff confirmed that medications should not be at the bedside without proper assessment and orders.
A resident reported feeling threatened by the food served after complaining about it, but the facility failed to report this allegation of abuse to the State Agency as required. The resident, who was cognitively intact, described receiving 'throw away food' and 'goopy' food, which they considered a threat. The facility's administrator did not report the incident, believing it was unnecessary due to a lack of harm, but later acknowledged the need to report it.
A resident reported feeling threatened after receiving 'throw away food' following complaints about the facility's food. The administrator did not recognize this as an abuse allegation and failed to conduct a thorough investigation, placing the resident at risk for repeated incidents and unidentified abuse.
A facility failed to provide written notice of transfer to a resident, their representative, and the State LTC Ombudsman, as required by policy. Staff interviews revealed that verbal notifications were given instead, and the resident was omitted from the list sent to the Ombudsman. The Executive Director confirmed the oversight.
A facility failed to transmit a resident's assessment data to CMS within the required timeframe. The discharge MDS for a resident was not completed, resulting in an 87-day delay. An MDS RN acknowledged the oversight, and the DON confirmed the expectation for timely completion.
The facility inaccurately assessed two residents using the MDS tool. One resident with an indwelling catheter was incorrectly coded as occasionally incontinent, while another resident's discharge status was wrongly recorded as discharged to an acute hospital instead of an Assisted Living Facility. These errors were identified during record reviews and interviews with the MDS RN and DON.
A facility failed to conduct a required Level II PASARR evaluation for a resident with bipolar disorder, as indicated by a positive Level I PASARR. The oversight occurred despite updated guidance from the Department of Social and Health Services, which staff were aware of but did not implement, placing the resident at risk of not receiving appropriate care.
The facility failed to conduct care conferences for two residents within the required seven days of admission, as per their policy. Both residents confirmed the absence of these conferences, and staff interviews corroborated the oversight. This deficiency placed the residents at risk of not having input on their care goals and unmet needs.
The facility failed to ensure proper medication administration and monitoring, as a nurse did not prime an insulin pen before dosing, and medications were left unattended for a resident. Additionally, vital signs were not consistently checked before administering blood pressure medication to a resident with hypertension, despite specific parameters for withholding the medication. Staff confirmed these practices were against facility expectations.
A resident with diabetes and muscle weakness did not receive necessary nail care or assistance with wheelchair transfers. Observations showed long, untrimmed nails with debris, and no documentation of scheduled care. Staff interviews confirmed the lack of scheduled nail care and assistance, despite the resident's expressed need and care plan requirements.
A facility failed to administer PRN Torsemide for a resident with significant weight gain and did not follow the bowel management protocol for another resident. Despite having orders for diuretic medication and bowel management, the staff did not take appropriate actions, leading to unmet care needs. Interviews revealed a lack of adherence to protocols and physician orders, placing residents at risk of medical complications.
A facility failed to provide consistent restorative services for a resident with limited ROM, as required by their care plan. Documentation showed missing records for active ROM exercises and ambulation training, and interviews revealed that the responsible CNA was often reassigned to other duties, leading to neglect of the restorative program. The DON confirmed the lack of documentation and acknowledged that the program was not carried out, placing the resident at risk for unmet care needs.
A facility failed to properly label, date, and store a nebulizer treatment set and tubing for a resident with COPD, who was prescribed Albuterol Sulfate Nebulization Solution. Observations showed the equipment was left on a chair without proper labeling or storage, contrary to facility policy. A nurse confirmed the equipment should have been labeled and bagged, and the DON stated it should be changed weekly and stored properly.
A facility failed to create and implement a care plan for a resident with dementia, as required by their policy. Despite the resident's diagnosis, their care plan lacked documentation of dementia-specific interventions. Observations showed the resident was placed in front of a TV without personalized care, and staff interviews confirmed the absence of a necessary care plan.
Two residents received unnecessary medications due to failure to adhere to physician orders. A resident with intact cognition was given PRN oxycodone for pain levels below the prescribed threshold, while another resident with hypertension received Carvedilol despite blood pressure and heart rate readings that should have prompted withholding the medication. Nursing staff acknowledged the errors.
A resident with moderately impaired cognition continued to receive unnecessary Mirtazapine despite a pharmacist's recommendation to taper and discontinue it, which was agreed upon by the physician. The facility failed to implement the recommendation within the expected timeframe, as confirmed by the DON.
The facility failed to ensure CNAs received the required 12 hours of annual training, including dementia care, for a staff member. Staff N, hired in early 2023, completed only 7.83 hours of training without any dementia training. Staff Development and the DON confirmed the deficiency.
The facility's assessment failed to include necessary resources for resident care during nights and weekends, lacked documentation of third-party agreements, and did not consider specific staffing needs for each shift. The Executive Director confirmed these omissions, acknowledging the absence of a staffing and retention plan, which placed residents at risk for unmet care needs.
