Cheney Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Cheney, Washington.
- Location
- 2219 North 6th Street, Cheney, Washington 99004
- CMS Provider Number
- 505346
- Inspections on file
- 35
- Latest survey
- August 20, 2025
- Citations (last 12 mo.)
- 23
Citation history
Health deficiencies cited at Cheney Care Center during CMS and state inspections, most recent first.
The facility did not consistently implement enhanced barrier precautions for three residents with conditions such as MRSA and urinary catheters, as required. Observations showed missing PPE signage and supplies, and staff interviews revealed a lack of awareness and inconsistent use of gowns and gloves during care. Additionally, infection prevention policies had not been reviewed annually, and staff were unclear about responsibility for policy updates.
The facility did not provide required education on the risks, benefits, and side effects of the COVID-19 vaccine to staff, nor did it maintain documentation of staff vaccination status. Interviews revealed that a nursing assistant had not received COVID-19 vaccine education, and Infection Prevention staff confirmed that only influenza and Hepatitis vaccine information was given. Human Resources discussed COVID-19 vaccinations only with new hires, and ongoing staff were not included, resulting in incomplete compliance with the facility's vaccination policy.
Two residents were administered psychotropic medications without documented informed consent prior to receiving the drugs. One resident with cognitive impairment received mirtazapine without a consent form on file, while another resident began taking escitalopram and mirtazapine before signing a consent form and later received Wellbutrin without any documented consent. Staff confirmed that consents should have been obtained before medication administration.
The facility did not provide required written notification to the State Long-Term Care Ombudsman when three residents were either transferred to the hospital or discharged home. Documentation and staff interviews confirmed that notifications were not sent due to lack of awareness and confusion about responsibility, resulting in noncompliance with notification requirements.
The facility did not ensure accurate and timely completion of PASRR screenings and referrals for three residents with mental health diagnoses. One resident was not referred for a Level II evaluation despite documented depression and anxiety, another was not reassessed after exceeding a short-stay exemption, and a third had inconsistent PASRR documentation following changes in psychotropic medication. Staff interviews confirmed these PASRR process failures.
A nurse prepared an antibiotic for a resident, handed it to them, and left the room without observing the medication being taken, contrary to facility policy requiring direct observation. The nurse later admitted this was not standard practice and did not verify the medication was consumed.
A resident with a history of stroke and diabetes, dependent on staff for ADLs, was not consistently provided with bathing, shaving, and nail care. Multiple observations showed the resident with greasy hair, facial stubble, and long, dirty fingernails, and documentation revealed missed scheduled showers without evidence of refusal. The care plan lacked specific interventions for grooming and nail care, and staff interviews confirmed inconsistencies in providing these services.
A resident with dementia and a history of falls did not receive consistent fall prevention interventions, including timely fall risk assessment, regular 15-minute checks, and use of hip protectors. Multiple unwitnessed falls occurred, some resulting in serious injuries, and staff were unclear about required interventions and documentation. Incident reports lacked thorough investigation, and care plan updates and communication were inconsistent.
A resident with ESRD on dialysis did not have their fluid restriction communicated or implemented due to a lack of coordination between facility staff and the dialysis center. The care plan and provider orders did not include the recommended fluid restriction, and staff were unaware of the need to monitor or limit the resident's fluid intake, resulting in inconsistent documentation and monitoring.
A resident with end-stage kidney disease, diabetes, and hypertension did not receive prescribed morning doses of hydralazine and calcium acetate on multiple dialysis days. Medications were not sent with the resident, and staff did not notify the provider or adjust orders, resulting in missed doses. Interviews confirmed a lack of communication and alternative arrangements for medication administration.
The facility did not consistently monitor or document medication refrigerator temperatures in the medication storage room, with multiple missed entries over several months. Although recorded temperatures were within safe limits, the lack of consistent checks placed stored medications, including tuberculin solution, at risk. Staff confirmed that daily monitoring was not reliably performed.
The facility did not provide food that was palatable, visually appealing, or at safe and appetizing temperatures during observed meals. Multiple residents expressed dissatisfaction with the taste and appearance of the food, and meal observations confirmed a lack of color variety and improper food temperatures. The dietary manager acknowledged ongoing complaints about the food's quality and appearance.
Surveyors observed that two resident snack refrigerators contained hard-boiled eggs and a bottle of honey mustard dressing that were not labeled with a name or date. The Dietary Manager confirmed that daily checks for labeling and expiration were supposed to occur, but these items were found unlabeled and undated.
A resident with significant care needs developed boils and a blister that were identified by staff but not properly assessed, documented, or reported to the physician as required by facility policy. Multiple staff members assumed others had completed necessary actions, resulting in no treatment being initiated and no incident report being filed. The resident's condition worsened, leading to hospitalization for scrotal cellulitis and MRSA abscesses.
A resident with MRSA required daily dressing changes under Contact Precautions, but a RN performed wound care without wearing a gown and without proper signage or PPE cart outside the room. The only contact precaution sign was inside the room and not easily visible, leading to a lapse in infection control protocol.
The facility failed to provide bed-hold notices to residents or their representatives upon hospital transfer, affecting four residents. Despite having a process for initial notification during admission, the facility lacked a clear procedure for subsequent notifications, relying on verbal communication. This deficiency was identified through interviews and record reviews.
The facility failed to complete required PASARR evaluations for three residents, leading to a deficiency in care. A resident with a history of stroke, anxiety, and depression did not receive a Level II review despite indicators of serious mental illness. Another resident with a history of stroke, Parkinson's Disease, and a suicide attempt also lacked a Level II review for intellectual disability. A third resident was admitted without a PASARR. The process was disrupted due to staffing changes.
A resident with a history of stroke and Parkinson's Disease was not re-admitted to the facility after hospitalization due to aggressive behavior. The resident was transferred to the hospital after an incident involving the Director of Nursing, and the facility informed EMS they would not take the resident back, contrary to their policy.
The facility failed to meet the behavioral health needs of two residents, leading to a deficiency in care. One resident, with a history of stroke, anxiety, and depression, did not receive a PASARR Level II assessment or adequate mental health counseling. Another resident, with a history of stroke, Parkinson's Disease, and depression, also lacked a PASARR Level II assessment and person-centered interventions. Staff interviews revealed a lack of consistent communication and documentation regarding resident behaviors and interventions.
