Edmonds Post Acute
Inspection history, citations, penalties and survey trends for this long-term care facility in Edmonds, Washington.
- Location
- 21400 72nd Avenue West, Edmonds, Washington 98026
- CMS Provider Number
- 505236
- Inspections on file
- 41
- Latest survey
- March 4, 2026
- Citations (last 12 mo.)
- 60
Citation history
Health deficiencies cited at Edmonds Post Acute during CMS and state inspections, most recent first.
Laundry was not handled in a sanitary manner when soiled bins were placed next to clean linens, a soiled bin touched clean rags, an unlabeled chemical was used for washer disinfection, and wet clean clothes were placed on a cart with dirty items. In addition, a CNA did not follow contact enteric precautions by removing gown and gloves before leaving a resident’s room and using hand sanitizer instead of soap and water. A resident with C-diff and ongoing diarrhea remained on precautions while staff documented loose stools and discussed possible colonization.
Surveyors found that the facility did not provide required written transfer/discharge notices and bed-hold information to several residents and/or their representatives when residents were sent to the hospital. Although facility policy required written notices specifying the reason, date, and destination of transfer along with appeal rights and Ombudsman contact information, review of electronic health records and transfer forms showed that these elements were missing, and no separate written notices were documented. Multiple transfer forms for residents sent to the hospital for issues such as abnormal labs, chest pain, uncontrolled pain, abnormal vital signs, suspected kidney infection, and unresponsiveness lacked any statement of appeal rights or Ombudsman contact details. In addition, bed-hold agreements were incomplete or absent, and there was no progress note documentation that bed-hold notices were provided, even though staff interviews confirmed that residents and representatives should have been notified and that such notification should have been documented.
Surveyors found that the facility failed to accurately complete MDS assessments for several residents, including incorrect coding of an indwelling catheter for a resident whose catheter had been discontinued months earlier, and inaccurate reporting of insulin injections for two residents that did not match MAR/TAR documentation. Another resident was incorrectly coded as having an ostomy despite no supporting orders or notes, while a resident was coded as being on a turning/repositioning program without an active care plan intervention or documentation of monitoring and reassessment. In addition, a resident receiving hospice services with a documented prognosis of six months or less was not coded for hospice or limited prognosis on the admission MDS, and the MDS coordinator and DON acknowledged these inaccuracies.
Staff administered medications to two residents in a common area near the nurse station, even though an LPN later stated this was not supposed to happen for privacy reasons and the DON said it was not expected. The facility also had multiple room environment issues, including a baseboard heater pulling away from the wall, a resident’s wheelchair and commode placed inside a marked heater safety zone, soiled and unmade bed linens, and a bed footboard with a dry brownish-red substance that housekeeping staff said looked like blood.
Food storage and hand hygiene failures were observed in the kitchen and dry storage areas. Refrigerated foods were found without proper labels or use-by dates, including an expired lettuce container that should have been discarded, and an opened vinegar container in dry storage was left uncapped. Staff were also observed handling food, dishes, and kitchen equipment with bare hands or contaminated gloves, changing gloves without hand hygiene, and touching clean items and cooking spray after handling raw meat.
Pest control was not effective in the kitchen or in a resident’s room. Staff observed small black flies and fruit flies around the dishwashing area, back entrance, and on surfaces in the kitchen, and staff reported the problem had been ongoing for weeks to months. A resident also had fruit flies on the curtain, bedside table, and sandwich bag, and said the bugs had bothered them and that prior reports to staff had not led to action.
A facility failed to maintain dignity for 3 residents. An LPN entered a resident’s shared room multiple times without knocking, introducing themselves, or stating their intentions. A cognitively impaired resident who was dependent for personal hygiene was observed with long facial hair despite no documented preference, and staff said they would not expect facial hair on a female resident unless it was the resident’s choice. During meal assistance, a CNA stood while helping a dependent resident eat instead of sitting eye to eye, which staff identified as the expected practice.
A paper MW2 Unit document containing residents' names and nursing notes was observed on top of a med cart with PHI visible to people in the hallway. An LPN confirmed the information could be seen, and the RCM and DON stated resident documents should be kept private and stored so information is not exposed.
Failure to Log and Investigate Missing Personal Property Grievance: A cognitively intact resident reported missing personal items after hospitalization, including a phone charger and documents, and the resident’s representative also raised concerns about a missing bag. Staff acknowledged that a grievance should have been filed and logged, but the grievance log showed no entry and no investigation was documented.
A resident’s admission MDS was not completed within the required timeframe. The RN/MDS Coordinator acknowledged that the assessment was completed late, and the DON stated it was expected to be completed timely.
A resident's Quarterly MDS was completed late after the ARD, missing the required 14-day completion window. The MDS Coordinator confirmed the timing requirement, Staff C stated the assessment was late, and the DON stated that MDS assessments were expected to be completed timely.
Late Completion of Discharge MDS Assessments: The facility failed to complete discharge MDS assessments for a resident within the required timeframe. Two discharge assessments were completed late, and the MDS Coordinator acknowledged they should have been completed on time. The DON stated that MDS assessments were expected to be completed timely.
A facility failed to develop and/or implement comprehensive care plans for two residents. One resident received rivaroxaban for DVT, but the care plan had no anticoagulant section despite staff stating anticoagulant residents should be monitored for bleeding and labs. Another resident’s ADL care plan directed staff to clean and trim nails, yet repeated observations showed long fingernails with brown material underneath, and staff stated the resident needed help with nail care.
A resident who was cognitively intact had no documentation showing quarterly care conferences were offered, attended, or declined, despite staff stating these meetings were to be scheduled and documented. Another resident reported a preference for morning showers and two showers per week, but the shower schedule and care plan listed evening showers and did not reflect the resident's stated preference. Staff acknowledged the care plan did not match the resident's shower preference.
Two residents did not receive needed ADL assistance for personal hygiene, nail care, and oral care. One resident who was dependent for personal hygiene was repeatedly observed with long fingernails and brown material under the nails, including after a bed bath, while staff said CNAs were responsible for cleaning and trimming the nails. Another resident who needed substantial/maximal help with nail care and oral care was observed with long, dirty fingernails and yellow-brown deposits on the teeth, and stated staff had not helped brush the teeth for nearly a week despite requests for assistance.
The facility failed to consistently monitor and treat constipation for a resident with constipation and a prior intestinal obstruction, with multiple extended periods of no documented BM and PRN bowel meds not always given per the bowel protocol. The facility also failed to maintain coordinated hospice documentation and communication for a resident on hospice, as the care plan lacked resident-specific hospice collaboration details and the EHR had no hospice POC or visit notes.
Failure to monitor and document a resident’s right heel stage 2 pressure injury. The resident’s care plan called for weekly RN wound assessments and documentation of wound healing, but after the initial skin evaluation showed a 3.5 cm by 4 cm heel wound, subsequent weekly skin checks and progress notes did not show ongoing assessment, monitoring, or documentation of the heel wound. The wound provider followed a different wound, and the RCM and DON both stated ongoing documentation should have been present.
A resident who smoked had a lighter and pipe left on the bedside table instead of being secured in a locked box/drawer as required by the facility's no-smoking policy. Staff gave conflicting statements about whether smoking materials could be kept with the resident, and a later observation found no locked box in the room.
Improper Storage of BIPAP Mask and Delayed O2 Tubing Change: A resident with sleep apnea and acute respiratory failure with hypoxia had an order for continuous O2 and BIPAP at night, but the BIPAP mask was repeatedly found lying uncovered on a pillow and the tubing was disconnected and dated as changed more than 2 weeks earlier. Staff stated the mask should be stored in a clear plastic bag and the O2 tubing should be connected and changed weekly.
Failure to care plan for PTSD and trauma-informed needs: A resident with PTSD had no documented care plan addressing trauma history or triggers, despite the facility policy calling for individualized trauma-informed and culturally competent care. The RCM and DON stated the resident should have had a care plan in place, and a CNA reported not knowing the resident had PTSD.
Daily nurse staffing postings were not updated for 2 days. A review found the posting still displayed an older date, with no current weekend postings available behind it for residents, families, or visitors to view. Staff stated the weekend receptionist was responsible for posting the current staffing information, and the DON confirmed the postings should have been updated daily.
Expired meds were found on a medication cart and in a medication room, including an opened Haloperidol, Fiber Lax, and Povidone-Iodine swab sticks. An opened Lidocaine patch was also left on a resident’s dresser instead of being stored in the med cart, and staff confirmed it should not have been left there.
Inaccurate ADL Dressing Documentation: A resident with dementia was observed wearing the same clothes over multiple days, yet the CNA ADL records showed inconsistent entries ranging from independent to dependent for upper and lower body dressing. Staff interviews confirmed the resident often refused dressing assistance and that refusal should have been documented instead of charting assistance that did not match what occurred.
Broken Laundry Dryer Not Kept in Working Order: The facility failed to keep 1 of 2 laundry dryers operational. Staff observed wet laundry piled on a cart beside the dryers while one dryer was in use and the older Uni-Dryer Model was out of service. Staff reported the dryer had been broken for a long time and they were waiting for a motor, while the Maintenance Director and ED acknowledged the issue had persisted for an extended period and that both dryers were needed.
Unsanitary Shower Room Conditions: The Southwest Hallway Shower Room was observed with a brownish red substance on the walls and floor around the shower, dark grey spots on the ceiling, hair throughout the room, and a shower chair with a dark grey substance on the legs. The Maintenance Director and Housekeeper Director identified the substances as possible mildew, mold, or soap scum, and the Housekeeper Director could not clearly confirm when the room was last cleaned. A CNA/Shower Aide said the room had been used the day before and the chair was sanitized between residents, while the IP, DON, and ED stated the shower rooms were expected to be clean.
CNA Annual Training Hours Not Documented: The facility failed to ensure a CNA had the required 12 hours of annual training. The facility assessment and policy required at least 12 hours of continuing education in a 12-month period, but the employee record did not show documentation of the required hours. Staff Development and the DON stated CNAs were expected to have 12 hours yearly, but the facility had no system to track the hours, and the CNA's record showed only 10.25 hours of training.