A facility failed to accurately assess a resident's UTI in their MDS assessment. The resident had a positive urine analysis and was treated with ciprofloxacin, but the UTI was not documented in the MDS within the required 30-day look-back period. Both the MDS Nurse and the DON acknowledged the oversight, which placed the resident at risk for unmet care needs.
Failure to Provide Ordered PT Services Due to Staffing Shortages
Penalty
Summary
The deficiency involves the facility’s failure to provide specialized rehabilitative services according to a resident’s established treatment plan. The facility’s policy on scheduling therapy services states that therapy is to be scheduled in accordance with the resident’s treatment plan. One cognitively intact resident, identified as Resident 15, was admitted in October 2025 and had a physician’s order dated 12/04/2025 for PT/OT to evaluate and treat, with partial weight bearing as tolerated. A PT Evaluation and Plan of Treatment dated 12/11/2025 specified a frequency of two times per week, with a certification period from 12/11/2025 through 02/23/2026. During an interview on 01/06/2026, the resident reported that the last time they received PT was two weeks prior. Record review of PT notes for Resident 15 showed no documentation of PT services provided between 12/19/2025 and 01/05/2026, an 18‑day gap, despite the ordered frequency. The PT (Staff R) stated that residents are to be seen according to the plan of treatment and that refusals should be documented with missed visit notes, but could not find any documentation explaining why Resident 15 did not receive PT during that period and referred the surveyor to the Director of Rehab. The Director of Rehab (Staff Q) stated that the resident did not receive PT services for two weeks due to staffing shortages and that they were not able to schedule the resident, and confirmed that absent staffing issues, the expectation was PT twice weekly. The Administrator (Staff A) stated they expected residents to receive therapy services per their treatment plan and confirmed that this expectation applied to Resident 15’s ordered twice‑weekly therapy.
Failure to Provide Required Transfer/Discharge Notices
Penalty
Summary
The facility failed to provide written notice of transfer or discharge to a resident and/or their representative, as well as to the Office of the State Long Term Care Ombudsman, as required by both facility policy and regulation. Review of the electronic health record for the resident who was discharged showed no documentation that such notice was given. Multiple staff interviews confirmed a lack of awareness or implementation of the process for providing and documenting these notifications. The Social Services Director, who was new to the role, was unsure if the notice had been provided and could not locate any related documentation. The Charge Nurse stated that providing such notice was a new policy and that nothing had been sent to the ombudsman. The Regional Nurse Consultant and the Administrator both acknowledged that the required notifications were not present in the resident's record and confirmed that notification to the ombudsman is a regulatory requirement. The facility's policy, revised in March 2021, specifies that residents and/or their representatives must be notified in writing, in a language and format they understand, of the specific reason for transfer or discharge, the date, the location, and their rights to appeal. It also requires that a copy of the notice be sent to the Office of the State Long-Term Care Ombudsman. Despite these requirements, there was no evidence that the resident or their representative received the required written notice, nor that the ombudsman was notified, at the time of the resident's discharge.
Failure to Maintain Safe Environment and Provide Adequate Supervision
Penalty
Summary
A deficiency was identified in the facility's failure to ensure that an area was free from accident hazards and that adequate supervision was provided to prevent accidents. The report notes that the environment did not meet safety standards, and there was insufficient oversight to protect residents from potential harm. Specific actions or inactions leading to this deficiency include the presence of accident hazards and a lack of proper supervision, as directly observed by surveyors during their review.
Failure to Suspend Alleged Perpetrator During Abuse Investigation
Penalty
Summary
The facility failed to follow and implement its abuse and neglect policies and procedures during the investigation of an abuse allegation involving a cognitively intact resident. According to the facility's policies, any employee accused of abuse, mistreatment, neglect, or exploitation must be immediately suspended pending the outcome of the investigation. However, when a resident reported feeling threatened and fearful after an interaction with a staff member described as the head of nurses, the staff member fitting that description (the Director of Nursing) was not suspended or ruled out as a possible alleged perpetrator at the outset of the investigation. The investigation report showed that the resident initially described the alleged perpetrator as a tall nurse and the head of nurses, which matched the Director of Nursing. Despite this, the Director of Nursing conducted a follow-up interview with the resident, during which the resident provided a different description. The Director of Nursing then ruled themselves out as the alleged perpetrator based on this new description and their claim of not being present during the alleged incident. There was no documentation that the Director of Nursing was suspended or excluded from the investigation process, as required by policy. Interviews with other staff confirmed their understanding that any staff member accused of making a resident feel threatened or afraid should be suspended pending investigation. Staff also identified the Director of Nursing as the head of nurses, matching the resident's initial description. The Executive Administrator stated that staff are expected to follow the facility's abuse and neglect policies, but the investigation did not reflect adherence to these procedures in this case.
