Clarkston Health And Rehab Of Cascadia
Inspection history, citations, penalties and survey trends for this long-term care facility in Clarkston, Washington.
- Location
- 1242 Eleventh Street, Clarkston, Washington 99403
- CMS Provider Number
- 505283
- Inspections on file
- 38
- Latest survey
- August 18, 2025
- Citations (last 12 mo.)
- 24
Citation history
Health deficiencies cited at Clarkston Health And Rehab Of Cascadia during CMS and state inspections, most recent first.
Surveyors found that survey results were posted in a binder on a wall in the main lobby, an area accessed only by using an elevator code and not routinely frequented by residents. Resident Council members reported that the lobby was locked and that residents needed staff assistance to reach it, and only one of sixteen residents knew where the survey results were posted. Staff, including a CNA, an RN, the Resident Care Manager, the DON, and the Administrator, confirmed that residents could move freely only between resident floors, that a code was required to access the lobby, and that residents typically did not go there unless they had an appointment. Staff acknowledged that residents have the right to see survey inspection results and that residents should be able to access them without having to ask staff.
The facility failed to maintain safe and palatable food temperatures, as multiple cognitively intact residents repeatedly reported receiving cold or lukewarm meals, including cold eggs, biscuits and gravy, and waffles. During a sampled lunch meal, surveyors measured hot foods such as mashed potatoes and carrots at temperatures below the recommended 140°F hot-holding standard. Resident council minutes over several months documented ongoing complaints about cold food, and the council confirmed that meals were typically lukewarm despite one recent instance of hot eggs. The Dietary Manager acknowledged the importance of serving food at appropriate temperatures to prevent foodborne illness.
Surveyors found multiple expired and undated food items in dry storage and in several refrigerators, including moldy produce, undated pies, waffles, French toast, sandwiches, fruit cups, and resident-specific items such as huckleberries and a chef salad, as well as an opened nutritional drink kept beyond its stated discard timeframe. During a lunch meal service, cold items such as milk, desserts, cheese sandwiches, and salads were held and in some cases served above recommended 40°F cold-holding temperatures, while a pureed soup was below the recommended 140°F hot-holding temperature. Staff acknowledged that food should be dated on receipt, expired items discarded, and hot and cold foods maintained at proper temperatures, and that hand hygiene and environmental cleanliness were required, but the observed practices did not meet these standards.
The facility did not ensure accurate PASARR Level I screenings or timely Level II referrals for three residents with indicators of serious mental illness. One resident with anxiety, depression, nightmare disorder, PTSD, and severe cognitive impairment had a PASARR showing serious mental illness indicators but was documented as not needing Level II, with no subsequent correction or referral. Another resident with depression, dementia, and severe cognitive impairment also had a PASARR indicating serious mental illness but was marked as not requiring Level II, and no follow-up was documented. A third cognitively intact resident with anxiety, depression, bipolar disorder, suicidal ideations, and PTSD was admitted under an exempted hospital stay with a PASARR indicating serious mental illness and requiring a Level II if discharge did not occur within the expected short stay, yet no Level II referral was made after the resident remained beyond that period. Interviews with the SSD, DON, and Administrator revealed unawareness and misinterpretation of updated PASARR guidance and timing requirements.
Surveyors found that the facility did not consistently update or individualize care plans and did not ensure resident participation in care planning. One resident’s care plan continued to list FULL CODE despite a POLST indicating DNR. Another resident’s care plan still called for a ROM restorative program even though restorative services had been discontinued, as documented in restorative notes. A resident who was dependent on staff for denture care had dentures left soaking in water with no care plan directions for denture care. Two residents at risk for pressure ulcers had air mattresses ordered and care planned, but there were no documented mattress settings in the care plans or TAR to guide staff. A cognitively intact resident reported never being invited to a care conference, and the record lacked required care conference documentation despite completed quarterly assessments, with staff acknowledging that expected quarterly care conferences had not occurred or were not properly documented.
Surveyors found that the facility failed to follow physician orders and internal protocols for wound care, seizure medication dosing, and constipation management. One resident with cognitive impairment had multiple arm dressings applied and changed over time without any corresponding physician orders, documentation, or care plan entries, despite staff describing the areas as skin tears. Another resident with a seizure disorder had a neurologist-ordered dose reduction of Fycompa documented, but nursing staff continued to administer the higher dose for several days while signing the MAR as if the lower dose had been given. Two residents with bowel function care plans and standing bowel protocols experienced multiple multi-day periods without bowel movements, yet ordered PRN laxatives, suppositories, and enemas were not administered and no reasons for these omissions were documented, even though staff described a protocol for escalating bowel interventions after several days without a BM.
The facility failed to ensure multiple NARs obtained NAC certification within 120 days of hire and lacked required documentation to permit continued work beyond that period. Several aides were hired and credentialed as NARs but either had not completed NAC training and testing within the required timeframe or had done so out of state without the necessary Washington documentation, including NAC program completion records and NAR certification application attestation forms. Payroll records showed these aides continued to work after the 120-day limit without the mandated paperwork, while interviews with HR and the administrator revealed unawareness of the attestation form requirement and an incorrect belief that the facility was in compliance.
Surveyors found that the facility did not maintain complete, accurate, and readily accessible medical records for several residents. One resident had no documented participation in care conferences in the EMR and lacked dental visit summaries, while another had a psychosocial history form without any resident identifier. A resident with seizure disorder had a note about high medication blood levels and a dose change but no corresponding lab results or evidence of efforts to obtain them. A cognitively intact resident who smoked had no smoking assessment in the EMR, and another resident with a significant fall and ED transfer had no care conference or updated fall interventions documented in the record. In addition, a resident transferred to the hospital for GI symptoms had no documented bed hold offer in the EMR, even though a paper bed hold agreement existed separately.
A resident with a history of stroke, right-sided hemiplegia, and moderately impaired cognition was observed with extensive bruising and dressings on both arms. The resident reported that aides on night shift had been rough during incontinence care and had pulled on their arm, describing this as abuse. A CNA noticed the large bruise and skin tears and acknowledged recognizing the resident’s statements as an allegation of physical abuse, stating they informed an RN. The RN later reported being unaware of the allegation until days afterward. Review of records showed no documentation that the facility identified or questioned the unexplained large bruise or reported the staff rough-handling allegation to the Administrator, DON, or State Agency within required timeframes, contrary to the facility’s abuse reporting policy.