The facility failed to manage and document residents' personal belongings, resulting in missing items and incomplete records for six residents. The facility's policy required inventorying belongings upon admission and updating the list throughout the stay, but this was not followed. Interviews revealed staff confusion about updating procedures, leading to risks of loss and diminished quality of life.
A facility failed to report and investigate a resident-to-resident altercation and an elopement involving a resident with severe cognitive impairment. The altercation was not reported to the SA, and no thorough investigation was conducted. Similarly, the elopement was logged but not reported to the SA Hotline, and the investigation was incomplete. The DON acknowledged these failures, admitting the facility did not follow its policies.
A facility failed to provide adequate discharge planning and communication for a resident, resulting in an incomplete Transfer/Discharge Report and lack of necessary medical information for the receiving community provider. The resident, who had experienced a stroke and UTI, was discharged without a comprehensive care plan, leading to a readmission to the hospital with sepsis and other complications. Facility staff acknowledged the failure to ensure a safe discharge process.
A facility failed to implement urology recommendations for a resident with a history of UTIs and kidney stones. Despite receiving specific dietary and hydration guidelines to prevent kidney stones, the facility's care plan did not include these measures. The resident's nutrition care plan lacked instructions to limit sodium and high oxalate foods or to include citrus fruits, and the recommended water intake was not ensured. A No Added Salt diet was only introduced six months later, and the DON acknowledged the oversight.
A resident with severe cognitive impairment and complex medical conditions was not provided with adequate fluids, as recommended by medical professionals. Despite orders to encourage fluid intake, documentation showed the resident received less than 1,000 cc of fluids on most days over two months. This deficiency was noted when the resident was hospitalized with a UTI, highlighting the facility's failure to monitor and ensure proper hydration.
The facility failed to maintain current oxygen orders and clean equipment for residents requiring respiratory care. A resident with dementia had an incomplete oxygen order, and another with quadriplegia used oxygen without a current order. Observations showed dusty filters and undated tubing, indicating poor maintenance. Staff interviews revealed inconsistencies in following policies for oxygen management, risking respiratory complications and infection.
The facility failed to serve meals at appropriate temperatures, risking decreased quality of life for residents. During lunch service, a cook did not recheck soup temperature after additional heating. A surveyor later found food temperatures significantly below required standards, violating health guidelines.
A resident was prescribed Trazodone and Seroquel for depression and hallucinations, respectively, but the informed consent forms were signed several days after the medications were first administered. The facility's records lacked documentation of prior education on the medications' risks and benefits. Interviews with staff confirmed that informed consents should be obtained before administering the first dose.
A resident with Alzheimer's disease was observed in an unclean wheelchair with food smeared on it over several days. Despite the facility's cleaning protocol, the wheelchair remained unclean, as confirmed by staff interviews.
A resident, who was cognitively intact and required assistance with daily activities, was discharged to a hospital due to suicidal thoughts. The facility failed to complete a discharge summary with a recapitulation of the resident's stay, as required. Despite expressing suicidal thoughts and being assessed for depression, the discharge summary only noted the hospital transfer without detailing the care and services provided.
The facility failed to follow its bowel management protocol for three residents, leading to a deficiency in care. Despite having no bowel movements for several days, the necessary medications were not administered, nor was there documentation of them being offered or refused. Staff interviews confirmed the protocol was not adhered to, and the Director of Nursing acknowledged the importance of following the medical order.
A facility failed to conduct a nutritional assessment for a resident at risk for compromised nutritional status upon admission. Despite policies requiring a comprehensive assessment within seven days, the assessment was missed, as acknowledged by the Dietetic Technician. The resident, with conditions such as malnutrition and diabetes, was not evaluated by the Dietetic Technician or Registered Dietitian, posing potential health risks.
The facility failed to accurately reconcile controlled medications in one medication cart. A bottle of narcotic pain pills was found with a taped cap marked with the number 56, which staff used instead of counting pills during shift changes. The DON confirmed the count matched the narcotic log and acknowledged the need for pill counts at every shift change.
A facility did not follow a pharmacist's recommendation to adjust the timing of Melatonin administration for a resident. The medication was given at bedtime instead of 60 to 90 minutes before, as suggested. Staff interviews confirmed the resident's usual bedtime, and the DON acknowledged the oversight.
The facility failed to ensure dietary staff had current Food Worker Cards, with two staff members lacking proper qualifications. Additionally, inadequate staffing in the dining room led to delayed assistance for residents, resulting in meals being served at unappetizing temperatures and affecting residents' dining experiences.
The facility failed to properly label, date, and monitor food items in the snack/nourishment refrigerators, posing a potential risk of foodborne illness. Observations revealed undated and expired food items, incomplete temperature logs, and inconsistencies in staff responsibilities for monitoring. Staff interviews highlighted a lack of awareness and adherence to procedures for ensuring food safety.
The facility failed to ensure proper infection control during meal service and medication administration. Staff did not perform hand hygiene or wear gloves when handling food, and a resident's nails were not maintained in a sanitary manner. Additionally, a nurse administered insulin without cleaning the injection site, contrary to infection prevention protocols.
Failure to Implement Enhanced Barrier Precautions and Annual Policy Review
Penalty
Summary
The facility failed to implement enhanced barrier precautions (EBP), including the use of personal protective equipment (PPE) such as gowns and gloves, for three out of four sampled residents who required these measures. Observations revealed that residents with conditions such as MRSA colonization, urinary catheters, and wounds did not have appropriate signage or PPE available at their room entrances, and staff were not consistently using gowns and gloves during high-contact care activities. For example, one resident with MRSA and a history of osteomyelitis and gangrene had no EBP signage or PPE at their room, and a used bandage with bloody drainage was found on the floor. Another resident with a urinary catheter did not have EBP signage or PPE receptacles at their room, and the resident reported not recalling staff wearing gowns during care. A third resident with a urinary catheter also lacked EBP signage and PPE bins, and reported staff only wore gloves, not gowns, during catheter care. Interviews with staff revealed gaps in communication and awareness regarding which residents required EBP. The Infection Prevention nurse was unaware of a resident's new catheter placement because it occurred on a day they were not present, and stated that nurses were expected to implement EBP in their absence. The nurse also missed identifying a resident as an MRSA carrier. Despite claims of a system to identify residents needing EBP, these lapses resulted in inconsistent implementation of required precautions. Additionally, the facility's infection prevention policies, including those related to EBP, had not been reviewed annually as required. All reviewed policies had a last review date from over a year prior, and staff were unclear about who was responsible for ensuring the policies were kept current. This lack of timely policy review contributed to the risk of outdated procedures being followed.