Failure to Report Suspected Abuse to Law Enforcement
Penalty
Summary
The facility failed to notify local law enforcement of a reasonable suspicion of abuse involving a resident. The incident involved a Certified Nursing Assistant (CNA) who allegedly did not respect the resident's request to stop touching her during a shower, making the resident feel powerless and vulnerable. The grievance form filled out by the resident indicated that the CNA's actions were perceived as abusive, yet the facility did not report the incident to law enforcement as required by their policy and state regulations. The facility's policy, as well as state guidelines, mandate that such incidents be reported to law enforcement, especially when involving staff-to-resident concerns. Despite the resident's clear expression of feeling abused and the facility's acknowledgment of the incident as an abuse allegation, there was no documentation of law enforcement being notified. Interviews with the Director of Nursing and the Executive Administrator confirmed that the facility did not contact the police, acknowledging a failure to comply with reporting requirements.
Failure to Post Nurse Staffing Information on All Floors
Penalty
Summary
The facility failed to ensure that nurse staffing information was posted in prominent locations on both floors, specifically on the second floor, as required by their policy. The policy, dated August 2018, mandates that within two hours of the beginning of each shift, the number of licensed nurses and unlicensed nursing personnel responsible for patient care should be posted in a prominent location accessible to patients and visitors. Observations on multiple dates revealed that the nurse staffing information was consistently posted only on the first floor by the administration office and not on the second floor. Interviews with staff and a resident confirmed the deficiency. Staff G, responsible for scheduling and staff development, acknowledged that the staffing information was only posted on the first floor and agreed that it was not in a prominent place accessible to all residents and visitors, particularly those on the second floor. Staff A, the administrator, believed the posting location was adequate due to the first floor's central activities and office locations. However, a resident noted that the posting was not easily visible, especially for older individuals, and suggested that it should be posted in other locations, including the second floor.
Food Safety and Hygiene Deficiencies in Facility
Penalty
Summary
The facility failed to adhere to professional standards of food safety, as evidenced by improper food handling and storage practices. Observations revealed that food items in the walk-in refrigerator were not labeled with use-by dates, and some items were past their use-by dates, such as sausage gravy, cheese, and egg salad. Staff C, the Dietary Manager, acknowledged these discrepancies and stated that the items should have been discarded. Additionally, in the dry storage room, an opened container of molasses and cinnamon raisin bread were found past their use-by dates, which Staff C also agreed should be discarded. Hand hygiene and glove use were not consistently practiced by the kitchen staff. Staff O, P, and Q were observed not performing hand hygiene after removing gloves, despite handling various food items and equipment. Staff O admitted to not washing hands after glove removal, while Staff P and Q acknowledged that they sometimes forgot to perform hand hygiene. Staff C, the Dietary Manager, and Staff E, the Infection Preventionist, both stated that they expected staff to perform hand hygiene before and after glove use. The use of hair coverings in the kitchen was also neglected. Staff C was observed without a hairnet while handling food, which they admitted was against the facility's policy. Additionally, uncovered food items were delivered to residents' rooms, with desserts being transported without covers, exposing them to potential contamination. Staff AA and Staff X were observed carrying uncovered desserts down hallways, and Staff C admitted that desserts were not covered due to frosting. Staff E and Staff B, the Director of Nursing, expressed concerns about uncovered food being carried long distances, as it could be exposed to contaminants.
Failure to Provide Access to Survey Results
Penalty
Summary
The facility failed to ensure that the survey result binder included the results for the 2021 recertification and complaint surveys that resulted in citations. Additionally, the facility did not post notices of the availability of survey reports in prominent and accessible areas for the public. This oversight prevented residents, their representatives, and visitors from exercising their right to review past survey results and the facility's plan of corrections. During a residents' meeting, two residents who regularly attended monthly meetings stated they were unaware of the availability of survey reports. Observations on the facility's first and second floors confirmed the absence of postings or notices regarding the survey reports. A review of the survey binder revealed missing recertification and complaint survey results for 2021, including specific complaint survey results from February, March, September, and October, as well as the recertification survey result from June. The Executive Director acknowledged the absence of these documents and confirmed that all annual recertification and complaint survey results with citations should be included in the binder.
Failure to Provide Baseline Care Plans to Residents
Penalty
Summary
The facility failed to develop and provide a baseline care plan and a written summary to residents and/or their representatives within 48 hours of admission, as required by their policy. This deficiency was identified for five residents during the survey. For Resident 94, the baseline care plan was not marked as provided to the resident or their representative, and the staff admitted to not giving a written summary. Similarly, Resident 194 did not recall receiving a written summary, and the staff confirmed that it was not provided unless requested. Resident 15 also expressed uncertainty about receiving the summary, and the records showed it was not provided. Resident 20's records lacked a baseline care plan entirely, and the staff could not locate it. Resident 5 was unsure about receiving the summary, and the records confirmed it was not provided. The Director of Nursing stated that the expectation was for the written summary to be offered and provided to residents, which was not consistently done. This failure to adhere to the facility's policy placed residents at risk for unmet care needs and a diminished quality of life.