A resident with anemia and gastritis who was cognitively intact reported abdominal pain consistent with prior GI bleeding and was sent to the hospital after the provider was notified. Staff reported that their usual process was to send a face sheet, POLST, medication list, recent clinical information, and to call the hospital with a report, documenting this in a progress note. For this transfer, however, the record contained no documentation of what information was actually conveyed to the hospital, and leadership acknowledged they could not identify any such documentation, resulting in a failure to ensure required transfer information was communicated.
A resident with respiratory failure, who was cognitively intact and identified as a smoker, did not have a comprehensive, person-centered care plan addressing their current smoking behavior, despite facility policy requiring such plans. The existing substance use disorder care plan only covered alcohol and nicotine dependence in general terms and lacked smoking-specific goals and interventions. Surveyors observed the resident smoking in the designated area on multiple occasions, and staff, including a CNA, an LPN, and the DON, confirmed that residents cleared to smoke should have this documented in their care plan, but acknowledged that no smoking care plan existed for this resident.
The facility failed to follow its restorative nursing policy for two residents with hemiplegia and significant ROM limitations by not consistently implementing, monitoring, or documenting splint/brace programs and resident refusals. For one resident, the RNP with hand and leg orthotics was discontinued after repeated refusals, but there was no documentation of reassessment, reasons for refusal, involvement of the resident’s representative, or discussion of risks, benefits, or alternatives, and therapy was not notified for re-evaluation. For another resident, orders for a right arm brace and a hand carrot device specified daily wear times, but the Treatment Administration Record did not show actual tolerance durations, and there was no documented evaluation of the effectiveness of these devices or clear identification of the RNP in the care plan.
A resident with BPH, obstructive uropathy, and a history of UTIs required an indwelling urinary catheter, yet surveyors repeatedly observed the catheter bag and tubing resting on the floor while the resident sat in a wheelchair. The resident’s care plan did not direct staff to keep the catheter bag and tubing off the floor, despite staff, including a CNA, an RN, and the DON, stating that catheter bags were to be hung under or on the side of wheelchairs and that keeping bags and tubing off the floor was important to prevent contamination and infection.
A resident with severe cognitive impairment, neuropathy, and diabetes did not receive ordered pregabalin and Humalog insulin as prescribed. MAR review showed pregabalin doses marked as not available on multiple occasions and missing or incomplete documentation for insulin doses and blood glucose checks. Nursing staff and leadership reported that nurses were expected to reorder medications when low, check the Cubex, notify the provider and pharmacy, and document blood sugars and insulin administration or refusals. A review of the Cubex confirmed that both pregabalin and Humalog insulin were available at the time the doses were omitted.
A resident with no natural teeth and medically complex conditions received new upper and lower dentures that were repeatedly described as too thick, ill-fitting, and uncomfortable, leading the resident to stop wearing them. The care plan required staff to coordinate dental care and transportation, and progress notes documented gum inflammation, an oral sore, pain, and ongoing refusal to wear the dentures. However, the record lacked documentation of the outcome of a key follow-up visit, any efforts to obtain an earlier appointment when problems persisted, or coordination of a later scheduled follow-up with the denturist, while the dentures remained unused in a denture cup and the resident continued to receive foods they reported difficulty chewing.
Surveyors found that staff failed to follow infection prevention practices, including Enhanced Barrier Precautions (EBP) and hand hygiene, for multiple residents with PICC lines and chronic wounds. One resident with a diabetic foot ulcer, wound vac, and PICC had documented EBP orders, yet staff routinely performed PICC access and wound vac care wearing only gloves, with no gowns, and the room lacked clear EBP signage and readily available PPE. Another resident with a PICC for recurrent bladder infections received IV therapy and PICC dressing changes without EBP being ordered or care planned, and staff again used gloves and masks but not gowns, with no consistent visual cue or accessible PPE. During medication passes, two RNs failed to perform hand hygiene before donning gloves, between residents, and after touching environmental surfaces, and one RN used the same pair of gloves for multiple tasks in a room, including handling IV equipment, adjusting the environment, picking up an item from the floor, and administering medications.
Two residents with indwelling urinary catheters did not receive proper monitoring and documentation of urinary output as required by physician orders and care plans. Staff frequently missed recording output, and low output readings were not followed by nursing assessments or provider notifications. One resident experienced a distended abdomen and leaking catheter that was not addressed until the following day, resulting in hospitalization for a UTI. Staff interviews revealed inconsistent documentation and confusion about monitoring requirements, particularly among agency staff.
A resident received more hydrocodone-acetaminophen than prescribed, exceeding the limit of four tablets in 24 hours on multiple occasions. Staff interviews revealed a lack of awareness and adherence to medication parameters, with the LPN not following restrictions and the Resident Care Manager unaware of specific instructions. Pharmacy audits were requested but not provided, indicating oversight lapses.
A resident reported receiving incorrect medication from an LPN, which was not effectively managing their pain. The resident showed the pills to an RN, who confirmed the issue and reported it to the ADON. The ADON informed the DON, who failed to document the investigation and did not report the allegation to the State Agency, as the abuse claim was not substantiated.
A resident with moderate cognitive impairment experienced significant health changes, including weight loss and dental issues, over five months without the facility informing their RR. The lack of communication prevented the RR from participating in care decisions, as acknowledged by the DON.
A resident with an impacted wisdom tooth and abscess experienced inadequate dental care and pain management at an LTC facility. Despite repeated complaints of pain and requests for dental services, the facility delayed in scheduling a dental appointment and providing effective pain relief. The resident's condition worsened, leading to a hospital transfer where a large erosive mass was identified. The facility's failure to address the resident's dental needs and pain management in a timely manner contributed to the resident's diminished quality of life.
