Cedar River Healthcare Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Renton, Washington.
- Location
- 17420 106th Pl Se, Renton, Washington 98055
- CMS Provider Number
- 505532
- Inspections on file
- 16
- Latest survey
- April 20, 2026
- Citations (last 12 mo.)
- 1
Citation history
Health deficiencies cited at Cedar River Healthcare Center during CMS and state inspections, most recent first.
Surveyors found that the facility did not provide occupational therapy (OT) services as ordered by physicians and outlined in the plans of care for two residents with fractures who required assistance with ADLs. Although the facility assessment and policy indicated that OT would be available and delivered per MDS findings and physician orders, documentation showed that scheduled OT sessions were missed without adequate explanation, and residents received fewer treatments than the three-times-weekly frequency established in their OT evaluations. The Director of Rehabilitation acknowledged that the OT plans of care were not followed and linked the missed sessions to OT staffing issues, while the administrator was aware of ongoing OT staffing problems.
The facility did not ensure that the QAA committee included all required members or that meetings were held as scheduled, with repeated absences of the Medical Director, DON, and Infection Preventionist, and missing documentation for some months, in violation of facility policy and regulatory requirements.
Staff failed to secure medical records and appointment information, leaving documents with resident names and medical details visible at nurse's stations and in public areas. In one case, a family member received another resident's insurance information via email. The DON confirmed staff were expected to keep all PHI confidential and out of public view, but these expectations were not met.
A resident who required maximal assistance with eating due to shoulder fractures was left unattended for 11 minutes after being given only a few bites of food, as a CNA prioritized delivering other trays. The DON and Administrator acknowledged the need for improved meal assistance practices to ensure a dignified dining experience, in line with facility policy.
Two residents were admitted from the hospital with incomplete or inaccurate PASRR documentation, including missing or incorrectly recorded diagnoses of anxiety and depression. Despite the presence of SMI indicators, required Level II evaluations were not performed prior to admission, resulting in the residents not being properly assessed for mental health needs.
Staff did not develop or update care plans to address all identified needs for four residents, including pain management after knee surgery, bilateral shoulder fractures, gout, and GERD. Care plans lacked necessary details for specific conditions and interventions, despite medical records and resident reports indicating these needs.
Staff did not follow physician orders for a resident with heart conditions, failing to notify the physician after a significant weight gain and administering blood pressure medication despite a low pulse. The facility's own policies for medication administration and weight monitoring were not followed.
Two residents assessed as needing assistance with ADLs did not receive scheduled showers or proper nail care. One resident missed multiple scheduled showers and had overgrown fingernails, while another, dependent on staff and requiring diabetic nail care, had long, cracked toenails despite documentation indicating care was provided. Staff interviews confirmed these lapses in care.
Staff did not promptly remove fall interventions that were determined to be unbeneficial for a resident with multiple complex conditions, leaving floor mats in place after they were discontinued. Additionally, a resident with a neurological disorder and fall risk was found using a low air loss mattress that extended beyond the bedframe, with staff confirming the need for adjustment to ensure safety.
A resident with multiple medical conditions experienced significant weight loss over several days, but staff did not notify the provider or dietitian as required by facility policy and physician orders. Documentation and staff interviews confirmed that the necessary notifications and interventions were delayed, and snacks were not provided until several days after being recommended in a nutritional assessment.
A resident with a history of stroke and swallowing difficulties did not consistently receive the full volume of tube feeding nutrition as ordered, with staff documentation showing repeated shortfalls and observations confirming leftover nutrition in the feeding bag at the end of scheduled periods. The MAR lacked a section for daily totals or remaining amounts, and staff were unclear about monitoring practices, leading to incomplete delivery of prescribed artificial nutrition.
A resident with multiple medical conditions and a history of refusing care, including daily weights and other treatments, was not referred to or assisted by social services despite a care plan assigning them this responsibility. Nursing staff attempted to address the refusals, but social services staff were unaware of the ongoing issues and did not participate in problem-solving, resulting in a failure to provide required medically-related social services.
A resident with a POLST form requesting CPR experienced an unexpected death due to staff's failure to initiate CPR, miscommunication about the resident's code status, and the misplacement of the POLST form. The staff mistakenly believed the resident was a DNR, leading to a delay in CPR initiation until emergency services arrived.
A resident was left in the same room with their deceased roommate for 19.5 hours, compromising their dignity and mental well-being. Despite being cognitively intact and having a history of depression and anxiety, the resident was not moved, nor was the deceased, due to a lack of process for such situations. Staff acknowledged the oversight and the discomfort it would cause.
The facility failed to ensure nursing staff and nurse aides had the necessary competencies to provide adequate care, affecting all 11 staff members reviewed. Despite the facility's assessment indicating that staff competencies should be evaluated, training records lacked documentation verifying staff competency according to their licensure or certification. Interviews revealed the absence of a system to verify staff competency, placing residents at risk.
A resident with a Physician Order for full resuscitation did not receive CPR when their heart stopped, leading to their death. The Director of Nursing confirmed that staff neglected to follow the order and the incident was not reported to the state agency as required, placing other residents at risk.