Failure to Implement Comprehensive Care Plans
Penalty
Summary
The facility failed to develop and implement comprehensive care plans for four residents, leading to unmet care needs and potential risks. Resident 23, who was admitted with dementia and severely impaired cognition, was observed using a tilt-in-space wheelchair without a corresponding care plan. Staff acknowledged the absence of a care plan for the wheelchair, which was necessary for the resident's positioning. Resident 193 was observed with a Ventolin inhaler at their bedside, but there was no care plan for self-administration of medication, despite an order allowing the inhaler to be kept at the bedside. Staff confirmed that a care plan should have been initiated for self-administration of medication. Similarly, Resident 9 had an Afrin nasal spray for unsupervised self-administration, but no care plan was in place, contrary to the facility's policy. Resident 29, diagnosed with dysphagia following a stroke, had a care plan requiring supervision during meals to prevent aspiration. However, staff left the resident unsupervised with a breakfast tray, contrary to the care plan's directives. Staff interviews confirmed the expectation for one-on-one supervision during meals, which was not followed, placing the resident at risk of aspiration.
Safety and Supervision Deficiencies in LTC Facility
Penalty
Summary
The facility failed to ensure the safety of the first-floor hallway carpet and provide adequate supervision for a resident, leading to potential accident hazards. Observations revealed multiple areas of bubbling in the carpet, creating bumps that residents had to navigate over, posing a tripping risk. Staff interviews confirmed awareness of the issue, with attempts to address it being delayed due to pending corporate actions. The Executive Director acknowledged the safety concern, noting that the facility primarily serves short-term rehabilitation residents who frequently use the hallways for therapy. Additionally, the facility did not provide the required supervision for Resident 29, who was at high risk for aspiration due to dysphagia following a stroke. Despite care plan instructions for one-on-one supervision during oral intake, Staff N left the resident's breakfast tray unsupervised, allowing the resident to drink independently. Staff interviews confirmed the need for strict adherence to the care plan, emphasizing the importance of supervision to prevent aspiration. The Director of Nursing reiterated the expectation for staff to follow care plans and not leave food or fluids within the resident's reach without supervision.
Expired and Improperly Labeled Medications Found in Medication Carts
Penalty
Summary
The facility failed to ensure that expired medications were disposed of in a timely manner and that drugs were properly labeled and stored according to current accepted professional standards. During an observation of the first floor Team 1 medication cart, several expired medications were found, including Senna plus, Iron, Bisacodyl, Aspirin, Vitamin D3, and Fish oil. Additionally, a bottle of Tylenol liquid was not labeled with the date it was opened or the date it should be discarded. Staff U, an LPN, acknowledged that the expired medications should have been discarded and that liquid medications should have been labeled with the date they were opened. Similarly, an observation of the first floor Team 2 medication cart revealed expired medications such as Vitamin D3, Aspirin, Fexofenadine hydrochloride, and Melatonin. A bottle of Lactulose solution was also found without a label indicating when it was opened or when it should be discarded. Staff V, an RN, confirmed that the expired medications should have been discarded and that liquid medications should have been labeled upon opening. The Director of Nursing, Staff B, stated that the facility's expectation was for expired medications to be discarded and for liquid medications to be labeled when opened.
Facility's Ineffective Resource Management Leads to Hazardous Carpet Conditions
Penalty
Summary
The facility failed to manage its resources effectively to maintain the residents' highest practicable physical, mental, and psychosocial well-being, as evidenced by the poor condition of the carpet in the first-floor hallways. Observations revealed multiple areas of bubbling in the carpet, creating potential hazards for residents, particularly those using mobility aids such as walkers and canes. Staff interviews confirmed the presence of these hazards, with one staff member noting that residents had to lift their feet to navigate the uneven carpet, increasing the risk of tripping. The facility's Executive Director acknowledged awareness of the carpet issue, which had been ongoing for several months. Despite attempts to address the problem, including contacting corporate for quotes to repair or replace the carpet, there was a lack of follow-through, as the corporate office claimed not to have received or could not find the quotes. This inaction left the hazardous carpet condition unaddressed, posing a risk to residents, particularly those undergoing short-term rehabilitation and using the hallways for therapy.
Infection Control Deficiencies in Hand Hygiene and EBP Implementation
Penalty
Summary
The facility failed to ensure proper hand hygiene practices and the use of gloves by staff members during resident care and meal tray delivery. Observations revealed that Staff K, an LPN, did not perform hand hygiene before entering resident rooms or after removing gloves while delivering meal trays. Similarly, Staff G, responsible for scheduling and staff development, did not perform hand hygiene before glove use when assisting residents. Interviews with the staff confirmed their awareness of the hand hygiene protocols, yet these were not consistently followed, as expected by the facility's infection preventionist and director of nursing. The facility also failed to implement Enhanced Barrier Precautions (EBP) for residents with indwelling catheters, which are necessary to protect against multidrug-resistant organisms. Residents 37, 193, and 5, all of whom had indwelling urinary catheters, did not have EBP signage on their doors, and staff did not wear gowns during high-contact care activities. Observations showed that catheter tubing was often touching the floor, contrary to the facility's catheter care policy. Interviews with staff indicated a lack of awareness regarding EBP requirements and the absence of a policy for EBP implementation. Resident 37's catheter tubing was observed touching the floor multiple times, and staff did not wear gowns during high-contact care. Similarly, Resident 193 and Resident 5, both with indwelling catheters, were not placed on EBP, and staff did not consistently perform hand hygiene between glove changes. The facility's failure to adhere to infection control protocols and implement EBP for residents with indwelling catheters increased the risk of infection for residents, staff, and visitors.