Failure to Educate and Document Staff COVID-19 Vaccination Status
Penalty
Summary
The facility failed to implement and document procedures to ensure staff were educated on the risks, benefits, and potential side effects of the COVID-19 vaccine, and did not maintain records of staff vaccination status. According to the facility's COVID-19 vaccination policy, staff documentation should include education on the vaccine, offering the vaccine or information on obtaining it, documentation of any exemptions, and the vaccination status of staff. However, interviews revealed that a nursing assistant employed for four years did not recall receiving education or information about the COVID-19 vaccine. The Infection Prevention staff confirmed that only influenza and Hepatitis vaccine information was provided to staff, and that COVID-19 vaccination status was not tracked. Further interviews indicated that Human Resources discussed COVID-19 vaccinations only with new employees, excluding long-term staff. The Infection Prevention staff also incorrectly cited HIPAA as a reason for not tracking staff COVID-19 vaccination status. The Director of Nursing was initially unaware of the facility's program for staff COVID-19 vaccinations and later confirmed that ongoing staff were not included in vaccination discussions. These actions and omissions resulted in a lack of education and documentation regarding COVID-19 vaccination for staff, as required by facility policy.
Failure to Obtain Informed Consent for Psychotropic Medications
Penalty
Summary
The facility failed to ensure that two residents were fully informed and provided consent prior to the administration of psychotropic medications. For one resident with Parkinson's disease, malnutrition, and anxiety, who was severely cognitively impaired and had a family member designated as decision-maker, mirtazapine was prescribed and administered to stimulate appetite. However, there was no documentation that consent describing the risks and benefits of the medication was obtained at the time it was prescribed. For another resident diagnosed with depression and receiving psychotropic medications, escitalopram and mirtazapine were prescribed and an informed consent form was signed two days after the medications were started. Additionally, Wellbutrin was later prescribed and administered without any documentation of informed consent, either verbal or written, prior to the resident receiving the medication. Staff interviews confirmed that informed consent should have been obtained before administration of these medications.
Failure to Notify Ombudsman of Resident Transfers and Discharges
Penalty
Summary
The facility failed to provide written notification to the Office of the State Long-Term Care Ombudsman regarding the transfer or discharge of three residents who were either hospitalized or discharged. For one resident, documentation showed they were admitted from the hospital and later transferred back to the hospital due to respiratory distress, but there was no record of Ombudsman notification. Another resident, who had a history of hip fracture and dementia and was severely cognitively impaired, was transferred to the hospital after a fall and subsequent hip pain, yet no Ombudsman notification was documented. A third resident was discharged home after meeting rehabilitation goals, but again, no notification was sent to the Ombudsman. Interviews with facility staff revealed a lack of awareness and confusion regarding the responsibility for notifying the Ombudsman about resident transfers and discharges. Staff confirmed that notifications were not sent in these cases, and there was no documentation to indicate that the required notifications had been made for any of the three residents reviewed.
Failure to Complete and Follow Up on PASRR Assessments for Residents with Mental Illness
Penalty
Summary
The facility failed to ensure proper completion and follow-up of Pre-admission Screening and Resident Review (PASRR) processes for three residents with mental health diagnoses. For one resident with depression and anxiety, a Level I PASRR screening was completed prior to admission but incorrectly documented that there was no serious mental illness, and no Level II evaluation was initiated. Another resident, who was initially exempt from a Level II evaluation due to an expected short stay, remained in the facility beyond the exemption period without a subsequent referral for a Level II assessment, and there was no documentation from facility management or the social worker regarding this oversight. A third resident with a history of depression and changes in psychotropic medication had a Level I PASRR completed after medication adjustments, which indicated serious mental illness indicators in one section but contradicted this in another section, resulting in no Level II evaluation being conducted. Interviews with facility staff confirmed that the required PASRR processes were not followed, including the need for timely and accurate assessments and referrals for Level II evaluations when indicated.
Medication Administration Not Observed by Nurse
Penalty
Summary
A licensed nurse failed to administer medication according to professional standards and facility policy for one resident. During a medication pass, the nurse prepared an antibiotic (Fosfomycin Tromethamine) by mixing it with water and, after observing the resident take other medications, handed the antibiotic mixture to the resident with instructions to drink it. The nurse then left the room without observing the resident consume the medication, contrary to the facility's policy, which requires nurses to observe residents taking their medications. The resident later confirmed that they had taken the medication, and the empty cup was observed, but the nurse did not return to verify this. In an interview, the nurse acknowledged that it was not standard practice to leave medication with a resident unsupervised and admitted there was no way to guarantee the medication was taken. This incident was identified during a survey and was found to be inconsistent with both professional standards and the facility's own medication administration policy.
Failure to Consistently Provide Bathing and Personal Hygiene/Grooming
Penalty
Summary
A deficiency was identified when a resident with a history of stroke and diabetes, who required staff assistance for activities of daily living (ADLs) such as bathing, shaving, and nail care, was not consistently provided with these services. Observations over several days revealed the resident had greasy hair, facial stubble, and long fingernails with black debris, indicating a lack of regular bathing and grooming. The resident reported that scheduled baths were often missed, and although staff would inform them of being on the bath schedule, the care was frequently not provided. Documentation showed that out of seven scheduled showers, only four were given, with an 11-day gap between some showers and no record of the resident refusing care during that period. Further review of the resident's care plan revealed that while it included interventions for bathing, toileting, oral care, and dressing, it lacked specific instructions or interventions for personal hygiene and grooming needs such as nail care and shaving. Staff interviews confirmed that nail care and shaving were typically performed during morning care or bathing, but for diabetic residents, nail trimming was done by nurses. However, the records did not specify which personal hygiene tasks were refused or completed, and repeated observations showed the resident remained unshaved and with long fingernails over several days.