Survey Results Not Readily Accessible to Residents Due to Restricted Lobby Access
Penalty
Summary
The deficiency involves the facility’s failure to post survey results in a location that was readily accessible and frequently used by most residents, as required by WAC 388-97-0480. During an observation in the early morning, surveyors noted that the main lobby was a small foyer with a reception desk, seating, and access to an elevator and stairways. The binder containing survey results was posted on the wall at the base of the stairs leading to the second floor, within the lobby area. However, access to this lobby required use of an elevator code. A keypad with a written numeric code was mounted at eye level in the elevator, along with a sign instructing that the lobby code should not be entered for residents without staff knowledge or supervision. In multiple interviews, residents and staff confirmed that residents did not typically frequent the lobby and that residents could move freely only between the first and second floors, not into the lobby without entering the elevator code. Members of the Resident Council reported that the lobby was locked due to the elevator code requirement and that residents would need staff assistance to access the lobby; only one of sixteen residents knew survey results were posted there. Staff, including a nursing assistant, an RN, the Resident Care Manager, the DON, and the Administrator, acknowledged that a code was required to reach the lobby and that this was intended as a safety measure to prevent confused or wandering residents from exiting the building. Staff also acknowledged that residents generally did not see or use the elevator code, that residents typically did not go to the lobby unless they had an appointment, and that residents should be able to access survey results without having to ask staff. The report states that this failure placed residents at risk of being unable to exercise their resident rights.
Failure to Maintain Safe and Palatable Food Temperatures
Penalty
Summary
The facility failed to ensure meals were served at palatable, safe, and appetizing temperatures, as required by WAC 388-97-1100(1)(2). Surveyors observed and interviewed two cognitively intact residents who consistently reported receiving cold food. One resident with a history of stroke, malnutrition, and depression stated on multiple occasions that their food was always cold, that it was a wonder when they received hot food, and specifically reported cold eggs and cold biscuits and gravy that had to be sent back. Another resident with heart failure, hypertension, and diabetes reported that while the food usually tasted good, it was cold, and specifically identified cold eggs and a cold waffle at breakfast. During a sampled lunch meal, surveyors measured food temperatures and found the mashed potatoes at 118°F and carrots at 126°F, which were outside the recommended hot-holding temperature of 140°F or above. Review of resident council minutes from three consecutive months showed repeated concerns about cold food during meals, and during an interview the resident council confirmed that cold food remained an ongoing issue, describing the food as typically lukewarm and noting that on one day the eggs were hot for the first time. The Dietary Manager acknowledged in an interview that it was important to serve food at appropriate temperatures to prevent foodborne illnesses.
Improper Food Storage, Dating, and Temperature Control During Meal Service
Penalty
Summary
The deficiency involves failure to store, label, date, and discard food in accordance with professional standards, as well as failure to maintain appropriate food temperatures and hand hygiene practices. Surveyors observed in the dry storage area a container of Frank's red-hot sauce that had expired, and in the large walk-in refrigerator multiple expired boxes of Thick and Easy thickening powder, apples with brown mold, and several bags of wilted, wet, and brown salad greens. Additional refrigerators contained undated lemon cream and apple pies, salad mix past its use-by date, waffles and French toast with no dates, and in a dining room refrigerator, undated sandwiches, fruit cups, a bag of huckleberries for a specific resident, and a chef salad for another resident. Another dining room refrigerator contained an opened container of Med Plus 2.0 nutritional drink that had been open beyond the seven-day discard timeframe, and a frozen chocolate milkshake with no date or name, despite staff stating the refrigerator was for residents. Staff interviews confirmed that food items were expected to be dated upon receipt and that dating and discarding expired food were recognized as important to prevent foodborne illness. The deficiency also includes failure to maintain required hot and cold holding temperatures during meal service and lapses in hand hygiene and environmental cleanliness. During a lunch meal observation, cold items such as milk and cookie dessert were measured above the recommended 40°F, and pureed corn chowder soup was below the recommended 140°F for hot foods. Later checks showed cheese sandwiches and chef salads held at temperatures above 40°F, and staff initially placed these items on trays for service until questioned about required temperatures, at which point some items were removed. A chef salad was ultimately served to a resident even though repeated temperature checks showed it remained above the recommended cold-holding temperature. Staff interviews indicated awareness that food should be heated, held, and maintained at appropriate temperatures, that hand hygiene and glove changes were required when gloves became soiled or after touching hair or face, and that refrigerators and kitchen floors needed to be kept clean for sanitization, yet the observed practices did not align with these stated standards.
Failure to Complete Accurate PASARR Level I Screenings and Required Level II Evaluations
Penalty
Summary
The facility failed to ensure that Pre-admission Screening and Resident Review (PASARR) Level I screenings were accurately completed and that required Level II evaluations were initiated for multiple residents with indicators of serious mental illness. Facility policy required a PASARR screening prior to admission, with a positive Level I screen triggering a Level II evaluation before admission, and mandated that individuals admitted under an exempted hospital discharge receive a Level II review within 40 days if they remained in the facility beyond 30 days. Surveyors found that these requirements were not followed for three of seven sampled residents reviewed for PASARR. One resident admitted with diagnoses including anxiety, depression, nightmare disorder, and PTSD had severe cognitive impairment and a PASARR dated 05/20/2025 that showed indicators of a serious mental illness. Despite these indicators, the PASARR documented that no Level II evaluation was indicated, and there was no evidence in social service progress notes from May through August 2025 that the Level I PASARR was corrected or that a Level II referral was made. Another resident with depression and dementia, also assessed as having severe cognitive impairment, had an 08/22/2024 PASARR that showed indicators of a serious mental illness but was likewise marked as not requiring a Level II evaluation. Social service notes from May through August 2025 contained no documentation that this resident’s PASARR Level I was redone or referred for Level II as required. A third resident admitted with anxiety, depression, bipolar disorder, suicidal ideations, and PTSD was cognitively intact and had a PASARR dated 06/17/2025 that showed indicators of a serious mental illness. This PASARR identified the resident as an exempted hospital stay expected to require fewer than 30 days of nursing facility services and specified that a Level II must be completed if the scheduled discharge did not occur. Review of social service notes from June through August 2025 showed no documentation that the PASARR Level I was redone or that a Level II evaluation was requested after the resident remained in the facility beyond the anticipated 30-day period. During interviews, the Social Service Director acknowledged being unaware of PASARR guidance changes and misinterpreted the timing requirements for redoing or referring PASARRs for Level II evaluations, and the Administrator and DON stated their expectation that PASARR Level I screenings be accurate and that Level II referrals be made when indicated.