Failure to Obtain Informed Consent for Psychotropic Medications
Penalty
Summary
The facility failed to inform a resident and/or their representative before administering psychotropic medications, specifically antidepressant and antianxiety medications. This deficiency was identified during a review of the facility's policy on psychotropic drug utilization, which mandates obtaining informed consent prior to the administration of such medications. The policy, last updated in November 2017, requires licensed staff to secure informed consent when a psychoactive medication is indicated in the plan of care. Resident 5, who was admitted to the facility with moderately impaired cognition, was receiving both antidepressant and antianxiety medications as per the order summary report. However, a review of the resident's electronic health record revealed that informed consent for these medications was not documented. During interviews, both a Licensed Practical Nurse and the Director of Nursing confirmed that informed consent should have been obtained and documented before administering the medications. Despite a verbal consent being mentioned, it was not recorded in the electronic health record or on a hard copy consent form.
Failure to Assess and Obtain Orders for Self-Administration of Medications
Penalty
Summary
The facility failed to ensure that residents were properly evaluated and assessed for self-administration of medications, and did not obtain the necessary physician orders for two residents. Resident 193 was observed with a Ventolin FHA inhaler and Stiolto Respimat inhaler on their bedside table without a completed self-administration assessment or a physician's order for the Stiolto Respimat. Despite the presence of an order for the Ventolin FHA, the assessment was incomplete, and the medications were left at the bedside, contrary to the facility's policy. Similarly, Resident 34 had Aspercreme and Xylimelts on their bedside table, which were their home medications. Although the resident claimed these were cleared by a doctor, there was no documented order or assessment for self-administration in their electronic health record. Staff interviews confirmed that medications should not be at the bedside without an assessment and order, highlighting the facility's failure to adhere to its policy and placing residents at risk for medication errors.
Failure to Report Alleged Abuse to State Agency
Penalty
Summary
The facility failed to report an allegation of abuse involving a resident, identified as Resident 7, to the State Agency as required. The facility's policy mandates that all alleged violations involving abuse, neglect, exploitation, or mistreatment must be reported immediately, or within 24 hours if the violation does not involve abuse and has not resulted in serious injury. Despite this, the facility did not report the incident involving Resident 7, who felt threatened by the food served to them after they complained about it. Resident 7, who was cognitively intact, reported to a registered nurse that they received 'throw away food' and 'goopy' food, which they considered a threat. The resident expressed fear regarding the situation. However, the facility's administrator, Staff A, stated that they were not informed of Resident 7 feeling threatened or afraid. Staff A mentioned that the resident only complained about the quality of the food, such as the casserole and meatloaf having fillers, and did not use terms like 'goopy' or 'throw away food.' The facility's incident log did not document Resident 7's concerns of feeling threatened or afraid, although the grievance log did note a grievance related to food and fear. Staff A admitted that they did not report the incident to the State Agency, as they interpreted the guidelines to mean that it was not necessary due to the lack of harm. However, upon reviewing the guidelines, Staff A acknowledged that the incident should have been reported and logged as an incident.
Failure to Investigate Abuse Allegation
Penalty
Summary
The facility failed to identify and thoroughly investigate an abuse allegation involving a resident who was cognitively intact. The resident reported feeling threatened and afraid after receiving what they described as 'throw away food' and 'goopy food' following complaints about the facility's food. The resident communicated these concerns to a registered nurse and later to the dietary manager. However, the administrator, who was aware of the resident's food complaints, did not initially recognize these concerns as an abuse allegation. The administrator stated that the resident never expressed feeling threatened or afraid during their conversations. The facility's incident log did not document the resident's concerns, although the grievance log did note a grievance related to food and fear. The administrator acknowledged that an investigation was not conducted and that the process for reporting and investigating abuse was not followed. The administrator admitted that they should have completed an investigation report and logged the incident in the facility's incident reporting log. The failure to investigate the resident's concerns placed the resident at risk for repeated incidents and unidentified abuse.
Failure to Provide Written Notice of Transfer
Penalty
Summary
The facility failed to provide written notice of transfer or discharge to a resident and their representative, as well as to the Office of the State Long Term Care Ombudsman, as required by their policy. This deficiency was identified during a review of the case of a resident who was transferred to an acute hospital. The facility's policy, dated June 2018, mandates that written notice be given to the resident and/or their representative, and a copy sent to the Ombudsman, especially when an immediate transfer is necessitated by urgent needs. However, the clinical health record lacked documentation of such written notice for the resident in question. Interviews with various staff members, including registered nurses, licensed practical nurses, and social services personnel, revealed that the facility's practice was to notify families verbally when residents were transferred to the hospital. The staff admitted that they did not provide written notifications. Additionally, the receptionist responsible for notifying the Ombudsman by fax on a monthly basis failed to include the resident in question on the list of discharged residents. The Executive Director confirmed that the nurses were responsible for notifying families and acknowledged that the Ombudsman was not notified about the resident's transfer.