A facility failed to investigate and document an incident where a resident did not receive CPR despite a Physician's Order. The DON did not conduct a thorough investigation or report the incident to the state agency, and staff involved were not interviewed. This failure to follow protocol placed other residents at risk.
A resident at high risk for pressure ulcers due to a stroke and hemiplegia developed a Deep Tissue Injury (DTI) on the left heel. The care plan lacked specific interventions for the resident's condition, and inconsistencies in staff assistance with bed mobility were noted. The facility's investigation identified risk factors but did not incorporate them into the care plan, leading to the preventable injury.
Failure to Provide Ordered Occupational Therapy Services as Planned
Penalty
Summary
The facility failed to provide specialized rehabilitative services, specifically occupational therapy (OT), as ordered by physicians and outlined in residents' plans of care for two residents. The facility assessment indicated that OT services were available seven days per week and that staffing would be sufficient to meet resident needs. Facility policy stated that specialized rehabilitative services, including OT, would be provided upon written physician order and as indicated by the MDS. For one resident with right shoulder and leg fractures who required extensive assistance with ADLs, the physician ordered skilled OT evaluation and treatment, and the OT evaluation established a plan of care for OT three times per week. However, OT treatment records showed the resident was seen only once during one specified week and twice during the following week, with missed scheduled sessions and no documented reasons other than a remark of "Others." The resident and the resident’s representative both reported that OT was not provided as frequently as planned, and the resident expressed that the rehabilitation services were not enough to help them return to their prior level of function. A second resident, who had a left arm fracture with muscle injury and required staff assistance with ADLs, also had a physician order for skilled OT evaluation and treatment, with an OT evaluation establishing a plan of care for three OT sessions per week. OT treatment notes showed this resident was seen only twice during a specified week, with another scheduled OT session missed and no documentation in the therapy record explaining the missed visit. The Director of Rehabilitation acknowledged that both residents’ OT plans of care were not followed and attributed the missed OT sessions to OT staffing issues. The administrator stated awareness of the facility’s OT staffing problems. The survey findings concluded that the facility did not ensure specialized rehabilitative services were provided as required by physician orders and residents’ plans of care, placing residents at risk of not attaining, maintaining, or restoring their highest practicable level of well-being.
Failure to Maintain Required QAA Committee Membership and Meeting Frequency
Penalty
Summary
The facility failed to maintain a Quality Assessment and Assurance (QAA) committee with the required members and did not consistently hold meetings as outlined in their policy. According to the facility's December 2024 QAPI Committee policy, the committee was to meet monthly and include the Administrator, Director of Nursing Services, Medical Director, and an infection control representative. However, review of meeting sign-in sheets revealed repeated absences of key members, including the Medical Director, Director of Nursing, and Infection Preventionist, across multiple meetings. Additionally, there was no documentation of QAPI meetings for certain months, specifically December 2024 and March 2025. During an interview, the newly hired Administrator confirmed that QAPI meetings were expected to be held monthly and that all required committee members should attend. The Administrator was unable to account for the missing meetings and acknowledged the absence of key participants in several documented meetings. This lack of compliance with both facility policy and regulatory requirements resulted in the deficiency cited by surveyors.
Failure to Protect Resident Health Information Privacy
Penalty
Summary
Facility staff failed to maintain the privacy and confidentiality of residents' medical information as required by facility policy and state regulations. Multiple observations revealed that appointment arrangement forms and medical information for several residents were left in plain view on nurse's station counters and in upright document stands, making them easily readable to anyone passing by. These documents included residents' names and details about their medical appointments, such as visits to oncology, hematology, orthopedic, urology, pulmonary, sleep, and radiology clinics, as well as information about blood draws. Additionally, a list of resident weights was left out in a public area, and the names of the residents could be matched to their weights using signage outside their rooms. In one instance, a family member of a resident reported receiving an email from the facility that contained insurance information for another resident, rather than for their own family member. The email included the other resident's name, admission status, co-pay amount, and supplemental insurance company. This error was acknowledged by the facility, and a corrected email was sent the following day. Interviews with facility staff, including the Director of Nursing, confirmed that the expectation was for all staff to maintain the privacy and confidentiality of resident information at all times. Staff were instructed to ensure that computer screens were not visible to others, carts were locked, and that report sheets and other information were not left visible in public areas. Despite these expectations, the observed actions and inactions led to the exposure of protected health information for multiple residents.
Failure to Maintain Resident Dignity During Meal Assistance
Penalty
Summary
Staff failed to provide care and services in a manner that maintained and promoted dignity for a resident who required substantial to maximal assistance with eating due to bilateral shoulder fractures. During observation and interview, a CNA assisted the resident with only four large bites of oatmeal before leaving the room to deliver other food trays, leaving the resident unattended for 11 minutes before returning to continue assistance. The resident expressed that they needed to be fed because they could not move their arms and noted that staff seemed very busy with other residents. The CNA confirmed that their practice was to give the resident a few bites and then return after distributing other trays. The Director of Nursing acknowledged that care staff needed help with tray services and had requested leadership assistance. The Administrator stated that their expectation was for staff to only place a tray in front of a resident when they were ready to assist with the entire meal, in order to promote dignity. The facility's policy required that residents be supported and provided with a dignified dining experience.