A cognitively intact resident with GERD was found with multiple cups of TUMS (calcium carbonate) tablets at the bedside, which the resident reported taking as needed, with inconsistent nurse observation. Review of physician orders showed a scheduled order for calcium carbonate before meals but no order authorizing self-administration or keeping the medication at the bedside. Facility policy required an assessment and an attending physician’s order, in conjunction with the interdisciplinary team, before allowing residents to self-administer medications. An LVN, the charge RN, and the DON all confirmed that no such assessment or order existed for this resident, resulting in a failure to follow the facility’s self-administration policy.
A resident who was cognitively intact, very tall, and dependent on staff for bed mobility was admitted with a standard bed that did not accommodate their height, resulting in their feet and toes, while wearing pressure-relieving boots, pressing against the footboard and causing reported knee pain. Despite facility policy requiring bed dimensions to match resident size and staff expectations that concerns be reported to maintenance, a CNA acknowledged the bed appeared small but did not request a longer bed, and the established process for ensuring an appropriate bed size at admission and upon staff observation was not followed.
Surveyors found that the facility did not follow its own policies requiring easy access to telephones and confidential mail delivery. A cognitively intact, mobility-dependent resident reported never having a phone in their room despite asking nurses, and repeated observations confirmed there was no phone connected to the wall jack. Staff, including a CNA, an LVN, and the Maintenance Director, all stated residents were supposed to have room phones, acknowledged this resident did not, and described limited alternatives such as using the nurse’s station or staff offices, with no common-area or cordless phones available. Another cognitively intact resident reported receiving multiple packages that had been opened, allegedly by Social Services to check for pills or liquids. An administrative assistant and a social services assistant described practices of diverting packages that sounded like medications to nursing, and one staff member delivered an already opened but not visibly damaged package to the resident. The resident documented several packages, distinguishing between those damaged in transit and others that appeared deliberately cut open, despite facility policy requiring mail to be delivered unopened unless the resident requests assistance.
Surveyors found that the facility did not maintain a homelike, sanitary environment in multiple rooms, including unrepaired structural damage and inadequate cleaning. In one room, the baseboard below the sink was visibly coming off the wall on repeated observations, though a housekeeper who routinely cleaned the room stated they had not noticed it, and maintenance leadership reported they were unaware of the issue. In another room, a bathroom ceiling had a hole with exposed piping following a prior leak; two residents reported ongoing leaking and dripping, and a RN and the Maintenance Director acknowledged that maintenance was aware and that the hole had been present for months. In the same area, a resident reported feces in a closet where wound supplies were stored and pointed out cobwebs on the fire sprinkler and ceiling; surveyors confirmed brown matter in the closet and cobwebs in several locations. The housekeeper and Housekeeping Supervisor both described expectations for daily room cleaning, closet disinfection, and routine dusting and cobweb removal, but they stated they were not previously aware of the feces complaint or the observed contamination.
A resident with dementia and a history of falls did not receive neurological assessments for the full required period after an unwitnessed fall, and documentation of physician-ordered 15-minute safety checks was missing from the EHR. Staff interviews confirmed that monitoring and documentation protocols were not followed, resulting in incomplete post-fall monitoring.
A resident who was cognitively intact reported being left soiled and threatened by staff, and stated that their complaint to social services was ignored. The facility's grievance log did not reflect this incident, and there was no documentation of investigation or follow-up, despite facility policy requiring all grievances to be logged and investigated.
Staff failed to consistently follow infection prevention and control protocols, including proper use of PPE such as N95 respirators, gowns, and gloves, and keeping doors closed for residents on transmission-based precautions. Observations included an LPN and CNA not using required PPE or keeping doors closed for COVID-19 positive residents, a CNA not wearing a gown while making a bed for a resident on EBP, and a housekeeper not wearing a gown while cleaning a room under Contact Enteric Precautions for C. difficile.
A resident with dementia, hemiplegia, limited ROM, and a history of stroke had a care plan requiring one-on-one feeding assistance, but staff did not consistently provide this support. Instead, a family member often assisted with meals because staff would leave the meal tray and not remain with the resident as required by the care plan.
A facility failed to thoroughly investigate an abuse allegation involving a resident with cognitive impairment. The investigation lacked interviews with all relevant staff and did not document a conclusion. A CNA assigned to the resident was not interviewed, and the LPN responsible admitted to not documenting interviews or the investigation's outcome.
The facility did not report an influenza outbreak involving two residents to the State Agency, as required by their Infection Prevention and Control Program policy. The Infection Preventionist admitted the oversight, and the Administrator confirmed the expectation for reporting. This failure increased the risk of infection for residents, staff, and visitors.
A resident refused medication from a CNA, as the facility failed to ensure medications were administered by trained and licensed staff. The DNS improperly gave medications, including a narcotic, to a CNA to administer, which was against professional standards. Staff interviews confirmed CNAs were not trained for medication administration.
The facility failed to designate a qualified Infection Preventionist (IP) to oversee its infection prevention and control program. Staff D, who was responsible for the program, had not completed the required specialized training and was not certified. A corporate IP visited the facility monthly and was available by phone, but the lack of a certified on-site IP posed a risk for unmet infection control issues.
The facility failed to maintain appropriate water temperatures for showers, affecting three residents, with delays in fixing the hot water issue. Broken blinds in two rooms were not promptly replaced, causing discomfort to residents. Additionally, oxygen equipment was improperly stored in a resident's room who did not require it, with no physician order for oxygen therapy.
The facility failed to accurately assess five residents using the MDS tool, leading to potential risks. A resident's pressure ulcer was not coded, while another's MDS inaccurately included pressure ulcers. Depression was not coded for a resident despite an antidepressant prescription. Insulin use was not reflected in two residents' MDS, and a discharge was incorrectly coded. These inaccuracies were acknowledged by staff during reviews.
The facility failed to follow professional standards in medication administration and treatment management. A resident received the wrong form of aspirin, insulin orders were not followed for two residents with diabetes, and a resident with a pressure ulcer did not receive prescribed wound care. Additionally, a staff member signed off on wound care they did not perform.
The facility failed to accurately complete daily nurse staffing forms, with discrepancies in staff numbers and hours worked for several days. Staff responsible for postings did not adjust hours worked for call-outs, contrary to policy. The Director of Nursing and Administrator expected updates to reflect actual staffing, but this was not consistently done, risking incomplete information for residents and visitors.
The facility failed to label and store a tuberculin vial properly in the East Medication Room Refrigerator. An opened and undated vial was found, contrary to the facility's guidelines requiring vials to be dated upon opening and discarded after 30 days. Staff acknowledged the oversight, with varying understandings of the vial's usability period. This placed residents at risk of receiving compromised medications.
The facility failed to maintain food safety standards in two unit refrigerators and the kitchen's dishwasher. In the West Nursing Station Unit Refrigerator, food items were improperly labeled and stored at temperatures above the federal standard. The East Nursing Station Unit Refrigerator also showed elevated temperatures. Additionally, the facility did not routinely test the chemical solution in the kitchen's dishwasher, relying on monthly external testing. These issues posed a risk of foodborne illness to residents.
The facility failed to maintain an adequate water management program, with no written description or diagram of the water system to prevent Legionella growth. A resident's catheter tubing was observed on the floor, indicating improper care. Staff did not follow hand hygiene protocols, with a CNA failing to sanitize hands after touching a facemask and another not performing hand hygiene between glove changes. Additionally, a nurse did not wear a gown while administering medication via a feeding tube, and a full sharps container was not replaced, increasing infection risk.
A resident with an indwelling urinary catheter had their dignity compromised when their catheter drainage bag was left uncovered and visible from the hallway. Observations confirmed the lack of a privacy bag, and staff interviews acknowledged the expectation for catheter bags to be covered. This oversight was against the facility's policy on resident rights, risking the resident's self-worth and quality of life.
A resident was administered Mirtazapine for depression without being informed of the risks and benefits until 22 days later. Facility staff acknowledged the oversight, as the protocol requires informing residents before starting psychotropic medications.
A resident was found self-administering folic acid without proper evaluation or orders, contrary to facility policy. Despite being cognitively intact, the resident had been taking the medication for about a week, with staff confirming the lack of necessary documentation and orders. The DON acknowledged the oversight, which placed the resident at risk for unsafe medication administration.
The facility failed to document advance directives for two residents, compromising their right to have healthcare preferences honored. One resident's advance directive was not placed in their medical record, while another resident's form was left blank, with no documentation of discussion or request for the directive.
A resident reported a missing personal cell phone, but the facility failed to log or investigate the grievance as per policy. Despite staff being informed, no formal grievance report was completed, and the issue was not documented in the grievance log. The missing phone was later found, but the oversight risked the resident's care needs.
Laundry Handling and Contact Enteric Precautions Not Followed
Penalty
Summary
The facility failed to ensure laundry was handled, stored, and processed in a sanitary manner in the laundry room. During a joint observation, three yellow bins of soiled laundry were seen inside the laundry room next to a rack of clean linens, and one soiled bin was touching a bin of clean housekeeping rags. Staff stated that dirty items should not be touching clean items. An unlabeled spray bottle containing blue liquid was also shown as the cleaner used for disinfecting the washing machines, and staff stated that every cleaner should be labeled. In another observation, a pile of wet clothes was placed on top of a rolling cart that had dirty items, including dirty shoes, on the bottom rack, and staff stated the wet clothes would need to be rewashed. The facility also failed to ensure Contact Enteric Precautions were followed for a CNA and a resident on contact enteric precautions. Observation showed the CNA entered the resident’s room wearing a gown and gloves, then removed the gown and gloves before leaving and used hand sanitizer instead of washing hands with soap and water. This occurred during two separate entries to deliver juice and a meal tray. The signage at the room indicated soap and water should be used when leaving the room, and the CNA stated they used hand sanitizer because there was no sink close by. The resident involved had diagnoses that included diarrhea and was documented as having C-diff. The resident was observed on contact enteric precautions, and staff stated the resident was on contact enteric precaution for C-diff. The resident reported ongoing diarrhea on multiple occasions, and bowel movement records showed loose stools or diarrhea across most of the reviewed period. Staff later stated the resident had completed antibiotics, that the provider believed the resident was colonized with C-diff, and that the resident had not been retested after antibiotics. Staff also stated the resident had been kept on contact enteric precautions previously and that the resident shared a room with two other residents.