Failure to Consistently Implement and Document Fall Prevention Interventions
Penalty
Summary
The facility failed to consistently implement and document care-planned supervision interventions and did not fully evaluate the effectiveness of fall prevention measures for a resident with a history of dementia, falls, and a recent femur fracture. Upon admission, the required comprehensive fall risk assessment was not completed in a timely manner, and individualized fall risk was not assessed. The resident experienced multiple unwitnessed falls, including incidents in the activity area and in their room, some resulting in significant injuries such as a hip fracture and a broken wrist. Documentation revealed that interventions such as 15-minute checks and the use of hip protectors were not consistently carried out or documented, and staff were often unclear about the specific interventions required for the resident. Observations and interviews indicated that staff did not always follow the care plan interventions, such as ensuring the resident wore hip protectors while in bed and performing 15-minute checks as ordered. There were repeated omissions in the documentation of these checks, and staff interviews confirmed that if checks were not documented, they were likely not performed. Additionally, staff were sometimes unaware of the location or use of hip protectors, and there was confusion regarding the frequency and nature of required supervision. The resident was able to move their fall mat and alarm, and staff acknowledged that the resident did not reliably use the call light, further increasing the risk of falls. Incident reports for several falls lacked thorough investigation, staff statements, or documentation of the circumstances leading to the falls. The care plan was not always updated promptly after incidents, and there was no evidence that the effectiveness of interventions was systematically evaluated following each fall. Staff interviews revealed uncertainty about the process for updating care plans and communicating changes, and there were lapses in ensuring that all staff were aware of and implementing the required interventions. These failures placed the resident at continued risk for accidents and injury.
Failure to Communicate and Implement Fluid Restriction for Dialysis Resident
Penalty
Summary
The facility failed to ensure consistent communication with the dialysis center regarding fluid restrictions for a resident with end-stage renal disease (ESRD) who was dependent on dialysis. The facility's hemodialysis policy required coordination and collaboration with the dialysis center to implement the dialysis care plan, but this was not followed. The resident, who was cognitively intact and independent in most activities of daily living, was observed with multiple fluid items in their room and expressed uncertainty about their fluid restriction and who was responsible for monitoring it. Review of the resident's care plan and provider orders revealed no mention of oral fluid restrictions or interventions to monitor fluid intake, despite the dialysis center's Registered Dietician stating the resident was supposed to be on a 1200 ml daily fluid restriction. Documentation of fluid intake was inconsistent, with many omissions and no data recorded for fluids given as needed. The facility's Registered Dietician was unaware of the fluid restriction recommendation and had not communicated with the dialysis center, while nursing staff were unclear about who determined and monitored fluid restrictions for dialysis residents. Interviews with facility staff indicated a lack of clear processes for communicating dietary or fluid needs between the facility and the dialysis center. The communication sheet sent with the resident to dialysis was used for general updates, but there was no evidence of direct communication regarding the resident's fluid restriction. As a result, the resident's fluid intake was not adequately monitored or restricted according to the dialysis center's recommendations.
Failure to Administer Ordered Medications for Dialysis Resident
Penalty
Summary
The facility failed to ensure that medications were administered as ordered for a resident receiving dialysis care. The resident, who had end-stage kidney disease, diabetes, and high blood pressure, had medication orders for hydralazine and calcium acetate to be given three times daily. On multiple occasions, the resident did not receive their morning doses of these medications on days they attended dialysis, as indicated by the medication administration record, which noted the resident was absent from the facility. There was no documentation that the provider was notified about the missed doses, and no alternative arrangements were made to administer the medications as ordered. Interviews with staff revealed that medications were not sent with the resident to dialysis, and the resident would miss the morning doses if they returned too late. Staff acknowledged that no discussions had occurred with the provider to adjust medication administration times or orders. The resident reported leaving the facility early for dialysis without breakfast and feeling hungry and tired upon return. Nursing leadership stated that they expected nurses to communicate with providers when medications were missed, but this did not occur in this case.
Failure to Consistently Monitor Medication Refrigerator Temperatures
Penalty
Summary
The facility failed to consistently monitor and document the medication refrigerator temperatures in the medication storage room, as required to ensure safe storage of drugs and biologicals. Review of the temperature log posted on the refrigerator showed that temperature checks were not recorded on nine occasions in June, eleven occasions in July, and nine occasions in August. When temperatures were documented, they were within the safe range, but the lack of consistent monitoring meant there were multiple undocumented periods. The refrigerator contained ten boxes of unopened tuberculin solution, an injectable medication used for tuberculosis screening. Staff interviews revealed that it was the responsibility of the night shift nurse to check and record the refrigerator temperatures daily. However, the Infection Preventionist acknowledged that this monitoring was not performed consistently. The failure to document refrigerator temperatures as required was observed during a review of the medication storage room, and the issue was confirmed by staff.
Failure to Provide Palatable, Attractive, and Properly Tempered Food
Penalty
Summary
The facility failed to serve food that was palatable, visually appealing, and at safe and appetizing temperatures during two observed meals and one test tray sampling. Multiple residents reported dissatisfaction with the food, describing it as unappetizing, bland, and lacking in seasoning. Observations of meal service revealed that the food presented was mostly brown or dull in color, lacking variety and visual appeal. Specific comments from residents included complaints about the food's appearance and taste, with one resident requesting an alternative meal after seeing and tasting the food provided. Temperature measurements of the test tray items showed that hot foods were served below the required 135 degrees Fahrenheit, and cold foods were served above the recommended 41 degrees Fahrenheit. The dietary manager acknowledged receiving complaints from residents and families regarding the food's appearance and confirmed that the lack of color variety made the food less appetizing. These findings were documented in accordance with WAC 388-97-1100(1)(2).
Unlabeled and Undated Food Items in Resident Snack Refrigerators
Penalty
Summary
During observations, two resident snack refrigerators were found to contain food items, specifically hard-boiled eggs and a bottle of honey mustard dressing, that were not labeled with a name or date. One refrigerator was located in the nurses' main charting room and the other on the transitional care unit. Staff M, the Dietary Manager, confirmed in an interview that the prep cook was responsible for daily checks of these refrigerators to ensure proper labeling and monitoring of expiration dates. Staff M also acknowledged the importance of labeling and dating food items to track ownership and duration of storage. Despite these procedures, the observed food items remained unlabeled and undated at the time of the survey.