Failure to Complete Accurate PASRR Assessments Prior to Admission
Penalty
Summary
The facility failed to ensure that Pre-Admission Screening and Resident Review (PASRR) assessments were completed accurately and as required for two residents reviewed for PASRR screening. For one resident, the Level I PASRR received from the hospital did not include a diagnosis of anxiety, which was later identified and corrected by facility staff. However, although the corrected Level I PASRR included an indicator for Serious Mental Illness (SMI), a referral for a Level II evaluation was not made as required. For the second resident, the Level I PASRR completed at the hospital marked the resident as having no SMI indicators, but also identified depression as an SMI indicator in a subsection. Despite this, the form concluded that a Level II evaluation was not required, and the resident was admitted without the necessary Level II PASRR evaluation. Staff interviews confirmed that the expectation was for Level I PASRRs to be accurate and for Level II evaluations to be obtained when indicated. In both cases, the residents were admitted from the hospital with incomplete or inaccurate PASRR documentation, and the required follow-up for Level II evaluation was not performed, despite the presence of SMI indicators such as anxiety and depression. This failure resulted in the residents not being properly evaluated for mental health needs prior to admission.
Failure to Develop Comprehensive Care Plans for Multiple Residents
Penalty
Summary
Facility staff failed to develop and implement comprehensive care plans (CPs) that addressed all identified care needs for four residents. For one resident with a history of spinal cord dysfunction, spinal stenosis, and a recent total knee replacement, the CPs did not include the resident's right knee pain or the need to keep the knee straight for healing, despite the resident reporting ongoing pain and limited mobility due to the surgery. Staff interviews confirmed that the knee pain and related interventions were omitted from the CP, which should have included these details for appropriate pain management and therapy. Another resident with fractures in both shoulders had a CP that only addressed the right shoulder fracture, even though medical records and care conference notes documented fractures in both shoulders. The resident required slings on both arms and needed staff to exercise caution during transfers and showers. Staff confirmed that the left shoulder fracture and necessary precautions were not included in the CP, despite the resident experiencing pain in both shoulders and requiring similar interventions for each. Additionally, two other residents with complex medical conditions did not have CPs developed for specific diagnoses being actively treated. One resident receiving medication for gout did not have a CP addressing gout management, including signs, symptoms, and interventions for acute episodes. Another resident with GERD and a physician's order for a proton-pump inhibitor lacked a CP for GERD and related medication use. Staff interviews confirmed that CPs for these conditions were missing, contrary to facility policy requiring CPs for each diagnosis or condition under treatment.
Failure to Follow Physician Orders for Medication and Weight Monitoring
Penalty
Summary
Facility staff failed to follow physician's orders for a resident with complex medical conditions, including heart disease, heart failure, and high blood pressure. The physician's orders required daily weight monitoring with notification to the physician if the resident gained more than two pounds in a day or five pounds in a week. On one occasion, the resident's weight increased by 4.2 pounds in a single day, but there was no documentation that the physician was notified as required by the order. The facility's policy also required monitoring for undesirable weight changes, which was not followed in this instance. Additionally, the resident had an order for a blood pressure medication that was to be held if their pulse was less than 60 beats per minute. Despite the resident's pulse being recorded at 57 beats per minute on one occasion, the nurse administered the medication instead of holding it as directed. The Resident Care Manager confirmed that the physician was not notified of the weight gain and that the medication should have been held when the resident's pulse was below the specified threshold.
Failure to Provide Required ADL Assistance and Nail Care
Penalty
Summary
The facility failed to provide necessary assistance with activities of daily living (ADLs) for two residents who were assessed as needing help. One resident, who had a compression fracture in the spine and required moderate assistance with bathing, was scheduled for showers twice weekly according to the care plan and facility policy. However, observations and interviews revealed that this resident repeatedly requested showers and was told by staff that it would be done the following day, resulting in no showers being provided over an eight-day period. The resident's fingernails were also observed to be overgrown, and staff confirmed that nail care should have been provided on shower days. Another resident, who was dependent on staff for dressing and repositioning and had diabetes, was assessed to require weekly diabetic nail care by a licensed nurse. Despite documentation indicating that nail care was provided, observations showed the resident's toenails were long, cracked, and curling, and the resident reported that requests for nail care were not fulfilled. Staff confirmed the importance of nail care and acknowledged that the resident's toenails had not been properly trimmed.
Failure to Timely Remove Unbeneficial Fall Interventions and Ensure Proper Mattress Fit
Penalty
Summary
Facility staff failed to remove fall interventions in a timely manner when they were assessed as unbeneficial for a resident with multiple complex medical diagnoses, including cancer, heart failure, kidney disease, muscle weakness, and Parkinson's disease. Despite documentation that floor mats were not an appropriate intervention and should be discontinued, observations showed that the mats remained at both sides of the resident's bed several days after the decision. The DON confirmed that staff did not implement the change as expected, resulting in the continued presence of the floor mats. Additionally, the facility did not ensure that a resident's mattress fit the bedframe properly. A resident with a progressive neurological disorder, wasting condition, and a history of falls was observed lying on a low air loss mattress that extended beyond the bedframe by one to four inches. Staff confirmed that the mattress overhang required correction and that extender bars were needed to secure the mattress for safety, as the mattress should be properly fitted to the bedframe.