Failure to Provide Required Written Transfer/Discharge and Bed-Hold Notices
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to provide required written transfer/discharge notices and bed-hold information to residents and/or their representatives in connection with multiple hospital transfers. The facility’s policy titled “Transfer or Discharge Notice,” revised in March 2021, required that residents and/or representatives be notified in writing, in a language and format they understand, including the specific reason for the transfer or discharge, the date, the receiving location, and an explanation of appeal rights. Record review for one resident showed a discharge MDS indicating admission and subsequent discharge to an acute hospital, with the EHR documenting discharge on a specific date but containing no evidence that a written transfer/discharge notice was provided. In interview, the Resident Care Manager stated that when a resident discharged to the hospital they would usually call the family and was unsure if a written notice was provided; the Executive Director confirmed that a written notice should have been provided and that there was no such documentation in the record. For another resident, a quarterly/discharge MDS showed admission to a short-term general hospital, and the facility’s Transfer Form documented transfer to the hospital for abnormal lab results. However, the Transfer Form did not include a statement of the resident’s appeal rights or Ombudsman contact information as required, and the EHR contained no documentation that a written transfer/discharge notice was provided to the resident or representative. A third resident had multiple discharge MDS entries indicating admissions to a short-term general hospital, and several Transfer Forms documented transfers for chest pain, uncontrolled pain, and shortness of breath. None of these Transfer Forms contained the required appeal rights statement or Ombudsman contact information, and the EHR lacked documentation that a written transfer/discharge notice was provided. A fourth resident also had multiple discharge MDS entries for hospital admissions, with Transfer Forms documenting transfers for surgery, abnormal vital signs with no urine output from a nephrostomy, increased temperature and heart rate, suspected kidney infection, and unresponsiveness. Each of these Transfer Forms lacked the required appeal rights and Ombudsman information, and the EHR showed no documentation that a written transfer/discharge notice was provided. Staff interviews further confirmed that the required written notices were not being provided. A registered nurse reported that when a resident was transferred to the hospital, they completed the transfer form/packet, made a copy for the resident, and verbally notified the resident or representative of the bed hold if the resident was alert, but did not reference providing written appeal rights or Ombudsman information. The Resident Care Manager stated they had never provided a transfer/discharge notice that informed residents or representatives of appeal rights and Ombudsman contact information and confirmed that the transfer form did not contain this information. The Executive Director acknowledged that the facility used the transfer form and that it did not include the required appeal rights and Ombudsman notification. Surveyors also found a deficiency related to bed-hold notices. The facility’s “Bed-Holds and Returns” policy, revised in October 2022, required that all residents/representatives receive written information about facility and state bed-hold policies at least twice: in advance (e.g., in the admission packet) and again at the time of transfer or within 24 hours for emergency transfers. For one resident, a discharge MDS showed admission to a short-term general hospital, and the resident stated they were not notified of a bed hold. The resident’s Bed-Hold and Return Agreement in the record was undated and not completed, and there was no documentation in the EHR or progress notes that a bed-hold notice was provided. The Medical Records Director confirmed that the agreement was loaded but incomplete and that there was no progress note documenting provision of a bed-hold notice. For another resident with a discharge MDS indicating admission to a short-term general hospital, the resident’s representative reported not being notified of a bed hold. Review of the EHR showed no documentation that a bed-hold notice was provided to the resident or representative. The Social Service Director stated that nursing would notify the resident of a bed hold and, if unable, the Business Office Manager would follow up with the representative and document at a minimum with a progress note. The Business Office Manager described a process of providing a bed-hold form, calling the representative, and documenting in progress notes, but acknowledged that no progress note was found indicating that a bed-hold notice was provided to these two residents or their representatives and stated that they should have been notified and it should have been documented. The Executive Director stated that the expectation was for staff to offer a bed-hold notice when a resident was discharged to the hospital and to follow up and document if they were unable to provide it at the time of transfer.
Inaccurate MDS Coding for Catheters, Insulin, Ostomy, Turning Programs, and Hospice
Penalty
Summary
The deficiency involves the facility’s failure to ensure accurate completion of the Minimum Data Set (MDS) assessments for multiple residents, contrary to the RAI 3.0 User’s Manual requirements for validated, interdisciplinary assessments over the defined look-back period. For one resident, the quarterly MDS indicated the presence of an indwelling catheter in Section H, even though observation and interview confirmed the resident did not have a catheter and reported it had been removed months earlier. Review of progress notes and physician orders showed the catheter had been discontinued the prior year, before the MDS look-back period. The MDS coordinator acknowledged that the catheter item was marked inaccurately and that the resident should not have been coded for an indwelling catheter. The facility also inaccurately coded insulin injections for two residents. One admission MDS showed seven days of injections and seven days of insulin injections in Section N, while the MAR and TAR for the look-back period documented insulin injections on only two days. For another resident, the admission MDS showed zero days of insulin injections, but the MAR and TAR documented insulin injections on seven consecutive days within the look-back period. In both cases, the MDS coordinator confirmed that the MDS coding did not match the documented administration of insulin and that the assessments were inaccurate. The DON stated an expectation that MDS assessments be completed accurately and acknowledged that these admission MDS assessments were inaccurate. Additional inaccuracies were identified for residents with ostomy status, turning/repositioning programs, and hospice/prognosis. One admission MDS coded an ostomy in Section H for a resident, yet provider orders, progress notes, and MAR/TAR contained no evidence of an ostomy device, and the MDS coordinator stated the resident never had an ostomy and that the MDS was not accurate. Another resident’s quarterly and annual MDS assessments were coded for a turning/repositioning program in Section M, but the care plan did not contain an active turning/repositioning program intervention, and the EHR lacked documentation that such a program was monitored or reassessed for effectiveness; the only related intervention had been resolved previously. The MDS coordinator stated there was no documentation to support the program and that the coding was inaccurate. For another resident, the EHR and hospice physician note documented admission to hospice services and a prognosis of six months or less, but the admission MDS did not code hospice services in Section O and marked “no” for a prognosis of less than six months in Section J1400. The MDS coordinator confirmed that hospice and prognosis should have been coded and that the MDS was inaccurate.
Medication Administration in Common Areas and Poor Room Conditions
Penalty
Summary
The facility failed to ensure a homelike environment when medications were administered to two residents in the common area in front of the nurse station. Staff observed administering morning medications to one resident in the common area because the nurse was behind time, and the nurse later stated that medications were not supposed to be given in common areas for privacy reasons. Another LPN later administered medications to a second resident in the same common area and stated that, as far as she knew, it was okay to give pills outside the room. The DON stated that medications were not expected to be administered to residents in common areas. The facility also failed to maintain a clean, safe, and homelike environment in several resident rooms. In one room, the baseboard heater was observed coming away from the wall on multiple occasions, and the resident stated it had been that way for a long time and that staff had been told about it. Staff who observed the condition stated it needed to be reported to maintenance, and the Regional Maintenance staff confirmed the heater was coming off the wall. The Executive Director stated maintenance was responsible for resident rooms and that a baseboard heater would not be expected to be coming away from the wall. Additional environmental concerns were identified in other resident rooms. One resident’s wheelchair and commode were observed inside a red marker placed around a baseboard heater, despite the resident stating there was nowhere else to place them; the Maintenance Director stated nothing should be in that area because it was a heater and that items there could be a fire risk. Another resident’s bed sheet was observed with brown and greenish-yellow stains and the bed was unmade, and the resident stated the bed had not been made for a week or since admission. In a separate room, a dark brownish-red dry substance was observed on the bed footboard on multiple days, and housekeeping staff stated it looked like blood and should have been cleaned.
Food Storage and Hand Hygiene Failures
Penalty
Summary
The facility failed to ensure foods were handled in accordance with professional food safety standards in the kitchen walk-in refrigerator, dry storage room, and during staff food handling activities. The report states that the facility’s policy required dry foods to be stored in a manner that maintained packaging integrity and refrigerated foods to be covered, labeled, dated, monitored, and used by their use-by date, frozen, or discarded. The hand hygiene policy stated that hand hygiene was the primary means to prevent the spread of infections and was required before and after handling food, after removing gloves, and between dirty and clean tasks. In the kitchen walk-in refrigerator, an observation showed a plastic container of pineapple dated 2/20/26 with no use-by date and a metal container of chopped red onions with no label and no use-by date. Staff C stated that food items were to be labeled with what they were and that the pineapple was good for seven days, but also stated that they did not expect staff to label it with the use-by date because they could count. A later observation showed a metal container labeled lettuce with a use-by date of 2/12/26, and Staff C stated that it should have been discarded. In the dry storage room, an opened, uncapped container of distilled vinegar dated 09/09/2025 was observed. Staff C stated that food items were expected to be capped or covered and that the vinegar should have had a cap. During kitchen observations, Staff GG was seen removing food scraps from a tray with bare hands, washing hands with water only, entering and leaving the kitchen without hand hygiene, scrubbing a sink with bare hands, and handling a scrub from murky sanitizer water containing used utensils, floating lids, and food debris. Staff HH was observed handling raw meat with gloves, touching a cooking spray bottle while wearing gloves used with raw meat, removing and replacing gloves without hand hygiene, and continuing food preparation without hand hygiene between glove changes. Staff C, Staff F, and Staff A all stated that hand hygiene was expected before handling food, between glove use, when moving from dirty to clean tasks, and when entering or leaving the kitchen.