Failure to Timely Transmit Resident Assessment Data
Penalty
Summary
The facility failed to transmit resident assessment data to the Centers for Medicare & Medicaid Services within the required timeframe for one resident, identified as Resident 30, who was reviewed for discharge assessments. According to the Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual, discharge Minimum Data Set (MDS) assessments must be completed no later than 14 days after the discharge date and submitted within 14 days of the MDS completion date. Resident 30 was discharged to a community, but a review of their MDS schedule on October 9, 2024, revealed that the discharge MDS was not completed, making it 87 days late. In a phone interview, Staff H, an MDS Registered Nurse, acknowledged that the discharge MDS for Resident 30 was not completed and was missed. Staff H stated that typically, the discharge MDS would be completed within 14 days from the discharge date and transmitted within the week. The Director of Nursing, Staff B, confirmed the expectation for timely completion of discharge MDS assessments.
Inaccurate MDS Assessments for Two Residents
Penalty
Summary
The facility failed to accurately assess two residents using the Minimum Data Set (MDS) assessment tool, which is crucial for identifying and meeting residents' care needs. Resident 5, who was admitted with an indwelling catheter, was incorrectly coded as occasionally incontinent in the MDS, contrary to the RAI manual's instructions to code such cases as 'not rated.' This error was identified during a joint record review and interview with the MDS Registered Nurse, who acknowledged the inaccuracy and indicated that the assessment would be modified. Resident 40's discharge status was inaccurately recorded in the MDS as discharged to an acute hospital, while nursing progress notes and a joint record review confirmed the resident was discharged to an Assisted Living Facility. This discrepancy was also recognized by the MDS Registered Nurse during a review of the electronic health record. The Director of Nursing expressed an expectation for staff to adhere to the RAI manual and ensure MDS accuracy, highlighting the facility's responsibility to conduct precise assessments.
Failure to Conduct Required PASARR Level II Evaluation
Penalty
Summary
The facility failed to properly review and validate the Preadmission Screening and Resident Reviews (PASARR) for a resident with a diagnosis of bipolar disorder. The resident's Level I PASARR, dated November 2, 2023, indicated a positive result for Serious Mental Illness/Intellectual Disabilities (SMI/ID) due to the diagnosis of bipolar disorder. However, the PASARR documentation did not show that a Level II evaluation was indicated or that a referral for such an evaluation was sent, as required by the updated guidance from the Department of Social and Health Services. Interviews with facility staff revealed a lack of adherence to the updated PASARR guidance. Staff F, responsible for reviewing PASARRs upon resident admission, did not ensure the accuracy and completion of the Level I PASARR, which should have led to a Level II referral. Additionally, Staff A, the Executive Director, acknowledged awareness of the new PASARR guidance but failed to ensure its implementation, resulting in the oversight. This deficiency placed the resident at risk of not receiving appropriate care and services tailored to their needs.
Failure to Conduct Timely Care Conferences for Residents
Penalty
Summary
The facility failed to conduct care conferences for two residents, which is a requirement to be completed within seven days of admission according to the facility's policy. Resident 37 was admitted to the facility, but a review of their electronic health record showed no documentation of a care conference. Interviews with the resident's representative and staff confirmed that no care conference had been held. Staff F, responsible for scheduling these conferences, acknowledged the oversight and stated that the resident should have had a care conference. The Director of Nursing and the Executive Director both expressed that care conferences are expected to be held within the stipulated timeframe. Similarly, Resident 193, who was admitted to the facility, did not have a care conference documented in their records. The resident confirmed that no care conference had been conducted since their admission. Staff F, during a joint record review, confirmed the absence of a care conference for this resident as well. The Executive Director reiterated the expectation that care conferences should occur within seven days of admission. This failure to conduct timely care conferences placed the residents at risk of not having input regarding their care goals and unmet needs, potentially affecting their quality of life.
Medication Administration and Monitoring Deficiencies
Penalty
Summary
The facility failed to ensure proper medication administration practices were followed, leading to deficiencies in care. A registered nurse, Staff T, did not prime an insulin pen before selecting a dose of 6 units for Resident 195, contrary to the manufacturer's instructions. This oversight was acknowledged by Staff T during an interview, and the Director of Nursing confirmed that the expectation was for nurses to prime the insulin pen before dose selection. Additionally, medications were left unattended for Resident 10, as observed when two medication cups with crushed medications in applesauce were found on the resident's bedside table without a licensed nurse present to ensure the medications were taken. Staff V, an RN, confirmed that leaving medications unattended was not acceptable, and this was reiterated by Staff J, an LPN/Charge Nurse, and Staff B, the Director of Nursing. Furthermore, the facility did not consistently check vital signs before administering blood pressure medication to Resident 25, who had a diagnosis of hypertension. The resident's medication administration record indicated that Carvedilol should be withheld if the systolic blood pressure was less than 100 or the heart rate was less than 55. However, vital signs were only documented once a day, despite the medication being administered twice daily. Staff U, an LPN, and Staff J confirmed that vital signs should be taken before each administration of blood pressure medication, and Staff B stated that this was the facility's expectation.