Failure to Assess, Monitor, and Notify Physician of Non-Pressure Skin Condition
Penalty
Summary
The facility failed to properly assess, monitor, and notify the physician regarding a non-pressure related skin condition for a resident with a history of stroke, anxiety, and depression, who required substantial to maximal assistance with most activities of daily living. Upon identification of boils and a blister during a skin assessment, staff documented the findings but did not initiate any treatment, complete an incident report, or notify the physician as required by facility policy. The electronic Medication Administration Record (eMAR) showed no treatments in place for the skin issues, and there was no documentation in the progress notes about physician notification or a treatment plan. Multiple staff interviews revealed that nurses and CNAs observed the resident's worsening skin condition, including boils and a popped blister, but assumed that appropriate reporting and documentation had already been completed by others. Staff failed to follow the facility's protocol for new skin issues, which included completing incident reports, notifying the physician and administration, and documenting the findings. The Infection Preventionist and other nursing staff were not aware of the full extent of the resident's skin issues until the condition had significantly worsened. The resident's condition deteriorated, resulting in increased pain, inability to sit, and the presence of blood and drainage from the affected areas. Eventually, the resident was sent to the hospital, where they were diagnosed with scrotal cellulitis and abscesses caused by MRSA. The lack of timely assessment, documentation, and physician notification contributed to the escalation of the resident's skin condition.
Failure to Follow Contact Precautions During Wound Care for MRSA-Positive Resident
Penalty
Summary
Staff failed to follow proper Contact Precautions during wound care for a resident with a history of stroke, anxiety, and depression, who had recently returned from the hospital with abscesses that tested positive for MRSA. Hospital discharge orders specified daily dressing changes and the use of Contact Precautions. During an observed dressing change, the registered nurse did not wear a gown, as required, and only donned gloves. There was no visible signage on the outside of the resident's door indicating Contact Precautions, nor was there a PPE cart available outside the room. The only sign present was inside the room and difficult to see due to poor lighting. When questioned, the nurse acknowledged that a gown should have been worn and attributed the oversight to the lack of visible signage and PPE cart. The infection preventionist confirmed that signage and PPE should have been placed outside the room and that a gown was required for the procedure. The failure to follow established infection control protocols was directly observed and confirmed through staff interviews and record review.
Failure to Provide Bed-Hold Notices to Hospitalized Residents
Penalty
Summary
The facility failed to provide a bed-hold notice to residents or their representatives at the time of discharge or within 24 hours of transfer to the hospital for four sampled residents. This deficiency was identified during interviews and record reviews. Resident 1, who had a history of stroke, anxiety, and depression, was transferred to the hospital due to increased numbness and pain but did not receive a bed-hold notice. Similarly, Resident 3, with Parkinson's Disease and a history of stroke, was transferred for evaluation after exhibiting aggressive behavior, yet no bed-hold notice was documented. Resident 6, also with a history of stroke, anxiety, and depression, was transferred due to confusion and unstable vital signs without receiving a bed-hold notice. Lastly, Resident 7, who had fractures and depression, was sent to the hospital for evaluation due to confusion and lethargy, but no bed-hold notice was provided. Interviews with facility staff revealed a lack of a clear process for providing bed-hold notices. Staff C, an LPN, indicated that the responsibility for giving bed-hold notices lay with the Resident Care Manager or Social Services Director. Staff A, the Director of Nursing, and Staff B, the Resident Care Manager, confirmed that while residents received a bed-hold notice during the admission process, a second notification should be given upon hospital transfer. However, the facility's current practice involved only verbal communication of this information, leading to the deficiency.
Failure to Complete PASARR Evaluations for Residents
Penalty
Summary
The facility failed to ensure that Pre-Admission Screening and Resident Review (PASARR) processes were completed for three residents, leading to a deficiency in care. Resident 1, who had a history of stroke, anxiety, and depression, was admitted with indicators of a serious mental illness requiring a Level II PASARR review. However, there was no documentation in the Electronic Medical Record (EMR) to show that the facility requested this review. During an observation, Resident 1 expressed feelings of anger and had previously hit a staff member, indicating a potential decline in mental health. Resident 3, admitted with a history of stroke, Parkinson's Disease, and a suicide attempt, also required a Level II PASARR review due to indicators of an intellectual disability. The facility failed to document a request for this evaluation. Resident 7, admitted with fractures, a history of stroke, and depression, did not have a PASARR completed prior to admission. The Director of Nursing acknowledged that the process for handling PASARRs was disrupted due to the departure of the Social Services Director, and the issue was not addressed until a new hire was made.
Failure to Re-admit Resident After Hospitalization
Penalty
Summary
The facility failed to consider re-admission for a resident who was hospitalized, which placed the resident at risk for increased anxiety and a diminished quality of life. The resident, who had a history of stroke and Parkinson's Disease, was admitted to the facility with difficulty in making their needs known. An incident occurred where the resident was found at their doorway screaming and swinging a cane at the Director of Nursing (DNS), posing a threat to staff and other residents. The resident then exited the building, and the police and Emergency Medical System (EMS) were called to transfer the resident to the hospital. During the transfer, Staff A informed EMS that the facility could not manage the resident's aggression and would not accept them back. A discharge notice was subsequently sent to the hospital at the time of the resident's discharge. This action was contrary to the facility's policy, which stated that residents should be permitted to return to the facility upon discharge from an acute care setting, unless there is evidence that the resident's status at the time of seeking to return does not allow for re-admission.