Pest Control Program Not Effective in Kitchen and Resident Room
Penalty
Summary
The facility failed to ensure an effective pest control system was in place for the kitchen and for Resident 140. The facility policy stated that it maintained an ongoing pest control program to keep the building free of insects and rodents, but observations in the kitchen showed small black flies flying around the dish washing area and back entrance door, with dozens more stationary on the ceiling, wall, and cabinet doors in that area on separate observations. Staff Q and Staff R stated the flies had been a problem for at least two months, and Staff C acknowledged awareness of the flies and said staff had been putting chemical down the drain and spraying. The maintenance director stated staff were expected to submit a TELS request if flies or rodents were observed and that an exterminator would then be called, and the maintenance log showed a work order for gnats in the kitchen submitted on 02/24/2026, with no documentation of an earlier work order. Resident 140 was observed with fruit flies in the room, including on the window curtain, bedside table, and on top of a sandwich bag. The resident stated the bugs bothered them a lot and said they had informed a nurse aide and a housekeeper two weeks earlier, but no action had been taken. On later joint observations with the housekeeping director and the infection preventionist, fruit flies were still present on the curtain, bedside table, and sandwich, and both staff stated that a resident's room should not have fruit flies. The DON also stated that bugs should not be in a resident's room.
Failure to Maintain Resident Dignity During Room Entry, Grooming, and Mealtime Assistance
Penalty
Summary
The facility failed to maintain resident dignity for 3 of 29 residents reviewed for dignity. The report cites the facility’s policies on Privacy and Dignity, which require residents to be treated with dignity and respect, with staff knocking before entering rooms, introducing themselves, explaining procedures, and supporting residents in a dignified dining experience. Surveyors observed Staff KK, an LPN, entering Resident 106’s shared room on multiple occasions without knocking, introducing themselves, or stating their intentions. Staff KK later stated staff are expected to knock, introduce themselves, and tell residents who they are and what they are going to do, and the RCM and DON also stated that staff should knock, sanitize hands, introduce themselves, and explain what they are going to do. Resident 121 was documented as moderately cognitively impaired and dependent for personal hygiene. The care plan did not document any preference for facial hair, yet surveyors observed the resident with many long whiskers on the chin on multiple occasions. A CNA stated that if a female resident had facial hair they would ask if she wanted it shaved, and if the resident could not communicate, they would help shave it; the CNA also stated the resident needed assistance with personal hygiene. Staff later stated they would not expect facial hair on a female resident unless it was the resident’s preference, but no such preference was documented. For Resident 60, surveyors observed a CNA standing on the left side of the bed and not at eye level while assisting the resident with lunch. The CNA stated they knew they should be sitting down while assisting the resident to eat, and other staff stated the expectation was for CNAs to sit down, be eye to eye, communicate with the resident, and assist with meals in that manner.
Failure to Protect Resident PHI
Penalty
Summary
The facility failed to ensure privacy and confidentiality of a resident document containing personal health information for 1 of 3 Unit Resident List/Document reviewed for confidentiality of records. On 02/27/2026 at 9:18 AM, surveyors observed a paper document titled MW2 UNIT sitting on top of the medication cart, with residents' names and nursing notes regarding the medication pass visible to anyone in the hallway. During a joint observation and interview on 02/27/2026 at 9:24 AM, an LPN confirmed the MW2 Unit document contained PHI and was placed on top of the medication cart where people walking in the hallway could see it. The LPN stated the document should not have been left visible. Later interviews with the Resident Care Manager and DON confirmed that PHI should be kept private and that resident documents should be flipped over, covered, or otherwise stored to prevent exposure of resident information.
Failure to Log and Investigate Missing Personal Property Grievance
Penalty
Summary
The facility failed to initiate and resolve a grievance for Resident 52 regarding missing personal items. Resident 52 was readmitted to the facility and was cognitively intact. On 02/24/2026, Resident 52 stated that their phone charger and documents were missing after their belongings were packed away when they were hospitalized, and that the facility had not replaced the charger or found the documents. Resident 52 also stated that their representative had spoken to Staff J, the Social Service Director, about the missing items. Review of the facility grievance log from September 2025 through February 2026 did not show that a grievance was logged for Resident 52’s missing charger or documents, and no investigation was documented. Staff J stated that when residents or representatives reported missing personal property, a grievance would be started and investigated, but Staff J was not aware of Resident 52’s missing charger. Staff J also stated that Resident 52’s representative had spoken to Staff A, the Executive Director, about a missing bag that had been packed when Resident 52 was hospitalized, and Staff J stated that a grievance should have been filed. Staff A stated that they expected a grievance form to be completed and logged when missing personal property was reported, and acknowledged that they should have filed a grievance but did not.
Admission MDS Not Completed Timely
Penalty
Summary
The facility failed to ensure that Resident 4’s admission MDS was completed in a timely manner. Review of the Resident Assessment Instrument (RAI) 3.0 User’s Manual showed that the admission assessment must be completed by the end of day 14, counting the date of admission as day 1. The facility’s policy stated that the RN is responsible for conducting and coordinating the completion of the resident assessment, and that the Resident Assessment Coordinator must date and sign each assessment to certify completion. Resident 4 was admitted to the facility on [DATE]. Review of the admission record and admission MDS showed that the MDS was completed on 08/05/2025, which was 12 days late. During a joint record review, the MDS Coordinator stated that the admission MDS should have been completed by 07/28/2025 and acknowledged that it was not completed timely. The DON also stated that Resident 4’s admission MDS was expected to have been completed timely.
Late Quarterly MDS Completion
Penalty
Summary
The facility failed to complete a Quarterly MDS assessment within the required timeframe for one resident, Resident 25, whose quarterly/discharge MDS had an ARD of 08/09/2025 but was completed on 05/25/2025, three days late. Review of the RAI Manual showed that a Quarterly MDS is used to track the resident's status between comprehensive assessments and that the completion date must be no later than 14 days after the ARD. During interview and joint record review, the MDS Coordinator stated that quarterly MDS assessments are due 14 days from the ARD, and the DON stated that MDS assessments were expected to be completed timely. Staff C stated that the assessment was completed late.
Late Completion of Discharge MDS Assessments
Penalty
Summary
The facility failed to complete and transmit discharge MDS assessments within the required timeframe for 1 of 29 residents reviewed, Resident 14. Review of the RAI Manual showed that a discharge non-comprehensive MDS must be completed no later than 14 days after the ARD and transmitted within 14 days of completion. Resident 14 had a discharge MDS with an ARD of 01/17/2025 that was completed on 02/03/2025, and another discharge MDS with an ARD of 05/03/2025 that was completed on 05/20/2025; both were documented as three days late. During interview and record review, the MDS Coordinator stated the discharge assessment was due 14 days from the ARD and acknowledged that Resident 14's discharge assessments were late and should have been completed on time. The DON stated that MDS assessments were expected to be completed timely.
Incomplete Care Plans for Anticoagulant Use and ADL Nail Care
Penalty
Summary
The facility failed to develop and/or implement comprehensive care plans for 2 of 29 residents reviewed. For Resident 7, the physician ordered rivaroxaban 20 mg by mouth for DVT, and the January and February 2026 MAR showed the medication was administered daily. Review of the resident’s comprehensive care plan printed on 02/25/2026 showed no care plan for anticoagulant usage. During a joint record review and interview, the RCM stated that residents receiving anticoagulants are monitored for bleeding and have labs done, and acknowledged that there should be a care plan for anticoagulants. The DON also stated that Resident 7 would be expected to have a care plan for anticoagulant use. For Resident 121, the admission MDS showed dependence for personal hygiene, and the ADL care plan revised on 12/19/2025 stated the resident required one-person total assist with personal hygiene, including cleaning and trimming nails on bath day and as necessary, with trimming to be done by CNA. However, observations on multiple dates showed long fingernails with brown material underneath both hands. A CNA stated the resident needed help with ADLs and that she could not clean under the nails or trim fingernails, and said the fingernails needed to be trimmed and appeared to have food underneath them. The RCM stated staff were expected to follow the care plan/Kardex and that CNAs should clean and trim the resident’s fingernails, and the DON stated staff should provide assistance with personal hygiene including nail care when the care plan directs it.
Missed Care Conferences and Inaccurate Shower Care Plan
Penalty
Summary
The facility failed to facilitate quarterly care conferences or care plan meetings for Resident 25, who was cognitively intact and had quarterly MDS assessments completed. Resident 25 stated they did not remember attending a care conference meeting. Review of the electronic record showed no documentation that Resident 25 attended or was offered a care conference, and no documentation that they declined to attend. Staff stated that care conferences were to begin on admission, be offered quarterly and as needed, and be documented in Social Services notes if offered or declined, but the record for Resident 25 did not show that this occurred. The facility also failed to ensure Resident 6's care plan was revised to reflect shower preferences. Resident 6 stated they preferred showers on day shift and had told the shower aide they wanted two showers a week. Shower documentation showed morning shower preferences on check-off sheets, while the bathing/shower task and shower schedule listed evening showers on Monday and Thursday. The comprehensive care plan did not document the resident's preference for morning showers and instead only addressed bathing/showering in general terms. Staff interviews showed that CNA/shower aides followed the shower schedule and that shower preferences were supposed to be communicated to the RCM and care planned. The RCM stated shower preferences would be care planned and acknowledged that Resident 6's care plan did not reflect the morning shower preference and should have been revised. The DON stated that shower preferences should be honored and that the care plan should have been revised to reflect the resident's preference.
Failure to Provide ADL Assistance for Hygiene Needs
Penalty
Summary
The facility failed to provide necessary assistance with ADLs for two residents who were dependent or required substantial assistance with personal hygiene, nail care, and oral care. The facility policy stated that residents unable to perform ADLs independently would receive services necessary to maintain grooming and personal and oral hygiene. Resident 121’s MDS showed dependence for personal hygiene, and the care plan directed one-person total assist with personal hygiene, including cleaning and trimming nails on bath day and as needed by CNA staff. However, observations on multiple dates showed Resident 121 with long fingernails and brown material under both hands’ fingernails, including after a hospice shower aide had completed a bed bath. Staff interviews confirmed that Resident 121 needed help with ADLs, that CNAs were responsible for nail care, and that the resident’s nails should have been cleaned and trimmed during the bed bath. Resident 13’s quarterly MDS showed substantial/maximal assistance was needed for nail care and oral care, and the care plan required oral care every morning, after meals, at bedtime, and as needed. Observation and interview showed Resident 13 had long, unclean fingernails with brown material underneath and stated staff had not trimmed the nails despite requests for help. The resident also had yellow-brown crust deposits near the gum line and stated they had not brushed their teeth for nearly a week because requested help had not been provided. Staff interviews confirmed the nails were long and dirty, the teeth needed cleaning, and that aides were responsible for nail care and oral hygiene unless the resident had diabetes, in which case a nurse would perform nail care.