Failure to Update Care Plans and Involve Resident in Care Planning
Penalty
Summary
The deficiency involves the facility’s failure to timely develop, review, and revise comprehensive care plans and to ensure resident participation in care planning. For one resident with a history of stroke and right-sided hemiplegia, a POLST dated 08/03/2022 documented a choice of Do Not Attempt Resuscitation/Allow Natural Death, while the care plan dated 08/05/2022 continued to direct staff to honor a FULL CODE status. The DON acknowledged that the care plan was not updated to reflect the resident’s POLST choice. This discrepancy showed that the resident’s advanced directive preferences were not accurately incorporated into the care plan. The facility also failed to update care plans to reflect changes in restorative nursing programs and specific care needs. One resident with cognitive impairment and limited ROM had restorative nurse notes on multiple dates in 2025 stating the resident was not currently working with restorative and was instead working with therapy, and that the restorative program had been resolved on 01/06/2025. However, the resident’s care plan from 03/22/2022 still indicated a need for a ROM program related to physical weakness and risk for contractures and directed staff to review the restorative program routinely, which the restorative nurse acknowledged should have been updated. Another resident, cognitively intact and dependent on staff for denture care, had dentures observed soaking in water with a transparent film, and reported the dentures had been sitting in the water for a long time and that staff “just soak them in water.” The care plan contained no recognition of the presence of dentures or their related care, despite staff interviews confirming the resident owned dentures and that denture care should be reflected in the care plan or task lists. The facility further failed to include specific instructions for specialty mattress settings in the care plans or medical records for two residents at risk for pressure ulcers. One resident, at risk for pressure ulcers and using a pressure-reducing device for the bed, complained of feeling like they were sitting on “two cinder blocks,” reported soreness over the left buttock, and was observed with an air mattress pump set to “Firm” rather than normal pressure. The care plan only stated “Air mattress to bed” and the record contained no instructions on the pump setting needed for pressure ulcer prevention and comfort. Another resident, with dementia, weakness, and multiple medical conditions, had an order and care plan for a bariatric bed with an air mattress to allow more room for bed mobility and prevent skin impairments, but neither the order summary nor the care plan specified mattress settings. A registered nurse confirmed that information on specialty mattress settings should be in the care plan or TAR and that the records for both residents lacked this information. Additionally, the facility did not ensure that a cognitively intact resident was offered the opportunity to participate in care planning or that required care conferences occurred and were properly documented. This resident reported not being invited to a care conference. The medical record showed quarterly assessments had been completed, but there were no care conference notes for the period reviewed. The resident care manager stated that care conferences were to be held shortly after admission and quarterly thereafter, with residents and families invited, and that these were documented under evaluations. The social service director identified a psychological evaluation form as the initial care conference and stated a subsequent conference was completed in May instead of April, but the progress note did not address required care conference elements such as the care plan, medications, or activities of daily living. The social service director also stated the resident was due for a care conference in July and was unsure why it did not occur, and confirmed the resident was not scheduled for a care conference in August. The DON stated that care conferences required an interdisciplinary team and were important for communication about medications, code status, therapy, and goals of care, and acknowledged that the resident should have had care conferences in April and July.
Failure to Follow Wound, Medication, and Constipation Protocols
Penalty
Summary
The deficiency involves the facility’s failure to provide treatment and care according to physician orders and established protocols, as well as failure to document and care plan skin conditions. For one resident with a history of stroke and moderate cognitive impairment, surveyors observed multiple dressings on both upper arms on several dates, some undated, blood-stained, dry, or partially detached. Review of the medical record from early July through mid-August showed no physician orders for these arm dressings, no documentation of when or why the dressings were initiated, and no monitoring notes. Skin inspection progress notes repeatedly documented “No new skin issues,” and the resident’s care plan contained no acknowledgment of impaired skin integrity to the arms, despite a nursing assistant stating the dressings covered skin tears and a nurse confirming the resident required dressing changes to arms and shins. Another deficiency involved medication administration and documentation for a resident with a seizure disorder and severely impaired cognition. The resident had been receiving Fycompa 12 mg nightly for an extended period. A progress note documented that the neurologist’s office reported the Fycompa level was too high and requested a dose decrease from 12 mg to 8 mg at bedtime. The MAR was changed to reflect an 8 mg nightly dose, and nurses signed the MAR indicating 8 mg was administered from that point through the end of the month. However, progress notes showed that the resident actually continued to receive the 12 mg dose for several days after the dose change until the 8 mg tablets arrived from the pharmacy. Staff interviews confirmed that the MAR should accurately reflect the dose actually given and that failure to reconcile the physician order and MAR could result in a medication error. Additional deficiencies were identified in the implementation of the facility’s constipation management protocol for two residents with bowel function care plans related to narcotic use, medications, and decreased mobility. For one resident with diabetes, hypertension, and dementia who required moderate assistance with ADLs, physician orders were in place for a stepwise PRN bowel regimen (Miralax, Dulcolax, Milk of Magnesia, Dulcolax suppository, and Fleet enema based on the number of days without a bowel movement). Bowel records showed multiple periods of three to six consecutive days without a bowel movement, yet MAR review revealed the ordered bowel medications were not administered during those periods, and there was no documentation explaining the omissions. For another resident with quadriplegia, multiple sclerosis, and opioid dependence who required total assistance with ADLs, similar standing bowel protocol orders and an additional PRN Miralax order were in place. Bowel records documented repeated three-day intervals without bowel movements, but MAR review again showed that bowel medications were not given as ordered and no reasons for the omissions were documented. Staff interviews described how bowel movements were monitored and how the bowel protocol was supposed to be initiated after a specified number of days without a bowel movement, and the DNS stated it was important to give bowel medications as ordered to prevent bowel obstruction and maintain good health.