Failure to Timely Address Significant Weight Loss
Penalty
Summary
The facility failed to ensure timely evaluation and intervention for a resident experiencing significant weight loss. According to facility policy, any weight change of five percent or more required immediate written notification to the dietitian, and physician orders required staff to monitor the resident's weight daily and notify the provider of more than two pounds of weight loss in one day or five pounds compared to the previous week. Despite these requirements, documentation showed that the resident experienced a weight loss of over six percent between 4/16/2025 and 4/21/2025, but there was no evidence that the provider or dietitian were notified as required. Progress notes did not reflect timely communication or intervention, and snacks were not implemented until five days after the nutritional risk assessment recommended them. The resident involved had diagnoses including congestive heart failure, dementia, gastric ulcer, and unilateral weakness, and required supervision or assistance with eating. Staff interviews confirmed that the required notifications were not made, with some staff unaware of the need to report weight loss, and others unsure of the reporting requirements. The lack of timely notification and intervention was contrary to both physician orders and facility policy, resulting in a delay in addressing the resident's nutritional needs.
Failure to Provide Ordered Volume of Tube Feeding Nutrition
Penalty
Summary
Facility staff failed to ensure that a resident who required tube feeding received the full volume of artificial nutrition as ordered by the physician. The resident, admitted for care after a stroke and with swallowing difficulties, had a physician order for 1440 CC of liquid nutrition to be administered via feeding tube over an 18-hour period each day. Review of the Medication Administration Record (MAR) revealed that on multiple days, the resident received less than the ordered amount, with discrepancies ranging from 105 CC to 241 CC below the prescribed volume. The MAR did not provide a place to document the daily total of nutrition provided or the amount remaining at the end of each feeding cycle. Observations confirmed that the feeding pump was not always running as scheduled, and significant amounts of liquid nutrition remained in the bag at the end of the feeding period. Staff interviews indicated a lack of clarity regarding documentation of daily totals and remaining nutrition, and staff were not certain if this information was being monitored. The facility's policy required documentation of the amount and type of feeding provided, but this was not consistently done, resulting in the resident not receiving the full prescribed nutrition.
Failure to Involve Social Services in Addressing Resident's Refusals of Care
Penalty
Summary
The facility failed to ensure that medically-related social services were provided for a resident who was reviewed for nutrition and demonstrated a pattern of refusing care. The resident, who had intact memory and diagnoses including respiratory failure, reduced mobility, and pressure injuries, was dependent on staff for transfers and was on a diuretic requiring daily weights. Despite a care plan that identified social services staff as responsible for addressing refusals of care, the social services department was not informed of the resident's frequent refusals to be weighed, nor were they involved in problem-solving these refusals. Documentation showed the resident refused daily weights on 18 out of 41 occasions, as well as other treatments such as constipation management and weekly skin assessments. Staff interviews revealed that while nursing staff attempted to discuss risks and benefits with the resident and involved the resident's spouse in signing a Risks vs. Benefits form, the social services staff were unaware of the extent of the refusals and had not been engaged to address the resident's behavioral health needs. The social services coordinator expressed that they could have intervened if they had been informed. This lack of involvement from social services in managing the resident's ongoing refusals of care constituted a failure to provide necessary medically-related social services as required.
Failure to Perform CPR Due to Miscommunication and Policy Non-Compliance
Penalty
Summary
The facility failed to ensure that staff performed Cardiopulmonary Resuscitation (CPR) for a resident who was reviewed for unexpected death. The deficiency occurred when staff did not follow the facility's policy for CPR, which included the ability to accurately assess signs of irreversible death, verify the Physician's Order (PO) for CPR status, and access the resident's POLST form. The staff also failed to initiate CPR, communicate effectively with the 911 operator, and provide accurate resident records to Emergency Medical Services (EMS) personnel. Resident 1, who was admitted to the facility with a diagnosis of sepsis and pneumonia after a COVID-19 infection, had a POLST form indicating a desire for CPR and full medical treatment. On the day of the incident, Resident 1 became weak and short of breath while walking with a Certified Nursing Assistant (CNA). The resident was brought back to their room, and oxygen was started. However, when the resident's condition worsened, the staff failed to initiate CPR, mistakenly believing the resident was a Do Not Resuscitate (DNR) case. The confusion was exacerbated by the misplacement of Resident 1's POLST form, which was not in the binder at the nurse's station. Instead, Resident 2's POLST form, indicating DNR, was mistakenly provided to the Fire Department personnel. This error led to a delay in CPR initiation, and the resident was pronounced dead upon the arrival of emergency services. Interviews with staff revealed a lack of clarity and communication regarding the resident's code status, contributing to the failure to provide timely CPR.