Constipation Monitoring and Hospice Coordination Failures
Penalty
Summary
The facility failed to consistently monitor and manage constipation for a resident with a history of constipation and unspecified intestinal obstruction. The resident was readmitted with diagnoses that included constipation and intestinal obstruction, and stated that staff were not tracking bowel movements and that it had been four days since the last bowel movement. The resident had physician orders for PRN polyethylene glycol, milk of magnesia if no bowel movement on the third day, bisacodyl suppository if MOM was ineffective, and sodium phosphate enema PRN. Record review showed multiple extended periods without documented bowel movements, including four days in August, four days and six days in September, eight days in October, and seven days in December. The MAR showed PRN bowel medications were given on some occasions after several days without a bowel movement, including on the fifth day in August, on the third and fifth days in September, and on the ninth day in October. The record also showed no PRN bowel medications were given during some periods without bowel movements, including September 1 through September 4 and December 7 through December 13. Staff interviews stated that the EHR should alert nurses after three days without a bowel movement, that nurses should assess the resident and provide PRN bowel medications, and that staff should follow the bowel protocol, but the resident’s bowel concerns were not consistently addressed as expected. The facility also failed to ensure consistent communication and collaboration of care with hospice staff for a resident receiving hospice services. The resident’s assessment showed hospice involvement, and the care plan included an intervention to incorporate the hospice plan of care, but there were no resident-specific interventions identifying hospice’s role or how hospice and facility staff would collaborate. The resident’s EHR contained no hospice plan of care or hospice visit notes. A hospice shower aide was observed providing a bed bath, and staff stated they relied on nurses, Kardex information, or communication with the shower aide to know which residents were on hospice and what services hospice provided. Facility staff and medical records staff stated they expected hospice documents and visit notes to be uploaded into the resident’s record, but the record review showed no such documentation.
Failure to Monitor and Document a Resident’s Heel Pressure Injury
Penalty
Summary
The facility failed to ensure ongoing assessment, monitoring, and documentation of a right heel stage 2 pressure ulcer/injury for one resident. The resident’s comprehensive care plan stated that a registered nurse would assess, record, and monitor wound healing weekly and as needed, including the wound perimeter, wound bed, and healing progress, and would report improvement or decline to the physician. The physician orders showed an active order for the resident’s right heel wound, and the weekly skin evaluation on 12/21/2025 documented the right heel pressure wound as measuring 3.5 cm by 4 cm. After the initial documentation, the weekly skin evaluations dated 12/28/2025, 01/04/2026, 01/15/2026, 01/18/2026, 01/25/2026, 02/08/2026, 02/15/2026, and 02/22/2026 did not show ongoing assessment, monitoring, or documentation of the right heel pressure ulcer/injury. Progress notes from December 2025 through February 2026 also did not show ongoing assessment, monitoring, or documentation of the wound. The resident was seen by the wound provider for a right lower leg wound, but not for the right heel pressure ulcer/injury. During interviews, the RCM stated the wound should have been monitored weekly and documented in progress notes and/or weekly skin assessments, and the DON stated they expected ongoing assessments, monitoring, and/or documentation of the right heel pressure ulcer/injury.
Smoking Materials Left Unsecured in Resident Room
Penalty
Summary
The facility failed to ensure smoking materials were properly stored for Resident 77. The facility's No Smoking Policy stated that residents who smoke could leave the facility and smoke off the property, and that residents retaining their own smoking materials must keep them in a locked cabinet when not in use, with the key in the resident's possession. The Smoking and Safety assessment showed that Resident 77 used cigarettes. On observation, a lighter and pipe were found on Resident 77's bedside table, and Resident 77 stated they smoked and were allowed to have their smoking materials with them. Staff EE, a CNA, was unsure whether residents could keep smoking materials with them and observed the lighter and pipe on the bedside table. Staff I, RCM, stated residents could keep smoking materials and would be given a locked box, but a later joint observation showed no locked box in the room. Staff H, RCM, stated the facility was a no smoking facility, that some residents smoked off property, and that smoking materials had to be in a locked box and should not be on the bedside table. Staff B, DON, and Staff A, Executive Director, both stated smoking materials should be secured in a secure box or locked box/drawer.
Improper Storage of BIPAP Mask and Delayed O2 Tubing Change
Penalty
Summary
The facility failed to properly store a resident’s BIPAP mask when it was not in use and failed to ensure timely changing of the resident’s O2 tubing. Resident 27 was admitted with diagnoses that included sleep apnea and acute respiratory failure with hypoxia and had an order for 3 liters of O2 continuously for shortness of breath and BIPAP use at night. The facility’s oxygen administration policy stated that staff would check the tubing connection to the oxygen cylinder and ensure it was adjusted to the prescribed flow rate. On observation, the resident’s BIPAP mask was repeatedly found lying on top of a pillow with no cover or storage bag. The O2 concentrator was observed set at 2.5 liters, and the tubing connecting the BIPAP to the O2 concentrator was disconnected and dated 02/09/2026. Staff interviews confirmed the mask should have been stored in a plastic bag, the tubing should have been connected, and the tubing should be changed weekly. The Resident Care Manager and DON stated that tubing was expected to be dated, initialed, and changed weekly, and that BIPAP masks should be kept in a clear bag when not in use.
Failure to Care Plan for PTSD and Trauma-Informed Needs
Penalty
Summary
The facility failed to ensure that a resident with a diagnosis of PTSD received culturally competent, trauma-informed care and services. Resident 76’s admission MDS dated 02/06/2026 showed a diagnosis that included PTSD, but the comprehensive care plan printed on 02/24/2026 did not document any care plan addressing PTSD, history of trauma, or triggers. The facility policy titled, Trauma-Informed and Culturally Competent Care, revised in August 2022, stated that individualized care plans should address past trauma and incorporate language needs, culture, cultural preferences, norms, and values. During an interview and joint record review on 03/03/2026, the Resident Care Manager stated that residents with PTSD should be care planned and monitored for PTSD behaviors, and that the resident should have had a care plan in place. A CNA stated that they looked at the care plan and Kardex when caring for residents, but did not know that Resident 76 had a diagnosis of PTSD. The DON stated that residents with a diagnosis of PTSD were expected to have a care plan and full interventions in place, and that Resident 76 should have had a care plan.
Daily nurse staffing postings not updated
Penalty
Summary
The facility failed to ensure that the daily nurse staffing information was posted for 2 of 7 days reviewed, specifically for 02/28/2026 and 03/01/2026. The deficiency was identified during interview and record review, and the report states that the incomplete posting left residents, family members, and visitors at risk of not being fully informed of current staffing levels. The facility policy titled, Daily Nurse Staffing Posting, revised in June 2024, required the daily nurse staffing report to be completed at the beginning of each shift and posted very close to the beginning of the shift, with any needed changes made as soon as possible. On 03/02/2026 at 5:12 AM, the Daily Nursing Staffing Report observed was dated 02/27/2026. During a joint observation at 6:12 AM, the posting was still dated 02/27/2026 and there were no other postings behind it. Staff Y, Medical Records, stated the weekend receptionist should have posted the current Saturday and Sunday postings. Staff CC, Staffing Coordinator, stated the weekend postings should have been prepared on Friday and made available behind the Friday posting, but acknowledged that the Saturday and Sunday postings were not available to residents and/or their families. The DON later stated the staffing posting should have been posted and updated for both weekend days.
Expired Medications and Improperly Stored Lidocaine Patch
Penalty
Summary
Expired medications were found stored in multiple areas of the facility during observation and interview. On the Midwest 1 medication cart, an opened Haloperidol had an expiration date of January 2026. In the West Medication Room, staff found one unopened Fiber Lax bottle with an expiration date of January 2026 and one unopened Povidone-Iodine Swab sticks package with an expiration date of May 2022. Staff stated these medications were expired and should have been discarded, thrown away, returned to the pharmacy, or destroyed in a drug buster, consistent with the facility policy that discontinued, outdated, or deteriorated drugs would be returned to the dispensing pharmacy or destroyed. Medication storage was also not maintained for Resident 65. During observation, an opened package of Lidocaine patch was sitting on top of the resident’s dresser to the right side of the bed, and the resident stated the nurse had left it there and would come back to apply it to the right knee. Staff later confirmed that medications and patches were supposed to be stored in the medication cart and that the Lidocaine patch should not have been left on the dresser. The Director of Nursing stated that the patch was expected not to have been left there.
Inaccurate ADL Dressing Documentation
Penalty
Summary
The facility failed to ensure resident records were accurate for one resident reviewed for ADL care. Resident 88 was readmitted with a diagnosis that included dementia with other behavior disturbance. The quarterly MDS dated 01/18/2026 showed the resident required setup or clean-up assistance for upper and lower body dressing. Observations on 02/25/2026, 03/02/2026, 03/03/2026, and 03/04/2026 showed Resident 88 wearing the same clothing, including pink pants, a purple long sleeve shirt, and a purple vest. Additional observations on 02/26/2026 and 02/27/2026 showed the resident lying in bed wearing the purple shirt and vest. Despite these observations, the upper body dressing record from 02/25/2026 through 03/03/2026 documented assistance ranging from independent to substantial/maximum assistance and dependent. The lower body dressing record for the same period documented independent, substantial/maximum assistance, and dependent entries. During interviews, CNA staff stated Resident 88 was pretty much independent but needed supervision and reminders, and that the resident refused hands-on help and would kick staff out. Staff stated that if the resident refused dressing assistance, refusal should have been documented instead of independent or assisted care. The MDS Coordinator, Resident Care Manager, and DON all stated that CNAs were expected to document ADL care accurately, and that if the resident refused dressing assistance, the record should show refusal.