Failure to Address Behavioral Health Needs in Residents
Penalty
Summary
The facility failed to ensure that the behavioral health needs of two residents were identified and met, leading to a deficiency in care. Resident 1, who had a history of stroke, anxiety, and depression, was not provided with a PASARR Level II assessment despite indications of a serious mental illness. The resident was on maximum doses of antidepressant and antianxiety medications, yet there were no documented non-medication interventions or person-centered care plans in place. The resident expressed feelings of hopelessness and had thoughts of self-harm, but the facility did not complete a referral for mental health counseling as requested by the provider. Resident 3, admitted with a history of stroke, Parkinson's Disease, and depression, also did not receive a PASARR Level II assessment despite indicators of an intellectual disability. The resident's care plan lacked target behaviors and person-centered interventions, and there was no documentation of an interdisciplinary team assessing the resident's response to stressors or evaluating the effectiveness of the medication regimen. The resident had a history of a suicide attempt and was on psychoactive medication, yet the facility did not provide adequate behavioral or emotional support. Interviews with staff revealed a lack of consistent communication and documentation regarding resident behaviors and interventions. The facility had been without a social worker for six months, which contributed to the lack of coordination in behavioral health services. Staff reported informal meetings to discuss residents, but there was no formal documentation of interdisciplinary team discussions or evaluations of the residents' care plans and medication effectiveness.
Failure to Manage and Document Residents' Personal Belongings
Penalty
Summary
The facility failed to ensure the proper management and documentation of residents' personal belongings, leading to missing items and incomplete records for six sampled residents. The facility's policy required staff to inventory all personal belongings upon admission, update the inventory throughout the resident's stay, and ensure all items were returned to the resident or their representative upon discharge or death. However, the facility did not adhere to this policy, resulting in missing items and incomplete inventory lists. For Resident 1, the facility did not account for personal belongings such as clothing or shoes at any point during their stay, and upon discharge, incorrect items were sent with the resident. Resident 2 reported missing satin nightshirts, and their inventory list lacked photographs of valuables. Resident 3's inventory list was undated, unsigned, and incomplete, with no photographs of valuables. Resident 4 had no inventory list maintained over their seven-year stay. Resident 5's inventory list was outdated and did not reflect their current belongings, and Resident 6's list was undated, unsigned, and lacked photographs of valuables. Interviews with staff revealed a lack of clarity and consistency in the process of updating and maintaining the Personal Belongings Inventory Lists. Staff were unsure who was responsible for updating the lists after admission, and there was no clear procedure for managing additional items brought in during a resident's stay. The facility's failure to maintain accurate and complete records of residents' personal belongings placed residents at risk for loss of personal items and diminished their quality of life.
Failure to Report and Investigate Resident Incidents
Penalty
Summary
The facility failed to implement its Abuse and Neglect Prohibition Policies and Procedures, specifically in reporting and investigating incidents involving a resident. One incident involved a resident-to-resident altercation where a resident with severe cognitive impairment and requiring assistance in mobilization was involved in a verbal and physical altercation with another resident. The facility did not report this altercation to the state agency (SA) nor did it conduct a thorough investigation to prevent recurrence and rule out abuse or neglect. The Director of Nursing confirmed the lack of reporting and investigation, stating that the facility was likely unaware of the incident. Another incident involved the elopement of the same resident, who was found outside the facility in a wheelchair without supervision. The facility logged the elopement event but failed to conduct a thorough investigation or report it to the SA Hotline as required by the facility's policies and the October 2015 Nursing Home Guidelines. The Director of Nursing acknowledged the incomplete investigation and the failure to report the elopement, admitting that the facility did not adhere to its abuse and neglect policies and procedures.
Inadequate Discharge Planning and Communication
Penalty
Summary
The facility failed to provide and document sufficient preparation or orientation for a safe discharge for one resident, which placed the resident at risk for unmet care needs and a diminished quality of life. The facility's policy required a Discharge Summary to be completed for anticipated or resident-initiated discharges, including a description of the resident's stay, diagnoses, treatment, and a final summary of the resident's status. However, when the resident was discharged to a community provider, the facility did not send the resident's medical file, leaving the receiving provider without crucial information about the resident's condition. The resident experienced a change in condition and was transferred to the hospital, where they were diagnosed with a stroke and a urinary tract infection (UTI). Upon readmission to the facility, the resident was evaluated and recommended for discharge to a community setting. However, the Transfer/Discharge Report provided to the community provider was incomplete, lacking relevant information such as behaviors, mobility status, and a post-discharge plan of care. The facility did not communicate the resident's clinical background or needs to the receiving provider, resulting in inadequate preparation for the resident's transition. The community provider and a State Agency (SA) were not adequately informed about the resident's status or discharge plan. The resident was readmitted to the hospital from the community setting with sepsis secondary to a UTI, obstructing kidney stone, and possible pneumonia. Interviews with facility staff revealed that they did not send all necessary documentation or communicate the resident's follow-up needs to the community provider, acknowledging the failure to ensure a safe and orderly discharge process.
Failure to Implement Urology Recommendations for Kidney Stone Prevention
Penalty
Summary
The facility failed to implement recommendations from a urology clinic to prevent kidney stones for a resident with a history of UTIs, kidney stones, and chronic kidney disease. The resident was readmitted to the facility and had been seen by a urology provider who removed a stent and recommended specific dietary and hydration measures to prevent kidney stones. These recommendations included drinking 8-10 cups of water daily, limiting sodium intake to less than 2,300 mg per day, consuming an appropriate amount of dietary calcium, and including citrus fruits in the diet. Despite these recommendations, the facility's nutrition care plan for the resident did not include instructions to limit high oxalate and sodium-rich foods or to include citrus fruits in the diet. Additionally, there were no specific interventions to ensure the resident drank the recommended amount of water daily. The facility only implemented a No Added Salt diet six months after the initial recommendation. The Director of Nursing acknowledged that the staff did not implement the urology clinic's recommendations, indicating a lapse in following through with the necessary care plan adjustments.
Failure to Ensure Adequate Hydration for a Resident
Penalty
Summary
The facility failed to ensure adequate hydration for a resident, leading to a deficiency in care. The resident, who had severe cognitive impairment and was independent with eating, was admitted with medically complex conditions. A urology visit recommended the resident drink 8-10 cups of water daily, equivalent to 1,920 to 2,400 cc, to maintain proper hydration. However, a nutrition assessment determined the resident required 1,800 cc of fluids daily. Despite these recommendations, the facility's Medication Administration Record (MAR) showed an order to encourage fluids, but there was no documentation that staff provided the necessary fluids. Fluid intake records revealed that for September and October, the resident's fluid intake was documented as below 1,000 cc for most days. This lack of adequate fluid intake documentation was confirmed by the Director of Nursing, who stated that fluid intake should be monitored to ensure residents meet hydration goals. The deficiency was highlighted when a collateral contact reported that insufficient hydration led to the resident's hospitalization with a urinary tract infection (UTI). The facility's failure to monitor and provide the required fluids placed the resident at risk for dehydration and related health issues.