Failure to Maintain Resident Dignity After Roommate's Death
Penalty
Summary
The facility failed to uphold the dignity and respect of a resident, referred to as Resident 2, by not providing a comfortable environment following the death of their roommate, Resident 1. Resident 2, who was cognitively intact but had a history of depression and anxiety, was left in the same room with the deceased Resident 1 for 19.5 hours. This situation arose because the staff did not have a process in place to address such incidents, resulting in Resident 2 being exposed to a potentially distressing environment that could harm their mental well-being, safety, and dignity. Interviews with staff members revealed that the body of Resident 1 remained in the room with Resident 2 from 10:00 PM until 5:30 PM the following day. Staff C, a registered nurse, acknowledged the incident and admitted that no efforts were made to move either resident to a different room. Staff B, the Director of Nursing, confirmed the duration the body remained in the room and recognized that the situation was not conducive to maintaining a homelike environment or the mental well-being of Resident 2. Both staff members acknowledged that a reasonable person would feel uncomfortable and possibly scared in such a situation.
Lack of Competency Verification for Nursing Staff
Penalty
Summary
The facility failed to ensure that nursing staff and nurse aides possessed the necessary competencies and skills to provide adequate care and ensure the safety and well-being of residents. This deficiency was identified for all 11 staff members reviewed, including Certified Nursing Assistants and Licensed Nurses. The facility's assessment indicated that staff competencies should be evaluated through skills validation, testing, and face-to-face encounters, covering areas such as Person-Centered Care, Activities of Daily Living, Disaster Planning, Infection Control, and Medication Administration. However, the training records reviewed did not contain documentation verifying that staff were competent to perform their specific job duties according to their licensure or certification. During interviews, the Staff Development Nurse and the Director of Nursing acknowledged the absence of a system to verify the competency of nursing staff upon hire or on an annual basis. The Director of Nursing confirmed that the facility did not evaluate nursing staff competencies to ensure care was provided according to professional standards, although it was recognized that such evaluations should occur. This lack of a competency verification system placed residents at risk for accidents, injuries, infections, and a diminished quality of life and care.
Failure to Report and Act on CPR Directive
Penalty
Summary
The facility failed to report an alleged neglect incident involving a resident who did not receive CPR despite having a Physician Order (PO) for full resuscitation. The incident involved Resident 1, who was admitted on a specific date and later died when their heart stopped beating and they stopped breathing. The nurse's progress note indicated that no CPR was initiated, contrary to the PO that specified 'Attempt Resuscitation/CPR' and 'Full Treatment.' This failure to act according to the PO was identified as neglect, especially since the resident's death was unexpected. During an interview, the Director of Nursing (Staff B) acknowledged that the staff neglected to follow the PO for full code and did not start CPR when Resident 1 stopped breathing and had no pulse. Furthermore, the facility did not report this incident to the state agency as required by state law. This oversight placed other residents with similar POs at serious risk of harm, including death, as the facility did not identify and report the alleged neglect after the catastrophic change in Resident 1's condition.
Failure to Investigate and Document Incident of Serious Bodily Injury
Penalty
Summary
The facility failed to timely initiate, document, and complete a thorough investigation regarding an incident involving a serious bodily injury to a resident. The incident involved a resident who had a medical event requiring CPR, but CPR was not administered despite a Physician's Order to do so. The Registered Nurse in charge of the resident at the time of the incident reported the event to the Director of Nursing (DON) but did not initiate an investigation. The facility's policy required that all reports of resident abuse and neglect be promptly reported to state agencies and thoroughly investigated, which was not adhered to in this case. Interviews with staff members revealed that no comprehensive investigation was conducted. The Licensed Practical Nurse and Certified Nursing Assistant who were present during the incident were not interviewed about the event. The DON provided an incomplete incident summary that lacked necessary interviews and documentation to rule out abuse or neglect. The DON acknowledged that a thorough investigation was not conducted and that the incident was not reported to the state agency, as required by the facility's policy.
Failure to Prevent Pressure Ulcer in High-Risk Resident
Penalty
Summary
The facility failed to provide appropriate care to prevent pressure ulcers for a resident who was admitted with no pressure ulcers but was at high risk due to a recent stroke and left side hemiplegia. The resident required maximum assistance with mobility and was unable to communicate needs effectively. Despite being assessed as high risk, the care plan did not include specific interventions related to the resident's condition, such as the number of staff required for safe repositioning to prevent friction and shear. The facility's policy required identification of risk factors and implementation of resident-specific interventions, but these were not adequately addressed in the care plan. The resident developed a Deep Tissue Injury (DTI) on the left heel, which was not anticipated or prevented due to the lack of specific guidance on the care plan. The facility's investigation identified multiple risk factors, including impaired mobility and the use of blood thinners, but these were not incorporated into the care plan to prevent the injury. Interviews with staff revealed inconsistencies in the provision of care, with documentation showing varying numbers of staff assisting with bed mobility. The Director of Nursing acknowledged that two staff members were needed to prevent friction and shear, but this was not documented in the care plan. The facility's investigation did not determine if the heel was dragged on the bed surface, and the Director of Nursing admitted that the DTI might have been preventable with proper assistance.