Failure to Provide Nail Care and Wheelchair Transfer Assistance
Penalty
Summary
The facility failed to provide necessary assistance with nail care and wheelchair transfer for Resident 20, who was admitted with diagnoses including diabetes, muscle weakness, and a need for assistance with personal care. Observations over several days showed that Resident 20's fingernails were long, untrimmed, and had brown debris underneath, with a split nail on the left thumb. Despite Resident 20 expressing discomfort and a desire for nail care, there was no documentation of nail care being scheduled or provided, particularly important due to the resident's diabetes diagnosis, which requires licensed nurses to perform such care. Additionally, the facility did not document any wheelchair transfers for Resident 20, despite the care plan indicating a need for substantial assistance with chair/bed-to-chair transfers. Interviews with staff revealed that fingernail care was not scheduled on the Treatment Administration Record (TAR) for October 2024, and there was no indication that Resident 20 refused care. The Director of Nursing expected nail care to be provided weekly by licensed nurses and for nurse aides to assist with transfers, but these expectations were not met, leading to the deficiency.
Failure to Administer PRN Medication and Follow Bowel Protocol
Penalty
Summary
The facility failed to provide care and services consistent with professional standards for a resident experiencing significant weight gain and the use of diuretic medication. Resident 20, who was admitted with a diagnosis of heart failure, had a significant weight gain of 12 pounds over three days. Despite having a PRN order for Torsemide to address fluid retention, edema, or weight gain, no action was taken to administer the medication or contact the physician. Staff interviews revealed that the order did not specify the amount of weight gain required to administer the medication, and the staff failed to reassess the resident or inform the charge nurse and physician about the significant weight gain. The facility also failed to implement the bowel management protocol for Resident 9, who experienced multiple episodes of constipation. The bowel protocol required the administration of Milk of Magnesia (MOM) if no bowel movement occurred in three days, followed by a Bisacodyl suppository if MOM was ineffective. Resident 9 did not have bowel movements for several days on multiple occasions, yet the MAR showed that MOM or Bisacodyl was not administered as required. Staff interviews confirmed that the bowel protocol was not followed, and there was no documentation of the resident refusing the medication. These deficiencies placed the residents at risk of unmet care needs and potential medical complications. The staff's failure to adhere to the established protocols and physician orders resulted in a lack of appropriate interventions for the residents' conditions. The Director of Nursing acknowledged the expectation for licensed nurses to follow physician orders and the bowel management protocol, highlighting the need for adherence to care standards.
Failure to Provide Consistent Restorative Services for a Resident
Penalty
Summary
The facility failed to consistently provide services to maintain or improve the range of motion (ROM) for Resident 145, who was on a restorative program due to limited ROM in the upper extremity on one side. The facility's policy required treatment and services to prevent further decrease in ROM, but documentation showed missing records for active ROM exercises and ambulation training for an entire week. Observations confirmed that Resident 145 was in bed during the times when exercises should have been conducted, and interviews with the resident revealed that no exercises had been performed with them recently. Interviews with staff highlighted that the Certified Nursing Assistant (CNA)/Restorative Aide responsible for the restorative program was often pulled to cover other duties, leading to the neglect of the restorative program. The Director of Nursing acknowledged the lack of documentation and confirmed that the restorative program was not carried out as required. This oversight placed Resident 145 at risk for a decline in ROM and unmet care needs, as the facility did not adhere to its own policy or the resident's care plan.
Failure to Properly Store and Label Nebulizer Equipment
Penalty
Summary
The facility failed to provide safe and appropriate respiratory care for a resident by not labeling, dating, and properly storing the nebulizer treatment set and tubing. This deficiency was observed in the case of a resident with Chronic Obstructive Pulmonary Disease (COPD), who had been prescribed Albuterol Sulfate Nebulization Solution to be administered via nebulizer every four hours as needed. Observations on two separate occasions revealed that the nebulizer machine treatment set and tubing were left on top of the resident's chair without being labeled or stored in a bag, contrary to the facility's policy. During an interview, a Licensed Practical Nurse/Charge Nurse confirmed that the nebulizer treatment set and tubing should have been labeled, dated, and bagged. The Director of Nursing also stated that the nebulizer set should be changed weekly and labeled when changed, and the mouthpiece should be rinsed and stored in a bag after each use. The failure to adhere to these procedures placed the resident at risk for respiratory infections and related complications.