Failure to Ensure Timely NAC Certification and Required Documentation for NARs
Penalty
Summary
The deficiency involves the facility’s failure to ensure that nurse aides (NARs) obtained their nursing assistant certification (NAC) within 120 days of hire and that required documentation was on file to allow them to continue working beyond that 120-day period, as required by WAC 388-97-1660(3)(a)(i). Surveyors found that for six sampled staff members (Staff K, L, M, N, O, and P), the facility did not consistently maintain documentation such as certification of completion of an NAC training program, Department of Health (DOH) authorization to test, passed skills test score sheets from the Washington State Board of Nursing (WABON), passed online written test sheets from Credentia, and completed NAR certification application attestation forms. These omissions were identified through review of the employee list, credential files, and payroll/time clock data, as well as interviews with facility staff. For Staff K, records showed a hire date of 09/20/2024 and Washington State NAR credentialing on 01/14/2025, but no documentation of NAC program completion, NAC examination passage, or a completed NAR certification application attestation form. Payroll records showed that Staff K continued to work numerous shifts after the 120-day deadline from the hire date. Text messages between Staff K and management indicated that Staff K had one last chance to test for the NAC but had not yet scheduled the test many months after hire. For Staff L and Staff M, both were hired in late 2024, credentialed as Washington State NARs within about a month of hire, and later completed NAC training and passed out-of-state Idaho NAC examinations well after 120 days from their hire dates. However, neither file contained a NAR certification application attestation form during the period they continued to work beyond 120 days. For Staff N, O, and P, the facility’s records showed each had passed an out-of-state Idaho NAC examination prior to or years before hire and were credentialed as Washington State NARs, but their files lacked documentation of NAC program completion and did not contain NAR certification application attestation forms as required for work beyond 120 days. Payroll/time clock data confirmed that each of these staff members worked shifts after their respective 120-day post-hire deadlines. During interviews, the Human Resources staff member stated that Staff N, O, and P had their NAC in Idaho but were working as NARs in Washington while waiting for Washington State NAC, and acknowledged uncertainty about whether any of the six staff had completed attestation forms. The Administrator stated that the facility was in compliance with NARs obtaining their NAC within 120 days of hire, despite the missing documentation identified by surveyors.
Incomplete and Inaccessible Medical Records for Multiple Residents
Penalty
Summary
The deficiency involves the facility’s failure to maintain complete, accurate, and readily accessible medical records in accordance with professional standards for multiple residents. For one resident, there was no documentation in the electronic medical record showing participation in care planning conferences over several months, and when paper care conference forms were later produced, they lacked the resident’s last name as a complete identifier. The same resident’s record also lacked visit summaries from several dental appointments where dentures were fitted and delivered. Another resident’s psychosocial history form, used to show that advance directives information had been reviewed with the representative, was produced without any resident identifier on it. The facility also failed to ensure that documentation from community providers and related clinical information were incorporated into the medical record. One resident’s record contained a progress note indicating that a community provider reported a seizure medication blood level was too high and recommended a dose decrease, but there was no documentation of the actual lab values or of efforts by the facility to obtain the lab results that led to the medication adjustment. Another resident, who was cognitively intact and identified on the facility’s smoking list, was observed smoking in the designated area on more than one occasion, yet the electronic medical record contained no smoking assessment or evaluation. A smoking assessment for this resident existed only on paper and had not been scanned or transcribed into the electronic record. Additional gaps in documentation included the absence of a care conference record and updated fall interventions in the electronic medical record for a resident with a history of falls who sustained an unwitnessed fall with head injury and was sent to the ED. Although a paper care conference summary dated after the hospital visit existed, it was not present in the resident’s medical record. For another cognitively intact resident who was transferred to the hospital with abdominal pain and a history of GI bleeding, there was no documentation in the medical record that a bed hold was offered at the time of transfer, even though a paper bed hold agreement form had been completed separately. These omissions and incomplete identifiers in both electronic and paper records were acknowledged by facility leadership as resulting in medical records that were not complete, accurate, or readily available.
Failure to Timely Report Allegation of Staff Rough Handling and Unexplained Bruising
Penalty
Summary
The deficiency involves the facility’s failure to report an allegation of staff-to-resident rough handling to the Administrator or designee and to the State Agency (SA) within the required timeframe. The facility’s abuse policy, revised 08/01/2023, required staff to immediately notify the Administrator, Director of Nursing, and Social Services upon knowledge of an allegation of abuse or neglect, and to report allegations of abuse or serious bodily injury to the SA immediately but no later than two hours, and all other allegations within 24 hours. The policy also required staff to identify potential abuse by reviewing grievances, complaints, and reports of allegations, and emphasized that all staff were mandated reporters. The resident involved, identified as Resident 81, had a history of stroke with right-sided hemiplegia, moderately impaired cognition, and required staff assistance with ADLs. On observation, the resident was noted to have scattered purple bruises on the right upper arm with dressings, and a large purple bruise on the left upper arm extending from the bicep to the elbow with yellow-green discoloration and a dressing above the left elbow. In an interview, the resident stated that some aides had been rough with them over the past weekend during incontinence care, reporting that staff pulled on their arm and that they had been abused by a couple of aides on night shift. Staff H, a nursing assistant, reported noticing the large bruise on the resident’s left arm on 08/11/2025 and acknowledged that the resident said they had already talked to management. In a later interview, Staff H stated the resident had mentioned night shift girls being rough and identified two girls as the alleged staff, and that Staff H recognized this as an allegation of physical abuse and reported it to Staff I, an RN. However, Staff I stated they were unaware of any allegation of staff-to-resident rough handling until 08/18/2025, when the resident told them that Staff H had not reported what happened. Review of the incident log and medical record showed no documentation that the facility recognized or questioned the large bruise or reported the allegation to the SA within the required timeframe. The Director of Nursing acknowledged that staff should have reported the allegation to the SA and the Administrator or designee when it was first known and that this did not occur.