Deficiencies in Oxygen Management and Equipment Maintenance
Penalty
Summary
The facility failed to ensure that residents had current and complete oxygen orders and that oxygen equipment was maintained in a clean manner. Resident 3, who had dementia and chronic respiratory failure, had an oxygen order that did not specify the liter flow, and observations showed inconsistent oxygen settings. The oxygen concentrator's filter was dusty, indicating a lack of maintenance. Similarly, Resident 11, with quadriplegia, had no current oxygen order during the survey period, yet was observed using oxygen. The tubing was not labeled with a change date, and the concentrator's filter was also dirty. Resident 17, diagnosed with chronic respiratory failure and COPD, used supplemental oxygen, but their care plan and provider's orders lacked instructions for maintaining or cleaning the oxygen filters. Observations revealed that the concentrator's filters were covered with thick dust. Staff interviews indicated that an outside company performed maintenance bi-monthly, but nursing staff were responsible for checking and cleaning filters as needed. However, this was not consistently done. Resident 28, with heart failure and lung disease, had a continuous oxygen order but no instructions for changing the tubing. The resident complained about the tubing's condition, and observations confirmed the tubing was hard and undated. The concentrator filter was also heavily dusted. Staff interviews revealed a lack of documentation and adherence to the facility's policy for changing oxygen tubing weekly. These deficiencies placed residents at risk for respiratory complications and infection.
Failure to Serve Meals at Appropriate Temperatures
Penalty
Summary
The facility failed to ensure that meals were served to residents at appropriate and appetizing temperatures, which could potentially decrease the quality of life for all residents. During a lunch meal service, it was observed that periodic checks of the food temperatures on the steam table were not conducted. Staff CC, a cook, was seen heating soup in a microwave and initially checked the temperature, but did not recheck it after additional heating before serving. This indicates a lapse in ensuring that food was served at the correct temperature. Further observations revealed that 63 minutes after the initial temperature check by Staff CC, a surveyor measured the temperatures of a sample tray. The recorded temperatures were significantly below the required standards: LoMein Noodles at 120°F, Mixed Vegetables at 110°F, Orange Chicken at 80°F, Cranberry juice at 56°F, Milk at 46°F, and Tuxedo cake at 50°F. These temperatures did not meet the requirements that hot food must be 140°F or greater and cold foods must be 41°F or less when served, as per the Washington State Department of Health guidelines.
Failure to Obtain Timely Informed Consent for Psychotropic Medications
Penalty
Summary
The facility failed to ensure that a resident was fully informed about the potential risks and benefits associated with the use of psychotropic medications. Resident 25, who had a diagnosis of hallucinations, was prescribed Trazodone for depression and Seroquel for hallucinations. The medications were administered starting on November 24, 2023, and November 25, 2023, respectively. However, the informed consent forms for these medications were signed by the resident on November 28, 2023, which was three to four days after the medications were first administered. The review of Resident 25's records did not show any documentation that education regarding the psychotropic medications, including the reasons for their prescription, the risks, or the expected benefits, had been provided to the resident prior to the administration of the medications. Interviews with the Resident Care Manager and the Director of Nursing confirmed that informed consents for psychotropic medications should be obtained before the first dose is given to ensure residents are aware of the side effects and risks associated with the medications.
Failure to Maintain Clean Wheelchair for Resident
Penalty
Summary
The facility failed to provide a clean, comfortable, and homelike environment for a resident diagnosed with Alzheimer's disease, who was moderately cognitively impaired and required assistance for activities of daily living. The resident was observed multiple times in an unclean wheelchair with food smeared on the sides and foot pedals. Despite the facility's protocol for cleaning wheelchairs weekly and as needed, the resident's wheelchair remained unclean over several days. Staff interviews confirmed the expectation to keep wheelchairs clean and acknowledged the unclean state of the resident's wheelchair.
Incomplete Discharge Summary for Resident with Suicidal Thoughts
Penalty
Summary
The facility failed to complete a discharge summary, including a recapitulation of the resident's stay, for a resident who was reviewed for discharge. The resident, who was cognitively intact and required moderate to maximum assistance with activities of daily living, was admitted on 12/30/2023 and had received physical therapy for four days. A discharge assessment indicated the resident was expected to return to the facility. However, the discharge summary completed by a Physician Assistant on 03/19/2024 only documented the resident's discharge to the hospital due to suicidal thoughts, without providing a detailed recapitulation of the care and services received at the facility. The resident had expressed suicidal thoughts to staff, including a specific incident on 03/16/2024 where they mentioned looking for plastic bags to suffocate themselves. This prompted an assessment for depression and the implementation of safety interventions, including increased supervision. Despite these measures, the resident continued to express suicidal thoughts over the following days, leading to their transfer to the hospital for evaluation on 03/19/2024. The Director of Nursing confirmed that a recapitulation of stay/discharge summary is required when a resident discharges from the facility, which was not completed in this case.
Failure to Implement Bowel Management Protocol
Penalty
Summary
The facility failed to implement its bowel management protocol for three residents, leading to a deficiency in care. The facility's policy required nursing staff to administer specific laxatives on consecutive days without a bowel movement (BM), and to notify the provider if no BM occurred by the sixth day. However, for Resident 2, the bowel management protocol was not followed, as documented in their medication administration record (MAR). Despite having no BMs for several days on multiple occasions, the necessary bowel medications were not administered, nor was there documentation of the medications being offered or refused. Similarly, Resident 18's care plan required adherence to the bowel protocol, but the MAR showed that bowel medications were not administered as needed. Resident 18 experienced multiple periods of three to five days without a BM, yet the protocol was not followed, and there was no documentation of medication administration or refusal. Interviews with staff confirmed that the bowel protocol was not adhered to, and the Director of Nursing acknowledged the importance of following the protocol as it was a medical order. Resident 193 also experienced a lapse in bowel management, with only one small BM recorded over four days. The MAR indicated that the bowel protocol was not followed during this period. Staff interviews revealed that the protocol was supposed to be monitored and followed up on by different shifts, but this did not occur. The Director of Nursing confirmed that the protocol was developed by the facility's medical director and emphasized the necessity of following it to prevent medication errors and potential complications.