Broken Laundry Dryer Not Kept in Working Order
Penalty
Summary
The facility failed to ensure essential equipment was kept in operating condition for 1 of 2 laundry dryers, a Uni-Dryer Model. During a joint observation and interview, a pile of wet clothes was seen placed on top of a rolling cart next to two dryers, with one dryer in use and the older Uni-Dryer Model not in use. Staff stated that the nonworking dryer had been broken for a while and that they were waiting for a motor. Record review showed the facility policy, Maintenance Service, required maintenance service for all areas of the building, grounds, and equipment. In interviews, the Maintenance Director stated the dryer had not been working for a long time and that a motor had been ordered by the prior corporate company but never arrived. The Executive Director stated laundry equipment was essential equipment, acknowledged that the issue should not have taken that long, and stated that both dryers were needed.
Unsanitary Shower Room Conditions
Penalty
Summary
The facility failed to maintain a safe, comfortable, and sanitary environment in 1 of 3 shower rooms reviewed, the Southwest Hallway Shower Room. During a joint observation with the Maintenance Director, the shower room was found to have a brownish red substance on the walls and ground around the shower area, dark grey spots on the ceiling above the shower, hair on the floor throughout the room, and a shower chair with a dark grey substance on the legs. The Maintenance Director stated housekeeping was responsible for cleaning the shower rooms and said the brownish red substance and ceiling spots looked like mildew or mold, or possibly soap scum. The Housekeeper Director stated housekeeping was responsible for cleaning the shower rooms and could not clearly identify when the Southwest Hallway Shower Room was last cleaned, noting the sign-off sheet by the door appeared to show an unclear date. The Housekeeper Director stated the shower room should be cleaned daily and that, based on its condition, it did not appear to have been cleaned. A CNA/Shower Aide stated the last shower in that room was given the day before the observation and that the shower chair was sanitized between residents, while deep cleaning was done by housekeeping. The Infection Preventionist, DON, and Executive Director each stated they expected the shower rooms to be clean, and the Executive Director stated housekeeping was responsible for cleaning them daily.
CNA Annual Training Hours Not Documented
Penalty
Summary
The facility failed to ensure Certified Nursing Assistants had the required 12 hours of annual training for 1 of 5 staff reviewed, Staff U. The facility assessment stated that nurse aide training must be sufficient to ensure continuing competence and must be no less than 12 hours per year, and the facility policy also required nursing assistants to have a minimum of 12 hours of continuing education in a 12-month period. Staff U was hired on 05/16/2023, and the employee record reviewed did not contain documentation showing the required annual training hours. During interview, Staff F, Staff Development, stated that CNAs needed 12 hours of yearly training but there was no way of tracking the actual hours. Staff B, the DON, also stated that CNAs were expected to have 12 hours of required annual training and that the facility did not have a system to track the hours. On joint record review, Staff F provided Staff U's training record for 01/01/2025 to 01/01/2026, which showed 10.25 hours of training, and Staff F stated that Staff U did not have 12 hours of annual training.
Failure to Assess and Obtain Order for Resident Self-Administration of Bedside Medication
Penalty
Summary
The deficiency involves the facility’s failure to evaluate, assess, and obtain a physician’s order for a resident to self-administer medication and keep it at the bedside. The facility’s medication administration policy, revised in April 2019, required that residents may self-administer medications only if the attending physician, in conjunction with the interdisciplinary care planning team, determined they had the decision-making capacity to do so safely. The resident’s admission MDS dated 01/20/2026 showed they were cognitively intact and had a diagnosis of GERD. Surveyor observation on 02/03/2026 at 2:00 PM revealed a stack of medication cups on the resident’s bedside table, with one cup containing three round tablets and another containing one round tablet. The resident identified the tablets as TUMS (calcium carbonate) and stated they took them when needed and that some nurses observed them taking medications and some did not. A subsequent observation on 02/04/2026 at 1:59 PM again showed a medication cup with three round tablets on the bedside table. Review of the resident’s physician orders printed on 02/04/2026 showed an order for calcium carbonate chewable tablets, 1,500 mg by mouth before meals for GERD, but no order authorizing self-administration or keeping the medication at the bedside. During an interview and joint observation on 02/04/2026 at 4:05 PM, an LVN confirmed that residents requesting medications at bedside must be assessed for safe self-administration and acknowledged that this resident did not have such an order and that the medication should not have been at the bedside. In a later interview and record review on 02/06/2026, the charge RN confirmed there was no order permitting self-administration or bedside medications, and the DON stated that staff were expected to complete an evaluation and obtain a physician’s order before allowing a resident to self-administer and keep medications at bedside. The lack of assessment and physician order for this resident’s bedside TUMS constituted the cited deficiency.
Failure to Provide Appropriately Sized Bed for Tall Resident
Penalty
Summary
The facility failed to reasonably accommodate a resident’s needs and preferences by not providing an appropriately sized bed, despite the resident’s height and dependence on staff for bed mobility. Facility policy on bed safety and bed rails, revised in August 2022, states that bed dimensions are to be appropriate for the resident’s size and that consideration is to be given to comfort, safety, and freedom of movement, with input from the resident and family. The admission MDS dated 01/20/2026 documented that the resident was cognitively intact, had a height of 78 inches, and was dependent on staff for bed mobility. Observations on multiple days showed the resident wearing pressure-relieving boots with their feet pressed against the footboard. During observations, the resident reported that their feet were touching the footboard and that this caused knee pain, and stated that staff were aware and had to repeatedly scoot them up in bed. A CNA acknowledged that the bed was “small but not too small,” confirmed that the resident required two-person assistance to be repositioned when they slid down, and had not requested a longer bed. A joint observation with this CNA showed the resident’s toes touching the footboard when the head of the bed was raised. The Maintenance Director stated that requests for longer beds must come from the nurse manager and be care planned, and that admissions typically notify maintenance if an incoming resident is tall so an appropriate bed can be provided or rented. The DON stated that staff should notify maintenance if a resident requested a longer bed or if staff observed that a bed was too small, and the Administrator stated they expected residents to have appropriately sized beds, indicating that the established process was not followed for this resident.
Failure to Ensure Private Telephone Access and Unopened Mail Delivery
Penalty
Summary
The deficiency involves the facility’s failure to ensure residents had reasonable access to telephones and privacy for calls, as well as failure to ensure mail was delivered unopened. Facility policy on resident telephone use stated that residents shall have easy access to telephones, that telephones are available for private calls, and that telephones will be in areas that offer privacy and accommodate residents with hearing impairment or who use wheelchairs. The mail policy stated that residents may send and receive personal mail and other communication confidentially, that mail will be delivered unopened, and that staff will not open mail unless the resident requests it, with such a request documented in the care plan. For telephone access, one cognitively intact resident who was dependent for mobility reported they had not had a telephone since admission and had asked several nurses for one. Multiple observations on different days confirmed there was no telephone in this resident’s room and that the wall jack had no phone plugged in. A CNA and an LVN both stated that residents were supposed to have telephones in their rooms and acknowledged that this resident did not have one, with the LVN stating the resident should have a phone and that maintenance would normally be notified to place a portable phone if needed. The Maintenance Director stated that before new residents are admitted, staff check the phone, TV, call light, and bed, and that some phone lines are not working and residents are informed before admission, but also stated they expected this resident to have had a phone. The Maintenance Director further stated that residents without a need for privacy could use the nurse’s station phone, and for privacy could use the Nurse Manager’s or Social Services’ offices, and confirmed there were no telephones in common areas and no cordless phones currently available. For mail, another cognitively intact resident reported that several delivered packages had been opened and that they were told Social Services staff opened them to check for pills or liquids. The Administrative Assistant stated that Life Enrichment staff delivered packages and that if a package sounded like it contained medication, Social Services ensured it was given to nursing; they also acknowledged the resident had complained about opened packages and that the resident was told packages that sounded like pills would be sent to the nursing station. The Social Services Assistant stated they sometimes delivered mail, that if packages sounded like pills they would give them to a nurse, and that they had delivered an already opened package to this resident, which did not appear damaged, and they did not know who opened it. The resident reported receiving five or six opened packages, distinguishing between some that arrived damaged with tears and others that appeared cut open, and provided photos showing a large plastic package with a straight-line opening and inner packages, including one opened package outside the main bag. The Administrator stated they expected residents to receive mail unopened and that some residents order their own medications, and further stated they would expect staff to open packages in the resident’s presence.
Failure to Maintain Repairs and Housekeeping in Resident Rooms
Penalty
Summary
The deficiency involves the facility’s failure to maintain a safe, clean, comfortable, and homelike environment in multiple resident rooms, as required by its own “Homelike Environment” policy. Surveyors observed that in one resident room, the baseboard below the sink was coming off the wall on two separate dates. The resident in that room reported that housekeeping was aware of the issue. During a joint observation, the housekeeper who cleaned the room stated they had not noticed the loose baseboard and indicated that if they had seen it, they would have notified maintenance. The Maintenance Director later confirmed they were not aware of the baseboard problem and would have expected staff to submit a work order if they observed it. In another room, surveyors identified a hole in the bathroom ceiling above the toilet with black piping exposed, following a previously documented work order for water dripping from the ceiling that had a completion date several months earlier. One resident in that room stated the ceiling had been leaking since the prior year, and the roommate reported that water had dripped on them a couple of times and that maintenance was aware. A CNA stated they would report environmental disrepair or resident complaints to nursing and maintenance but said they had not seen the hole. A RN confirmed that the hole in the bathroom ceiling had been reported to maintenance and that maintenance was aware of it, while also stating they were not aware of the loose baseboard in the other room. The Maintenance Director acknowledged knowing about the ceiling hole and a slow drip and stated the hole had been present since October of the previous year. Surveyors also found housekeeping deficiencies in the same resident room where the baseboard was loose. The resident reported feces in the closet and said they had notified housekeeping and the Administrator in Training. Observations showed a smear of brown matter on the inside of the closet door and on the edge of the shelf, as well as cobwebs on the fire sprinkler above the resident’s bed, on the ceiling above the television, and by the closets. The resident stated their wound supplies were stored in that closet and expressed concern about infections. The housekeeper assigned to the room stated they cleaned closets and deep-cleaned rooms at discharge, claimed not to be aware of the brown matter, and acknowledged they were supposed to clean cobwebs. During a joint observation, the Housekeeping Supervisor confirmed expectations that closets be disinfected daily, rooms cleaned daily, cobwebs cleaned, and dusting done at least weekly, but also stated they were not aware of any complaints about feces in the closet until the surveyor’s observation.