Failure to Document and Communicate Required Information During Hospital Transfer
Penalty
Summary
The deficiency involves the facility’s failure to document and communicate the minimum required information to the hospital at the time of a resident transfer. A cognitively intact resident with diagnoses including anemia and gastritis with bleeding was admitted to the facility and later complained of abdominal pain, which they identified as a symptom they had previously experienced with a gastrointestinal bleed. Nursing staff notified the provider and arranged transport to the hospital via a facility van, but the resident’s record contained no documentation of what information was actually conveyed to the hospital at the time of transfer, as required. Multiple staff interviews confirmed that the facility’s usual practice was to send a face sheet, medication list, POLST, recent labs or vital signs, and other pertinent information with the resident, and to call the hospital with a verbal report, documenting this in a progress note. However, the Resident Care Manager and DON both acknowledged that, for this resident, they were unable to find any documentation specifying what information was sent or reported to the hospital. The Administrator also stated they expected staff to document what information was conveyed at transfer, but this was not done for the resident in question, resulting in a failure to ensure that the appropriate minimum information, including practitioner and resident representative contact information, advance directive information, care plan goals, special instructions, and other necessary information, was communicated at the time of transfer.
Failure to Develop Smoking-Specific Care Plan for Resident with Respiratory Failure
Penalty
Summary
Surveyors found that the facility failed to develop and implement a comprehensive, person-centered care plan with measurable objectives and services for a cognitively intact resident who smoked. The facility’s care plan policy required a comprehensive care plan to be developed and implemented within seven days after completion of the comprehensive assessment, consistent with the resident’s specific conditions, risks, needs, behaviors, and preferences. The resident was admitted with diagnoses including respiratory failure and was identified on the facility’s smoking list as choosing to smoke. The existing substance use disorder care plan, dated 07/15/2025, addressed alcohol and nicotine dependence with interventions such as encouraging the resident to discuss feelings, learn relaxation skills, and use fluids, exercise, and deep breathing to minimize withdrawal symptoms, but it did not include goals or interventions related to the resident’s current smoking behavior. On multiple observations, the resident was seen smoking cigarettes in the designated smoking area outside the facility. Staff interviews confirmed that the resident smoked and that, per facility practice, residents assessed as safe and allowed to smoke should have this reflected on their care plan. A nursing assistant, an LPN, and the DON each stated that if a resident was safe or cleared to smoke, it would be documented on the care plan, and the DON acknowledged upon review of the medical record that there was no smoking care plan in place for this resident, despite the expectation that the care plan accurately reflect the resident’s care needs.
Failure to Monitor and Manage Restorative Splint/Brace Programs and Refusals
Penalty
Summary
The deficiency involves the facility’s failure to provide appropriate restorative nursing care, including splint and brace use, to maintain or improve range of motion (ROM) and mobility for residents with hemiplegia and contracture risk. Facility policy required that Restorative Nursing Programs (RNP), including splint/brace assistance, have measurable objectives and interventions in the care plan, with implementation documented in the medical record and resident tolerance and compliance monitored. The policy also specified that nursing was responsible for overall coordination and supervision of the RNP, even when therapy staff participated. For one resident with a history of stroke, right-sided hemiplegia, moderately impaired cognition, and functional ROM limitations, the quarterly assessment showed no RNP or therapy services despite prior placement on a restorative splint/brace program. The care plan identified risk for contractures and instructed staff to monitor skin under the splint, provide hand hygiene, refer to therapy as needed, and “see restorative programs,” but contained no documentation of refusals or rejections of the RNP. The medical record showed the last restorative evaluation in early 2024 documented splint/brace assistance six days per week, with the resident choosing not to wear the leg brace but wearing a wrist/hand brace. Subsequent restorative progress notes over multiple quarters stated the resident was not currently on restorative and “chooses not to participate,” yet there was no associated documentation explaining why the resident continued to refuse, no evidence that the resident or legal guardian were involved in reviewing risks and benefits of non-participation or alternatives, and no documentation that therapy was notified of ongoing refusals for re-evaluation. For another resident with seizures, hemiplegia/hemiparesis, severely impaired cognition, and functional ROM limitations, observations showed inconsistent use of a right forearm brace at different times of day. Therapy documentation indicated restorative aides had been trained on donning and doffing the right hand brace and that the brace use was to continue. Physician orders on the Treatment Administration Record directed staff to apply a right arm brace in the morning for 6–8 hours and to apply a right-hand carrot device twice daily for 60–90 minutes, but the TAR contained no documentation of how long the resident actually tolerated either device. Restorative nurse notes over several quarters stated the resident was not currently working with restorative and was working with therapy, with plans to evaluate quarterly and as needed, yet there was no documentation that the facility evaluated the effectiveness of the brace or carrot or whether the ordered tolerance goals were met. The resident’s care plan referenced reviewing the restorative program routinely to validate effectiveness and adjust as indicated, but did not specify what the RNP consisted of or acknowledge the purpose of the right-hand carrot or arm brace.
Failure to Maintain Proper Catheter Bag Positioning and Care
Penalty
Summary
The facility failed to provide appropriate catheter care to minimize the risk of urinary tract infections for one resident who required an indwelling urinary catheter. The resident had diagnoses including benign prostatic hyperplasia, obstructive uropathy, and a history of urinary tract infection, and the quarterly assessment documented the need for a urinary catheter. Surveyors repeatedly observed the resident seated in a wheelchair with the catheter collection bag and tubing resting on the floor during multiple observations over several days. The resident’s medical record showed treatment for UTIs on 06/08/2025 and 07/17/2025. The urinary catheter care plan, dated 05/19/2025, did not include instructions for staff to keep the catheter bag and tubing off the floor. Staff interviews confirmed that facility staff were aware of the importance of keeping catheter bags and tubing off the floor. A nursing assistant stated that catheters were to be hung underneath the resident’s wheelchair and that it was important to keep the collection bag and tubing off the floor to prevent contamination. A registered nurse similarly stated that catheter bags were hooked underneath wheelchairs and that keeping the bags and tubing off the floor was important to prevent infection, and acknowledged that the resident had frequent UTIs. The DON stated that catheters were hung underneath or on the side of the wheelchair below the level of the bladder and confirmed it was important to keep the tubing and collection bag off the floor to prevent infection, also acknowledging that the resident had experienced UTIs. Despite this, the resident’s catheter bag and tubing were repeatedly observed resting on the floor.