Failure to Conduct Nutritional Assessment for At-Risk Resident
Penalty
Summary
The facility failed to document a detailed nutritional assessment at the time of admission for a resident identified as being at risk for compromised nutritional status. This oversight was observed through a review of the facility's undated nutritional management policy, which mandates a comprehensive nutritional assessment upon admission. The policy states that the dietitian should use the data from this assessment to estimate the resident's calorie, nutrient, and fluid needs. However, for Resident 10, who was admitted with a new right above-knee amputation and other health conditions such as malnutrition, diabetes, and obesity, no such assessment was completed by the Dietetic Technician or the Registered Dietitian. Interviews with facility staff revealed that the initial dietary preferences were assessed by the admission nurse or resident care manager and communicated to the kitchen. The Dietetic Technician stated that the nutritional assessment should be completed within seven days of admission, with the Registered Dietitian reviewing it weekly. Despite these procedures, the nutritional assessment for Resident 10 was missed, as acknowledged by the Dietetic Technician. This lapse in protocol resulted in a potential risk of impaired nutrition and other health complications for the resident.
Failure to Accurately Reconcile Controlled Medications
Penalty
Summary
The facility failed to accurately reconcile controlled medications in one of the two medication carts reviewed for medication storage. During an inspection of the narcotic drawer on Cart One, a bottle of narcotic pain pills labeled for a current resident was found with the cap wrapped in clear plastic tape, marked with the number 56. Staff D, an RN, indicated that the medication was from the resident's home supply and that the number 56 was used to detect any tampering. Staff D admitted to relying on the number written on the tape rather than counting the pills during shift changes. Later, Staff B, the Director of Nursing, confirmed the presence of the tape and counted the pills, finding 56 pills, which matched the narcotic log. Staff B acknowledged that nurses should have been counting the pills at every shift change.
Failure to Address Pharmacist's Recommendations for Medication Administration
Penalty
Summary
The facility failed to address recommendations from the pharmacist regarding the administration of Melatonin for one resident. The Consultant Pharmacy Report recommended that the Melatonin be administered 60 to 90 minutes before the resident's bedtime. However, the medication administration records for April and May 2024 showed that the medication was given at bedtime, between 7:00 PM and 10:53 PM, without any documented response from the provider or nursing staff to the pharmacist's recommendation. Interviews with staff confirmed that the resident typically went to bed between six to seven o'clock, and the Director of Nursing acknowledged that the recommendation should have been followed up on.
Deficiencies in Dietary Staff Qualifications and Dining Room Assistance
Penalty
Summary
The facility failed to ensure that dietary staff had the required qualifications, specifically current Food Worker Cards, for two dietary staff members. Staff W, a dietary aide, did not have a Washington State Food Workers card prior to a specified date, and Staff X, a prep staff member, did not have a current card at all. Observations confirmed that both staff members were involved in food preparation and serving without the necessary qualifications. The dietary manager acknowledged the lack of compliance with the requirement for all kitchen staff to have a valid Food Workers card, which poses a potential risk for unsafe food handling practices. Additionally, the facility did not provide adequate staffing in the dining room during meal times, resulting in delayed assistance for residents. Resident 15 was left without assistance for 41 minutes after being brought into the dining room, and their meal was served at an unappetizing temperature. Similarly, Resident 17's meal was left unattended for 19 minutes before assistance was provided. The Director of Nursing acknowledged that insufficient staffing could lead to cold food and an unpleasant dining experience, affecting the residents' dignity and quality of life.
Improper Food Labeling and Temperature Monitoring in Refrigerators
Penalty
Summary
The facility failed to ensure proper labeling, dating, and monitoring of food items in the snack/nourishment refrigerators, which posed a potential risk of foodborne illness for all residents. During an observation, it was found that the refrigerator on the Transitional Care Unit contained an open apple and grape juice container without an opened date, a foil-covered container labeled with a name and room number but not dated, an open half-full gallon jug of Kikkoman soy sauce with a date but no year, and sugar-free coffee creamer with an expired date. Additionally, the temperature logs for March, April, and May were incomplete, with only a few readings recorded, and no temperature log was present for June. Staff O, a Nursing Assistant, was present during the observation and removed the undated and expired food from the refrigerator. Interviews with staff revealed inconsistencies in the responsibility for monitoring the snack/nourishment refrigerators. Staff O stated that whoever placed items in the refrigerator was supposed to label and date them, and the kitchen was responsible for checking expired and old food. Staff E, an LPN, mentioned that the night shift was responsible for checking the temperatures, while Staff DD, a Dietary Aide, stated that the kitchen staff was supposed to monitor the temperatures when checking or filling the refrigerators. However, Staff DD admitted that this was not done daily, and they were unaware of the missing temperature logs for June and the incomplete logs for May.
Infection Control Deficiencies in Meal Service and Medication Administration
Penalty
Summary
The facility failed to ensure proper infection prevention and control practices during meal service and medication administration. Observations revealed that staff did not perform hand hygiene or wear gloves when handling food and feeding residents. For instance, a nursing assistant fed a resident a sandwich and handled a straw without gloves or hand hygiene. Additionally, a dietary aide was observed handling trash and then serving food without washing hands or changing gloves. These actions were contrary to the facility's hand hygiene policy and CDC guidelines, which emphasize the importance of hand hygiene in preventing the spread of infections. Another deficiency was noted in the maintenance of a resident's personal hygiene. A resident was repeatedly observed with brown matter under their nails during meal times, and their nails were not cleaned before or after meals. This lack of personal hygiene maintenance was acknowledged by the Director of Nursing, who stated that nail care was important to prevent infection. The failure to maintain the resident's nails in a sanitary manner posed a risk of infection and diminished the quality of life for the resident. Furthermore, the facility failed to cleanse a resident's skin prior to administering an injectable medication. A registered nurse administered insulin to a resident without cleaning the injection site with alcohol, citing the resident's preference to avoid alcohol due to a burning sensation. However, the resident later stated they had no such preference, and the nurse acknowledged the importance of cleaning the site to prevent infection. The Infection Preventionist confirmed that not using an alcohol wipe could lead to an infection at the injection site.
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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