Failure to Complete and Document Neurological Assessments and 15-Minute Safety Checks Post-Fall
Penalty
Summary
The facility failed to ensure that neurological assessments were completed as required following a resident's unwitnessed fall. According to facility policy, neurological assessments should be performed for 48-72 hours post-fall, but documentation showed that assessments for the resident in question were only completed for approximately 15 hours. Staff interviews and record reviews confirmed that the neurological assessment forms were not completed or dated beyond the initial period, and the expected protocol for continued monitoring was not followed. Additionally, the facility did not ensure that 15-minute safety checks, which were ordered by a physician for the resident due to fall risk, were consistently documented. Although staff stated that these checks were performed and documented on specific forms, there was no evidence in the electronic health record (EHR) to confirm that the checks were completed as ordered. Staff interviews revealed uncertainty about the location and completion of the documentation forms, and a review of the EHR did not show any record of the 15-minute interval checks during the relevant period. The resident involved had a history of dementia, falls, and venous thrombosis and embolism, and was identified as being at high risk for falls and injury. The lack of complete neurological assessments and missing documentation of 15-minute checks following an unwitnessed fall and during a period of increased risk constituted a failure to follow facility protocols and physician orders for monitoring and documentation.
Failure to Investigate and Resolve Resident Grievance
Penalty
Summary
The facility failed to thoroughly investigate and promptly resolve a grievance for one resident who was cognitively intact at the time of the incident. The resident reported that, in early September, staff left them soiled and dripping urine, and threatened not to answer their call light all night. The resident stated they informed social services staff, but felt ignored. Review of the facility's grievance log did not show any grievance filed for this incident. An undated grievance form indicated the resident had reported a delay in staff response to their call light, resulting in wet clothing and bedding, and expressed dissatisfaction with the staff's attitude. However, there was no documentation of follow-up or investigation regarding the grievance. Staff interviews revealed that the social services assistant was aware of the resident's complaint and had spoken to the staff member involved, but did not document any actions taken or follow-up. The administrator confirmed that the facility's process required grievances to be logged and investigated, regardless of whether the resident wanted to pursue the matter further. The administrator was not aware of the incident until the day of the survey and acknowledged that the grievance could be a potential allegation of abuse or neglect, which should have triggered an investigation according to facility policy.
Failure to Follow Infection Control Practices During COVID-19 Outbreak and Transmission-Based Precautions
Penalty
Summary
The facility failed to ensure proper infection prevention and control practices were followed by staff during a COVID-19 outbreak and in the care of residents on transmission-based precautions. Observations revealed that staff did not consistently use appropriate Personal Protective Equipment (PPE), such as N95 respirators, gowns, and gloves, as required by facility policy and posted signage. For example, an LPN was observed wearing a KN95 mask with ear loops instead of a fit-tested NIOSH-approved N95 respirator while entering and exiting a resident's room on Aerosol Contact Precautions for COVID-19. The same staff member was also seen in the hallway and entering other rooms with only a KN95 mask, despite being instructed to wear an N95 respirator during the outbreak. Additionally, signage instructed that resident room doors should remain closed for those on Aerosol Contact Precautions, but the doors were repeatedly observed open during multiple checks. A CNA was observed entering and working inside a resident's room on Aerosol Contact Precautions with the door left open, contrary to posted instructions. The CNA acknowledged awareness of the requirement to keep the door closed but stated it was not done due to being busy. Another CNA was seen making a bed for a resident on Enhanced Barrier Precautions (EBP) for a history of multidrug-resistant organisms without wearing a gown, despite signage and policy requiring gown and glove use for high-contact activities such as changing linens. The CNA confirmed knowledge of the need to use PPE in such situations but did not comply at the time of observation. A housekeeper was observed cleaning a room under Contact Enteric Precautions for a resident with a positive C. difficile diagnosis without wearing a gown, as required by posted signage and facility policy. The housekeeper later acknowledged the expectation to wear a gown in such circumstances. Interviews with supervisory staff, including the Infection Preventionist, Resident Care Manager, and Director of Nursing, confirmed that staff were expected to follow all posted precautions, including the use of appropriate PPE and keeping doors closed for residents on transmission-based precautions. However, these expectations were not consistently met during the survey observations.
Failure to Implement Care Plan for One-on-One Feeding Assistance
Penalty
Summary
A deficiency was identified when the facility failed to implement a care plan for a resident with significant Activities of Daily Living (ADL) needs. The resident had a care plan in place for ADL self-care performance deficit related to dementia, hemiplegia, limited range of motion, and a history of stroke, which included an intervention for one-on-one feeding assistance. Despite this, observations and interviews revealed that staff did not consistently provide the required one-on-one assistance during meals. Instead, a collateral contact (family member or representative) was often present and ended up assisting the resident with meals because staff would leave the meal tray and not return promptly to provide the necessary support. Staff interviews confirmed that they were expected to follow the care plan and remain with the resident for the entirety of the meal when one-on-one assistance was required. The Director of Nursing also stated that staff were responsible for assisting residents with meals and that any involvement of a resident representative in feeding should be documented in the care plan. The failure to implement the care plan as written resulted in the resident not consistently receiving the required assistance with eating.
Failure to Conduct Thorough Abuse Investigation
Penalty
Summary
The facility failed to conduct a thorough investigation into an alleged abuse incident involving a resident with moderate cognitive impairment. The incident was reported to law enforcement by a mandatory reporter, and the resident claimed that a nurse or aide physically grabbed their legs, resulting in bruises. The facility's investigation, dated the day after the incident, did not include interviews with all potential witnesses or staff members who might have been involved, and there was no documented conclusion or outcome of the investigation. Staff interviews revealed inconsistencies in the investigation process. A Certified Nursing Assistant who was assigned to the resident during the relevant time was not interviewed. The Licensed Practical Nurse responsible for the investigation claimed to have interviewed all staff within a 48-hour period but admitted to not documenting these interviews or the investigation's conclusion. The facility administrator could not confirm whether a thorough investigation had been conducted, acknowledging that staff interviews should have been documented and a conclusion written.
Failure to Report Influenza Outbreak
Penalty
Summary
The facility failed to report a communicable disease outbreak involving two residents who tested positive for influenza, a highly contagious virus. According to the facility's Infection Prevention and Control Program policy, outbreaks must be reported to the appropriate public health authorities. However, the Infection Preventionist, Staff D, acknowledged that they did not report the influenza outbreak involving Resident 2 and Resident 3 to the State Agency, despite the policy requirement. The Administrator, Staff A, confirmed that it was expected for such a report to be sent to the State Agency. This oversight placed residents, staff, and visitors at an increased risk of infection and related complications.
Improper Medication Administration by Untrained Staff
Penalty
Summary
The facility failed to ensure that medications were administered by trained and licensed nursing staff according to professional standards of practice. This deficiency was identified during a review of medication administration for a resident who had intact cognitive abilities. The resident reported that the Director of Nursing Services (DNS) gave their medications, including a narcotic pain medication, to a Certified Nursing Assistant (CNA) to administer. The resident refused to take the medication from the CNA, stating that medications should be administered by a nurse. Interviews with various staff members, including Licensed Practical Nurses (LPNs) and CNAs, confirmed that the facility did not employ medication technicians and that CNAs were not trained to administer medications. Staff members acknowledged that it was inappropriate and unsafe for CNAs to administer medications, and the DNS admitted to preparing and handing the medication to the CNA, recognizing it was a mistake. The facility's failure to adhere to proper medication administration protocols placed the resident at risk for unmet care needs and potential adverse effects.
Failure to Designate a Qualified Infection Preventionist
Penalty
Summary
The facility failed to designate a qualified staff member to serve as an Infection Preventionist (IP) to oversee the infection prevention and control program. The facility's policy requires that the IP obtain specialized Infection Prevention and Control (IPC) training beyond initial professional training, with evidence of training provided through a certificate of completion. The policy also states that the IP should be employed on-site and at least part-time. However, Staff D, who was designated as the IP, had not completed the test for their specialized training and was not certified at the time of the survey. Interviews with facility staff revealed that Staff D was responsible for the infection prevention and control program despite not being certified. Staff D mentioned that a corporate IP, who was certified, visited the facility once or twice a month and was available by phone for guidance. The Director of Nursing Services and the Administrator confirmed that Staff D was responsible for the program and worked closely with the corporate IP, who visited the facility monthly. This lack of a certified on-site IP placed residents, staff, and visitors at risk for unmet infection control issues and lack of oversight of infection control practices.
Deficiencies in Water Temperature, Blinds Maintenance, and Oxygen Equipment Storage
Penalty
Summary
The facility failed to maintain appropriate water temperatures for showers and bathing, affecting three residents. Resident 4 reported taking cold showers for three weeks due to a delay in fixing the hot water issue. Resident 25 mentioned the facility was without hot water for about two months, and Resident 73 experienced two cold showers due to the lack of hot water. Staff interviews revealed that the water temperature fluctuated, dropping to 97 degrees, and it took a week to obtain the necessary part to repair the water heater. The facility also failed to maintain or replace broken blinds in residents' rooms, affecting two rooms. Observations showed broken blinds covered with a blanket in one room, which was later removed, causing discomfort to the resident due to light exposure. Staff interviews indicated that broken blinds were reported, but the maintenance department had not yet ordered replacements, despite measurements being taken weeks prior. Additionally, the facility failed to appropriately store oxygen equipment for one resident. Observations showed an oxygen concentrator and tubing in a resident's room who did not use oxygen. Staff confirmed there was no physician order for oxygen for this resident, and the equipment should not have been present in the room. The administrator acknowledged the expectation for staff to report maintenance issues and for oxygen equipment to be stored correctly.