Failure to Administer Ordered Pregabalin and Insulin Despite Availability
Penalty
Summary
The facility failed to ensure medications were administered as ordered for one resident with severe cognitive impairment and diagnoses including arthritis, migraines, neck fracture, and neuropathy. The resident’s care plan identified a risk for pain and directed staff to give medications as ordered. Review of the Medication Administration Records (MARs) showed that pregabalin 150 mg three times daily for neuropathy was documented as not available on two consecutive days, despite a prior progress note indicating the medication had been reordered. Humalog insulin ordered per sliding scale before meals had blank MAR entries for two evening shifts, and a separate Humalog order for 20 units before meals, with an additional 15 units per sliding scale, also had a blank entry on one date and a documented blood sugar of 135 with no insulin administered on another date. During interviews, an RN stated that medications were to be reordered when a week’s supply remained, and if not available, staff were to check the Cubex, contact the pharmacy, and notify the provider, acknowledging that the provider should have been notified when the pregabalin was unavailable. The Resident Care Manager stated nurses were responsible for ordering medications when low, confirming that the pregabalin issue should have been addressed immediately when the first dose was unavailable, and noted that blood sugars and whether insulin was given or held should have been documented. The DON reiterated that staff were expected to reorder medications, check the Cubex, notify the provider, and obtain a pull code from the pharmacy, and that blood sugars or refusals should be documented. A review of the Cubex showed that both pregabalin and Humalog insulin were in fact available, indicating that the medications were omitted despite being accessible.
Failure to Coordinate Follow-Up Dental Care for Ill-Fitting Dentures
Penalty
Summary
The deficiency involves the facility’s failure to coordinate and document necessary follow-up dental care for a resident who was cognitively intact, medically complex, and edentulous. An annual assessment documented that the resident had no natural teeth, no abnormal mouth tissue, and a sore on the gum line being treated/monitored, with a note that dental appointments were to be arranged as ordered or requested PRN. The resident’s oral/dental health care plan, initiated in 2019, included an intervention for staff to coordinate arrangements for dental care and transportation as needed. Progress notes showed the resident was fitted for dentures at a dental clinic and received new upper and lower dentures, with follow-up appointments scheduled. After receiving the dentures, the resident repeatedly reported they were too thick, did not fit correctly, and felt foreign, and the resident chose not to wear them due to discomfort. Despite documentation that the resident was not tolerating the dentures, had inflamed upper gums, and later developed an open sore on the bottom right inner gums with associated pain and gum grinding, the medical record did not contain documentation of the summary of the 12/06/2024 follow-up appointment or any efforts by the facility to notify the denturist and secure an earlier appointment before the planned January 2025 visit. The record also lacked documentation that the facility coordinated the January 2025 follow-up appointment with the denturist. The resident reported that staff should have, but did not, set up the January dental appointment and stated they could not eat with the dentures because the fit and bite felt wrong and the teeth were too large. The dentures were observed sitting unused in a denture cup with a transparent film on the water, and the resident continued to refuse or not wear the dentures over several months while receiving meals that included items they reported difficulty chewing.
Failure to Implement Enhanced Barrier Precautions and Hand Hygiene During IV and Medication Care
Penalty
Summary
The deficiency involves the facility’s failure to implement and follow its infection prevention and control program, specifically related to Enhanced Barrier Precautions (EBP) and hand hygiene. Surveyors found that staff did not consistently use gowns along with gloves for high-contact care activities for residents with indwelling devices and chronic wounds, despite facility policy and CDC guidance. The facility’s policy on Transmission-Based Precautions stated that EBP were to be used for residents with open chronic wounds, indwelling medical devices such as PICC lines, or colonization with multidrug-resistant organisms, and that staff were to use gowns and gloves for high-contact care including dressing, bathing, transferring, hygiene, changing linens, device care, and wound care. EBP were intended to be in place for the resident’s entire length of stay unless the device was removed or the wound healed. One resident with a non-pressure chronic right foot ulcer, a wound vac, and a PICC line was identified as requiring EBP per the care plan and provider orders. On multiple observations, there was no EBP signage or other identifying symbol on the room door or frame, and PPE such as gowns was not readily available. The resident reported that staff only wore gloves, not gowns, when changing the wound vac. During IV care, an RN washed hands and donned gloves but did not wear a gown while disconnecting IV medication and flushing the PICC, and later again performed PICC access and IV medication administration with gloves only and no gown. A flower symbol indicating EBP was added to the door frame weeks after admission, but PPE remained not readily available in the room. Another resident with pneumonia and a history of bladder infection had a PICC line placed for IV antibiotics. The care plan documented antibiotics for a bladder infection but did not include EBP related to the PICC, and there were no provider orders for EBP despite active orders for PICC dressing changes. Observations showed the resident in bed with an IV pump and evidence of recent IV use, but no EBP signage or PPE readily available. The resident stated that staff wore gloves and a mask, but not gowns, when changing the PICC dressing. A flower symbol indicating EBP was placed on the door frame more than a month after PICC insertion, and PPE was still not readily available. Multiple staff, including nursing assistants, RNs, the Resident Care Manager, the Infection Preventionist, and the DON, described that EBP required gloves and gowns for high-contact care and that flowers on door frames were used to indicate EBP, but acknowledged that EBP should have been implemented and followed for these residents. The deficiency also included failures in hand hygiene during medication administration. In one observation, an RN put on gloves without performing hand hygiene, drew up insulin, walked down the hall wearing the same gloves, and administered insulin to a resident. After removing gloves, the RN did not perform hand hygiene and immediately began dispensing medications for another resident, handling over-the-counter vitamins with bare hands before later performing hand hygiene and administering the medications. In another observation, a different RN sanitized hands and donned gloves, then used the same gloves to open blinds, adjust the bed and light, remove old IV bags, hang new IV medication, wipe the IV cannula, flush the IV line, connect the new IV bag, adjust pillows, retrieve an additional pillow, and pick up a cup from the floor before administering the remainder of the resident’s medications. Both nurses later acknowledged they should have performed hand hygiene at appropriate times, and the Infection Preventionist and DON stated that hand hygiene should be performed before glove application, after glove removal, before dispensing medications, after medication administration, between residents, and after touching items in the room.