Latest citations in Washington
Inaccurate PASARR screening affected two residents. One resident with vascular dementia, depression, and adjustment disorder had a PASARR level one that did not reflect mental health diagnoses, and staff stated it was inaccurate. Another resident with PTSD had a PASARR level one that did not include the PTSD diagnosis, with no additional PASARR level one or level two found in the EHR; staff stated the screening was not accurate and should have been repeated.
Undated open meds were found on 2 medication carts, including an open insulin vial and multiple open eye drop bottles with no dates. An LPN and an RN both stated the items should have been dated when opened, and the DON stated open multidose vials or bottles found without a date should be discarded immediately.
A resident with respiratory failure, HTN, and anxiety became SOB and diaphoretic, received a breathing tx, and was sent by EMS to the hospital. The facility could not locate the required SNF/NF to Hospital Transfer form or other transfer records showing what information was communicated to the receiving provider.
Care plans for two residents were not updated to match their current status and care needs. One resident had PTSD and generalized anxiety disorder and was receiving a psychotropic medication, but the care plan listed monitoring for antipsychotic and anticonvulsant meds that were not prescribed and did not include the anxiety diagnosis or related behaviors and interventions. Another resident had new upper and lower dentures, but the oral/dental care plan only noted edentulous status and difficulty chewing, with no mention of dentures or denture-related interventions.
Failure to Provide Individualized Activities: A resident with anxiety, depression, and weakness was cognitively intact but said they could not attend group activities because of leg problems and wanted more in-room activities. The resident mostly stayed in bed watching TV, and staff documentation showed only limited room visits with no consistent activity documentation despite a care plan goal for participation two to three times per week.
Failure to maintain heel offloading for a resident with a reopened DFU. A resident with dementia and dependence for mobility had a left heel wound that had healed and then reopened; the wound care provider recommended heel floating and pressure relieving boots at all times, but observations showed the resident in bed with heels on the mattress and later reclined in a wheelchair with the heel resting on the footrest strap and no boots in place. Staff stated the resident had not refused the boots or heel floating, and the care plan was not updated after the wound reopened.
Failure to Address Hearing and Vision Services for a Resident: A resident with dementia, bilateral hearing loss, and impaired vision was observed without eyeglasses or a hearing device, despite records showing admission with eyeglasses and a personal sound amplifier. The care plan addressed vision only and did not include hearing-related interventions, while staff interviews confirmed the resident’s hearing was strained and that the resident’s device use and vision needs were not fully reflected in the plan of care.
Respiratory care was not provided consistently for two residents receiving O2. One resident with COPD and chronic respiratory failure had an O2 order missing the indication for use and Sats parameters, no MAR documentation of O2 therapy, and inconsistent Sats charting. Another resident with respiratory failure was observed on continuous O2 via NC, but provider orders for O2 therapy and tubing changes were not present after readmission, despite the care plan stating the resident was dependent on O2.
A resident with dementia, hearing loss, and missing lower teeth had an MDS showing obvious or likely cavities or broken natural teeth, and the care plan identified oral/dental health problems with an intervention to coordinate dental care and transportation. Staff stated the resident’s dental needs were captured on the MDS, but no referral was made for dental services or follow-up with the dentist, and the DON said the lack of referral did not meet expectations.
Inaccurate Meal Intake Documentation: A resident with DM, dysphagia, and protein-calorie malnutrition was observed eating less than 25% of a meal, but the POC documented 76-100% intake. The CNA said the resident usually ate only 25-50% of meals and that intake was sometimes documented based on what a coworker reported. The LPN/RCM and DON stated meal intake should be documented accurately.
Inaccurate PASARR Screening for Two Residents
Penalty
Summary
The facility failed to ensure that two residents were screened for additional mental health supports through the PASARR process. Resident 97 was admitted with diagnoses including vascular dementia, depression, and adjustment disorder, and was able to make needs known. Review of the PASARR level one dated 04/10/2026 showed no mental health diagnoses and no need for a PASARR level two, even though the resident’s record included mental health diagnoses. During interview, the Regional Social Services staff and the Administrator stated the PASARR was inaccurate, needed modifications, and did not meet expectations. Resident 6 was admitted with diagnoses including heart failure, respiratory failure, and PTSD, and was able to make needs known. Review of the PASARR level one dated 03/30/2026 showed no serious mental illness indicators marked and no PASARR level two indicated, and the EHR contained no other documented PASARR level one or level two. The Social Services Director stated the hospital-provided PASARR was reviewed for accuracy and, if inaccurate, another level one would be completed, and stated this resident’s PASARR did not include PTSD and should have had another level one completed. The Administrator also stated the PASARR was not accurate and another level one needed to be conducted, but none could be located in the EHR.