Failure to Implement Dementia Care Plan
Penalty
Summary
The facility failed to develop and implement a care plan and interventions for a resident diagnosed with dementia, identified as Resident 25. Despite the facility's policy requiring an interdisciplinary team to create a patient-centered plan for individuals with confirmed dementia, Resident 25's comprehensive care plan lacked any documentation addressing dementia care needs. This oversight was discovered during a review of the resident's records, which showed no dementia care plan or interventions, even though the resident had been diagnosed with dementia. Observations over several days revealed that Resident 25 was placed in a wheelchair in front of a television in the lounge, indicating a lack of personalized care interventions. Interviews with staff, including an LPN and the Director of Nursing, confirmed the expectation that residents with dementia should have a specific care plan. However, the staff acknowledged the absence of such a plan for Resident 25, highlighting a gap in the facility's adherence to its own dementia care policy.
Failure to Adhere to Medication Orders for Two Residents
Penalty
Summary
The facility failed to ensure that residents were free from unnecessary medications, affecting two residents. Resident 20, who had intact cognition and was prescribed PRN oxycodone for severe pain rated 7 to 10, received the medication for pain levels below 7 on multiple occasions in October 2024. This was contrary to the physician's order, as confirmed by interviews with nursing staff, including a Registered Nurse and a Licensed Practical Nurse, who acknowledged that the medication should not have been administered for pain levels less than 7. Resident 25, diagnosed with hypertension, had an order for Carvedilol to be held if the systolic blood pressure (SBP) was less than 100 or the heart rate (HR) was less than 55. Despite this, the medication was administered on several occasions in July, August, and September 2024, when the resident's SBP was below 100 and HR was below 55. Interviews with nursing staff, including a Licensed Practical Nurse and the Director of Nursing, confirmed that the medication should have been withheld according to the specified parameters.
Failure to Implement Pharmacist's Recommendation for Psychotropic Medication
Penalty
Summary
The facility failed to ensure that a resident was free from unnecessary psychotropic medication, specifically involving the administration of Mirtazapine, an antidepressant. The resident, who had moderately impaired cognition, was admitted to the facility and was receiving both Citalopram and Mirtazapine for depression. A pharmacist recommended tapering and discontinuing Mirtazapine, which the resident's physician agreed to on 09/24/2024. However, the recommendation was not implemented in a timely manner, as the resident continued to receive the full dose of Mirtazapine 21 days after the physician's agreement. During a review and interview, it was confirmed that there was no documentation of the resident refusing the tapering recommendation, and the expectation was that such recommendations should be implemented within 72 hours if agreed upon by the physician. The Director of Nursing stated that the facility's policy required timely implementation of pharmacist recommendations, which was not adhered to in this case, placing the resident at risk of receiving unnecessary medication.
Deficiency in CNA Training Requirements
Penalty
Summary
The facility failed to ensure that Certified Nursing Assistants (CNAs) received the required twelve hours of annual training, including dementia management training, for one of its staff members, identified as Staff N. According to the facility's assessment updated on June 14, 2024, CNAs are required to complete at least 12 hours of training per year, which must include dementia care. However, a review of Staff N's employee record revealed that they were hired on January 9, 2023, and had only completed 7.83 hours of training by January 9, 2024, with no documentation of dementia training. During an interview, Staff E from Staff Development confirmed the deficiency, acknowledging that Staff N did not meet the training requirements. Additionally, the Director of Nursing, Staff B, expressed the expectation that all CNAs, including Staff N, should have completed the required training.
Facility Assessment Lacks Resource and Staffing Evaluation
Penalty
Summary
The facility failed to update its facility-wide assessment to accurately determine and identify the resources needed for resident care. The assessment, last updated on June 14, 2024, did not include essential elements such as resources necessary for resident care during nights and weekends, nor did it document contracts or agreements with third parties for services or equipment during normal operations and emergencies. Additionally, the assessment lacked consideration of specific staffing needs for each resident unit and shift, and there was no plan for maximizing recruitment and retention of direct care staff. During an interview, the Executive Director, Staff A, acknowledged the absence of documentation in the facility assessment regarding the evaluation of resources necessary for resident care, including nights and weekends. Staff A also confirmed that the assessment did not include contracts or agreements with third parties, such as hospice, and did not consider specific staffing needs for each shift. Furthermore, Staff A admitted that the facility did not have a staffing and retention plan documented in the assessment. This oversight placed residents at risk for unmet care needs.
Failure to Accurately Assess Resident's UTI in MDS
Penalty
Summary
The facility failed to accurately assess a resident's condition in their Minimum Data Set (MDS) assessment, specifically regarding a diagnosis of a urinary tract infection (UTI). The resident, who was admitted to the facility, had a positive urine analysis and was treated with the antibiotic ciprofloxacin for a UTI starting on May 16, 2024. Despite this, the quarterly MDS assessment with an Assessment Reference Date (ARD) of June 11, 2024, did not include the UTI diagnosis, which was within the 30-day look-back period required for accurate documentation. During a joint record review and interview, the MDS Nurse acknowledged that the resident's MDS assessment was not coded for the UTI, despite the resident receiving treatment for it. The Director of Nursing also confirmed that the MDS should have been accurately completed to reflect the UTI diagnosis. This oversight in the assessment process placed the resident at risk for unidentified or unmet care needs, as the UTI was not documented in the MDS as required by the Long-Term Care Resident Assessment Instrument (RAI) guidelines.
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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