Failure to Monitor and Document Indwelling Catheter Care
Penalty
Summary
The facility failed to properly monitor and document the use and function of indwelling urinary catheters for two residents with complex urinary needs. Both residents had physician orders and care plans requiring staff to measure and record urinary output every shift, as well as to monitor for signs and symptoms of catheter-associated complications. However, review of treatment administration records (TARs) revealed numerous missed opportunities for documentation of urinary output, with 21 out of 62 entries missing for both residents in March, and additional missed entries in April. There were also multiple instances where urinary output was recorded as less than 30ml per hour, but no corresponding nursing assessments or notifications to medical providers were documented in the progress notes. For one resident with a neurogenic bladder and a history of urinary tract infections (UTIs), the lack of monitoring and response to low urinary output led to a situation where the resident experienced a distended abdomen, pressure, and leaking catheter, which was only addressed after a significant delay. The catheter was eventually replaced, resulting in immediate relief and drainage of a large volume of urine. The resident later reported that staff did not respond promptly to their concerns and that they were diagnosed with a UTI upon hospital admission. Interviews with staff confirmed that documentation was inconsistent, particularly among agency staff, and that there was confusion regarding which residents required output monitoring. The second resident, admitted with obstructive uropathy and also requiring an indwelling catheter, experienced similar lapses in care. Documentation of urinary output was frequently missing, and low output readings were not followed up with assessments or provider notifications. Progress notes failed to address these changes in condition, and staff interviews confirmed awareness of ongoing issues with monitoring and recording urinary outputs for residents with specific orders. The facility's policy required appropriate catheter care and monitoring, but these standards were not consistently met for the residents reviewed.
Significant Medication Errors Due to Non-Adherence to Physician's Orders
Penalty
Summary
The facility failed to ensure that a resident received medications in accordance with the physician's order, resulting in significant medication errors. The resident had an order for hydrocodone-acetaminophen to be administered every six hours as needed, with a maximum of four tablets in a 24-hour period. However, the resident was administered more than the prescribed limit on multiple occasions in September and October 2024. This oversight placed the resident at risk for medical decline and discomfort. Interviews with facility staff revealed a lack of awareness and adherence to the medication administration parameters. Staff F, an LPN, did not follow the restriction of administering no more than four tablets in a 24-hour period. Staff A, the Director of Nursing, indicated that the nursing team was responsible for ensuring correct medication administration, but Staff C, the Resident Care Manager, was unaware of the specific instructions for the resident's pain medication. Additionally, pharmacy audits for the resident were requested but not provided, indicating a lapse in oversight and communication regarding medication management.
Failure to Report and Investigate Medication Misappropriation
Penalty
Summary
The facility failed to implement its Abuse and Neglect Prohibition Policies and Procedures by not reporting allegations of abuse to the State Agency within the required timeframe and not completing thorough investigations. This deficiency was identified in the case of a resident who reported receiving incorrect medication from a Licensed Practical Nurse (LPN). The resident, who was prescribed hydrocodone-acetaminophen for pain management, reported that the medication administered by the LPN tasted different and was ineffective. On one occasion, the resident did not swallow the medication and later showed the pills to a Registered Nurse (RN), indicating that one of the pills was not their prescribed medication. The RN confirmed the resident's report and informed the Assistant Director of Nursing (ADON) about the incident. The ADON interviewed the resident, who alleged that the LPN was administering an over-the-counter medication instead of the prescribed narcotic. The ADON reported the concern to the Director of Nursing (DON), who was responsible for investigating and reporting such allegations. However, the DON did not document the investigation and did not report the allegation to the State Agency, as they did not substantiate the abuse claim. This lack of documentation and reporting placed the resident and other residents at risk for abuse and misappropriation.
Failure to Inform Resident Representative of Health Changes
Penalty
Summary
The facility failed to inform the Resident Representative (RR) of significant changes in the health status and treatment of a resident over a five-month period. The resident, who had moderate cognitive impairment and medically complex conditions, experienced multiple events that met the definition of a change in condition, such as lethargy, confusion, a chronic wound, and significant weight loss. Despite these changes, there was no documentation to show that the RR was notified, as required by the facility's policy. Throughout the resident's stay, there were numerous instances where the staff did not communicate with the RR about the resident's health status. These included changes in medication, new diagnoses, and referrals to specialists. The resident also experienced a significant weight loss of 16.96% over six months, yet there was no record of the RR being informed or involved in discussions about addressing this issue. Additionally, the resident had dental issues that were not communicated to the RR until a later appointment. The lack of communication was acknowledged by the Director of Nursing, who agreed that the communication with the RR was lacking and managed poorly. The RR expressed concerns about not being informed of the resident's refusals of care, changes in condition, and other significant health events. This failure to communicate effectively precluded the RR from contributing to informed decision-making regarding the resident's care and treatment options.
Inadequate Dental Care and Pain Management for Resident
Penalty
Summary
The facility failed to provide timely and adequate dental services and pain management for a resident with an impacted wisdom tooth and abscess. Initially, the resident reported pain and swelling in the gum area, and the facility's medical provider prescribed an antibiotic. However, there was no documentation of non-pharmacological interventions, and the resident continued to experience pain. Despite the resident's repeated requests for dental care and stronger pain medication, the facility delayed in scheduling a dental appointment and addressing the resident's pain effectively. The resident's condition worsened over time, with increased swelling, bleeding, and severe pain. The facility's staff documented the resident's ongoing complaints and the ineffectiveness of the prescribed pain medication. However, there was a lack of timely communication with the provider and the dentist, resulting in prolonged suffering for the resident. The facility's response to the resident's pain and dental needs was inadequate, as evidenced by the delayed referral to a dentist and the insufficient pain management provided. Ultimately, the resident's condition deteriorated significantly, leading to a hospital transfer where a large erosive mass was identified. The facility's failure to address the resident's dental issues and pain management in a timely manner contributed to the resident's diminished quality of life and increased risk of complications. The report highlights the facility's shortcomings in coordinating dental care and managing the resident's pain effectively.
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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