Undated Open Medications on Medication Carts
Penalty
Summary
The facility failed to ensure proper storage and labeling of medications for 2 of 3 sampled medication carts reviewed for medication storage and labeling, including carts on the 400 and 500 halls. On the 500 hall medication cart, an open vial of insulin and an open bottle of eye drops were observed with no dates. During interview, an LPN stated that when an insulin vial or bottle of eye drops is opened, it should be dated immediately and said both items should have been dated upon opening; the LPN stated they would dispose of the undated vial and bottle. On the 400 hall medication cart, two open bottles of eye drops were observed with no dates. During interview, an RN stated both bottles should have been dated as soon as they were opened and said they would get new eye drops and dispose of the undated bottles. The DNS/RN stated that if an eye drop was opened it should have been dated immediately and that any open multidose vial or bottle found without a date should be discarded immediately.
Missing Hospital Transfer Documentation
Penalty
Summary
The facility failed to ensure hospital transfer documentation was completed for one resident who was transferred to the hospital after complaining of not being able to breathe and appearing diaphoretic. The resident had diagnoses of respiratory failure, high blood pressure, and anxiety disorder, and was able to make needs known. A breathing treatment was provided, and the provider agreed to send the resident out for further evaluation, after which emergency transportation took the resident to the hospital. Record review found no documentation showing what information was provided or communicated to the receiving facility for the transfer. Staff stated that transfer documentation should have included a SNF/NF to Hospital Transfer form, the resident's face sheet, and the medication and treatment administration records, but they were unable to locate documentation showing these items were completed or sent for the resident's hospital transfer.
Care plans did not reflect current diagnoses, medications, or denture status
Penalty
Summary
The facility failed to ensure that care plans were revised and accurately reflected residents’ current status and care needs for 2 of 21 sampled residents. Resident 6 was admitted with diagnoses including heart failure, respiratory failure, and PTSD, and was able to make needs known. The EHR showed Resident 6 also had generalized anxiety disorder and was receiving a psychotropic medication, but the current care plan dated 05/05/2026 documented monitoring for side effects of antipsychotic and anticonvulsant medications even though Resident 6 was not prescribed those medications. The care plan also identified PTSD but did not include generalized anxiety disorder or behaviors to monitor and interventions related to PTSD or anxiety disorder. Staff F, LPN/CC, stated the care plan did not accurately reflect the resident’s current status or prescribed medications, and Staff B, DNS, stated it did not meet expectations because it did not address the anxiety disorder or target behaviors and interventions. Resident 71 was admitted with diagnoses including PTSD, high blood pressure, and depression and was able to make needs known. Observation on 05/06/2026 showed a denture cup by the sink with the resident’s name on the lid and new upper and lower dentures dated 01/12/26. The resident stated the lower dentures did not fit well and that denture adhesive had been provided, but the dentures still did not fit right and the resident had not told staff yet. The focused oral/dental care plan, initiated on 06/23/2026, identified the resident as edentulous and having difficulty chewing, but did not show that the resident had dentures or include interventions related to denture use or maintenance. Staff E, CNA, stated they had not seen the resident wear dentures and were unaware of the new dentures, Staff C, LPN/CC, stated the care plan should have been updated when the dentures were obtained, and Staff B, DNS, stated the care plan should have reflected the dentures and interventions.
Failure to Provide Individualized Activities
Penalty
Summary
The facility failed to provide individualized activities for Resident 5, who was admitted with diagnoses including anxiety disorder, depression, and weakness. The admission MDS dated 01/14/2026 showed the resident was cognitively intact. During interviews on 05/03/2026 and 05/06/2026, Resident 5 stated they could not attend in-person activities because of their legs, wanted more activities to occupy them, mostly stayed in bed watching TV, and did not remember the last time activities staff visited to offer activities. The resident also stated activities staff would need to offer something they were able to do because they had difficulty doing some activities. The activities care plan dated 12/26/2026 showed a goal for Resident 5 to participate in activities two to three times per week. Progress notes documented one visit on 12/22/2026 to provide a welcome packet and encourage participation in daily activities, but no further activity documentation was found in the progress notes. Staff H stated room visits should include puzzles, arts and crafts, visiting, and chatting, and that documentation was placed in tasks, but the task record showed no documentation of activities for the past 30 days. Staff J stated paper documentation existed for room visits and that Resident 5 was on a list for room visits every Monday and Wednesday, while the room visit documentation showed only four visits on 01/26/2026, 02/06/2026, 03/10/2026, and 04/08/2026.
Failure to Maintain Heel Offloading for Reopened DFU
Penalty
Summary
The facility failed to consistently implement pressure reducing strategies for a resident with a left heel diabetic foot ulcer that had reopened. The resident was admitted with diagnoses including left hip fracture with surgical repair, a blood clot of the left lower leg, and dementia, and was dependent on staff for mobility and unable to make needs known. The baseline care plan and care plan both included heel offloading interventions, and the wound care provider initially recommended heel floating with pillows or wedge and pressure relieving boots. The wound later resolved, but a weekly skin assessment documented that the left heel wound reopened and was very painful to touch. After the wound reopened, the contracted wound care provider documented that the DFU to the left heel had reopened and recommended the resident wear pressure relieving boots at all times. The current care plan reviewed after the wound reopened did not include new interventions related to the reopened wound. Observations showed the resident seated in a reclined wheelchair with the left foot/heel resting on the footrest strap and no pressure relieving boots in place, and later lying in bed with both heels directly on the mattress without being floated and without boots. Staff interviews indicated the resident had not refused the boots or heel floating, and the LPN/CC and DON stated the resident should have been assessed and the plan of care updated when the wound reopened.
Failure to Address Resident Hearing and Vision Needs
Penalty
Summary
The facility failed to address one resident’s hearing and vision needs. Resident 112 was admitted with diagnoses including a leg fracture, dementia, and hearing loss in both ears, and was able to make needs known. The record showed the resident lost their glasses and was given readers, but the resident did not wear them because they were concerned that wearing glasses that were not their prescription would further degrade their vision. Observation did not show glasses in the resident’s room, and the resident stated they did not use a hearing aid. The resident was observed to be hard of hearing, requiring an elevated voice and repeated questions to understand. The admission MDS dated [DATE] documented adequate hearing with hearing aid and adequate vision with corrective lenses, while the significant change MDS dated [DATE] documented moderate difficulty hearing without a hearing aid and impaired vision without corrective lenses. The care plan initiated 02/24/2026 addressed impaired vision with interventions to arrange consultation with eye care practitioners as needed and remind the resident to wear glasses, but it did not include a focus area or interventions for hearing loss or use of hearing aids. A resident clothing list showed the resident admitted with one pair of eyeglasses and one Super Ear headset personal sound amplifier, yet observation and interview showed the resident in bed without eyeglasses or a hearing device, with the amplifier stored in the bedside table drawer. Staff interviews confirmed the resident’s hearing was strained, that the hearing device and glasses were not being used, and that the resident’s hearing device use should have been included in the plan of care and the resident should have been referred for eye care assessment.
Respiratory Care Orders and Documentation Not Maintained
Penalty
Summary
The facility failed to provide respiratory care consistent with professional standards of practice for two residents receiving oxygen therapy. One resident with COPD and chronic respiratory failure with hypoxia was observed multiple times lying in bed receiving oxygen at 2 L via nasal cannula. The resident’s oxygen order, dated 02/15/2026, allowed 1 to 4 L per minute continuously via nasal cannula, but it did not include an indication for use or oxygen saturation parameters. The April and May 2026 MARs did not show documentation of oxygen therapy being provided, and the TARs showed only an order to change oxygen tubing if damaged or visibly soiled, not an order for oxygen therapy. Oxygen saturations were not documented consistently daily from 04/01/2026 through 05/04/2026. A second resident with respiratory failure, high blood pressure, and anxiety disorder was observed in the room receiving oxygen at 6 L via nasal cannula on multiple occasions. The resident stated they needed oxygen therapy to breathe, and the care plan identified the resident as dependent on oxygen and to receive oxygen per provider orders. However, provider orders reviewed on 05/04/2026 showed no orders for oxygen therapy or for changing oxygen tubing. Staff stated the oxygen and tubing-change orders had been discontinued when the resident went to the hospital and were not added back to the MAR or TAR when the resident readmitted to the facility.
Failure to Refer Resident With Identified Dental Needs
Penalty
Summary
The facility failed to ensure that Resident 112 received needed dental care. Resident 112 was admitted with diagnoses including a leg fracture, dementia, and hearing loss in both ears. Observation on 05/03/2026 showed the resident had missing lower teeth. The admission MDS, dated [DATE], documented obvious or likely cavities or broken natural teeth, and the care plan dated 02/24/2026 identified oral/dental health problems related to likely cavities or broken teeth with an intervention to coordinate dental care and provide transportation. During interviews, Staff G, Regional Social Services, stated Resident 112's dental needs were captured on the 02/24/2026 MDS and the resident was not referred for dental services. Staff M, Social Services Director, stated residents with dental needs should be referred to social services to be scheduled for assessment by a dental care practitioner, and that Resident 112 should have been referred after the MDS assessment. Staff B, DON, stated residents with identified dental needs should be referred for follow-up with a dentist and that Resident 112 should have been referred to the in-house dental provider; Staff B stated the lack of referral did not meet expectations.
Inaccurate Meal Intake Documentation
Penalty
Summary
The facility failed to accurately document the amount of food eaten for Resident 13, who was admitted with diagnoses including diabetes mellitus, dysphagia, and protein-calorie malnutrition. The quarterly MDS dated 02/12/2026 showed the resident was moderately cognitively impaired. During observation on 05/05/2026 at 12:09 PM, a meal tray was delivered to the resident’s room, set up on a bedside table, and the resident was observed eating slowly, eating less than 25% of the meal, then laying back in bed and closing their eyes while the tray remained in the room. Staff later removed the tray, but the POC documentation for lunch on 05/05/2026 recorded that Resident 13 ate 76-100% of the meal. During interview, the CNA stated the resident typically ate 25-50% of meals and never ate all of the food, and that if they did not pick up a tray they would ask a coworker what the resident ate before documenting it. The CNA stated they were told the resident ate 75-100% of lunch, so that is what was entered. The LPN/RCM stated staff should document meal intake accurately in POC, and the RN/DNS stated it was their expectation that all staff document meal intake accurately.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release June 24, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