Inaccurate MDS Assessments for Multiple Residents
Penalty
Summary
The facility failed to accurately assess five residents using the Minimum Data Set (MDS) assessment tool, leading to potential risks for the residents. Resident 61 had a stage 2 pressure ulcer that was not coded in their annual MDS, despite documentation in the wound care progress notes. Conversely, Resident 76's quarterly MDS inaccurately included stage 1 and stage 2 pressure ulcers, which were not documented in the Electronic Health Record (EHR) during the look-back period. Additionally, Resident 76's significant change MDS failed to code for depression, despite a physician's note indicating an antidepressant prescription for depression and poor appetite. Resident 62's admission MDS incorrectly marked a change in behavior as zero, despite having no prior MDS assessment, which should have been marked as N/A. Resident 16's quarterly MDS assessments did not reflect the administration of insulin and hypoglycemic medications, even though the Medication Administration Record (MAR) showed daily insulin administration during the look-back periods. These inaccuracies in coding insulin use were acknowledged by the MDS coordinator during joint record reviews. Resident 95's discharge MDS was inaccurately coded for discharge to an acute hospital, while the social services progress notes indicated a discharge to home. The Director of Nursing Services and the MDS coordinator both acknowledged the expectation for accurate MDS assessments, highlighting the discrepancies found during the survey. These inaccuracies in the MDS assessments could lead to unidentified and unmet care needs for the residents involved.
Medication and Treatment Management Deficiencies
Penalty
Summary
The facility failed to adhere to professional standards of practice in medication administration and treatment management for several residents. For one resident, the facility did not administer the correct form of aspirin as prescribed. The resident was supposed to receive a chewable aspirin tablet, but instead, an enteric-coated aspirin was given. The registered nurse involved was unaware of the difference between the two forms and did not verify the medication properly before administration. Another resident with diabetes had specific physician orders to hold insulin if their blood sugar was below a certain level and if they had not eaten. However, the facility failed to follow these orders correctly. The resident's insulin was held even when their blood sugar was below the threshold, but they had consumed their meals. This oversight was acknowledged by the Director of Nursing Services, who confirmed that the insulin should have been administered under those circumstances. Additionally, the facility did not provide the necessary wound care treatment for a resident with a pressure ulcer. The resident reported not receiving the prescribed daily wound care, and observations confirmed the absence of wound dressing on multiple occasions. Furthermore, a staff member signed off on the medication administration record for wound care they did not perform, which is against professional standards. The Regional Director of Clinical Operations and the Director of Nursing Services both stated that they expected staff to follow the physician's orders and not sign off on treatments they did not administer.
Inaccurate Daily Nurse Staffing Postings
Penalty
Summary
The facility failed to ensure the daily nurse staffing form was accurately completed for the number of staff worked and actual hours worked for six days within a month. The facility's policy required the daily nurse staffing posting to be completed at the beginning of each shift, reflecting the actual number and shift of licensed and unlicensed nursing staff responsible for resident care. However, the review of the daily nurse staffing postings revealed discrepancies, such as adjustments made for Certified Nursing Assistant (CNA) staffing totals without corresponding adjustments for actual hours worked, and missing data for certain shifts. Interviews with staff members highlighted a lack of adherence to the policy. Staff BB, responsible for posting the daily nurse staffing information, admitted to not adjusting the hours worked when there were call-outs and stated that modifications were made the following day if changes occurred. The Director of Nursing Services and the Administrator both expressed expectations that the staffing postings should be updated as needed, including adjustments for call-offs and actual hours worked. The failure to post complete and accurate staffing information daily placed residents, family members, and visitors at risk of not being fully informed of current staffing levels.
Failure to Label and Store Tuberculin Vials Properly
Penalty
Summary
The facility failed to appropriately label and store drugs and biologicals in the East Medication Room Refrigerator, specifically concerning a multi-dose vial of tuberculin. During an observation and interview, it was found that the vial was opened but not dated, contrary to the facility's Omnicare Medication Storage Guidance, which requires vials to be dated upon opening and discarded after 30 days. Staff O, an LPN, acknowledged the oversight, and Staff J, the Resident Care Manager, confirmed that vials should be dated and initialed when opened, with a 28-day usability period. Staff B, the Director of Nursing Services, also stated that the vials should be dated and are good for 30 days after opening. This deficiency placed residents at risk of receiving compromised and ineffective medications.
Food Safety and Sanitation Deficiencies in Facility
Penalty
Summary
The facility failed to ensure food safety standards were met in two unit refrigerators and the kitchen's dishwasher. In the West Nursing Station Unit Refrigerator, a covered cup of cottage cheese was found without a label or date, and a cup of vanilla pudding was dated beyond the three-day limit for safe consumption. The refrigerator's thermometer showed temperatures of 48, 58, and 54 degrees Fahrenheit, which are above the federal standard of 41 degrees Fahrenheit for refrigerated food storage. Staff acknowledged the issues, noting that the thermometer was not working properly and that maintenance would be informed. Similarly, the East Nursing Station Unit Refrigerator also displayed a temperature of 48 degrees Fahrenheit, prompting staff to call maintenance. Additionally, the facility did not routinely test the chemical solution used in the kitchen's low-temperature dishwasher. The Dietary Manager was unaware of the requirement to perform chemical tests, relying instead on a monthly visit from Ecolab for testing. The Administrator confirmed that chemical tests had not been conducted and that the facility had only recently begun testing after being informed of the requirement. These oversights placed residents at risk for foodborne illness due to improper food storage and inadequate dish sanitation.
Infection Control Deficiencies in Water Management, Catheter Care, and PPE Use
Penalty
Summary
The facility failed to maintain an adequate water management program to prevent the growth of Legionella and other waterborne pathogens. The facility's policy required a detailed description and diagram of the water system, identifying areas at risk for bacterial growth. However, interviews with the Maintenance Director and Administrator revealed that there was no written description or diagram of the facility's water system, indicating a lack of compliance with the policy and CDC guidelines. Resident 36 experienced inadequate catheter care, as observations on multiple occasions showed the catheter tubing on the floor. Interviews with various staff members, including a Registered Nurse, Resident Care Manager, Infection Preventionist, and Director of Nursing Services, confirmed that the catheter tubing should not be on the floor, highlighting a failure in maintaining proper catheter care standards. The facility also failed to ensure proper hand hygiene and use of personal protective equipment (PPE) during resident care. Staff T, a Certified Nursing Assistant, did not perform hand hygiene after touching their facemask while assisting Resident 9 with meals. Additionally, Staff R, a CNA, did not perform hand hygiene between glove changes while providing care to Resident 61, and Staff M, a Registered Nurse, did not wear a gown while administering medication via a feeding tube to Resident 76, despite Enhanced Barrier Precautions being in place. Furthermore, the facility did not replace a full sharps container in the Southeast shower room, as required by their policy, posing a risk of healthcare-acquired infections.
Failure to Maintain Resident Dignity with Uncovered Catheter Bag
Penalty
Summary
The facility failed to maintain the dignity of Resident 88, who had an indwelling urinary catheter, by not ensuring the catheter drainage bag was covered with a privacy bag. Observations on two separate occasions revealed that the resident's catheter drainage bag was uncovered and visible from the hallway, exposing the yellow urine inside. This lack of privacy was confirmed during a joint observation with Staff AA, a Certified Nursing Assistant, who acknowledged that the catheter bag should have been covered to maintain the resident's dignity. Interviews with facility staff, including Staff J, the Resident Care Manager, and Staff B, the Director of Nursing Services, confirmed the expectation that catheter drainage bags should be covered and not visible from the hallway. The facility's policy on resident rights, dated August 2022, emphasized treating each resident with respect and dignity, which was not adhered to in this instance. This oversight placed Resident 88 at risk for decreased self-worth and a diminished quality of life, as the visible catheter bag compromised their dignity.
Failure to Inform Resident of Psychotropic Medication Risks
Penalty
Summary
The facility failed to inform a resident and/or their designated representative before administering a psychotropic medication, specifically Mirtazapine, which is used to treat depression. This deficiency was identified for one resident who was reviewed for unnecessary medications. The resident, who had been diagnosed with generalized anxiety disorder and major depressive disorder, was readmitted to the facility and started on Mirtazapine without being informed of the risks and benefits of the medication until 22 days after the medication was initiated. Interviews with facility staff, including the Resident Care Manager and the Director of Nursing Services, revealed that the facility's protocol was to inform residents of the risks and benefits of psychotropic medications before administration. However, in this case, the protocol was not followed, as the resident was not informed until well after the medication had been started. The Director of Nursing Services acknowledged that the information should have been provided on the day the medication was started.
Failure to Ensure Safe Self-Administration of Medication
Penalty
Summary
The facility failed to ensure the safe self-administration of medication for Resident 56, who was found to have a bottle of folic acid capsules on their nightstand without proper evaluation or orders. Despite being cognitively intact, Resident 56 had been self-administering folic acid for about a week without a self-medication administration evaluation or physician orders, as required by the facility's policy. Observations on multiple occasions confirmed the presence of the medication on the resident's nightstand, and interviews with staff revealed a lack of documentation and orders for the self-administration of folic acid. Staff K, a Licensed Practical Nurse, and Staff E, the Resident Care Manager, both acknowledged the absence of necessary orders and evaluations for Resident 56's self-administration of folic acid. The Director of Nursing, Staff B, confirmed that the facility's expectations were not met, as residents should have completed self-medication administration evaluations and secure storage for their medications. This oversight placed Resident 56 at risk for inaccurate or unsafe medication administration.
Failure to Document Advance Directives for Two Residents
Penalty
Summary
The facility failed to ensure that advance directives were obtained and documented in the medical records for two residents, which compromised their right to have their healthcare preferences honored. For Resident 76, although the advance directive was electronically signed and indicated that their collateral contact was the POA for health care, the document was not placed in the resident's medical record. This oversight was confirmed during an interview with the Social Services Director, who acknowledged that the advance directive should have been included in the medical record. For Resident 73, the facility did not document whether an advance directive was discussed or obtained. The advance directive policy and record form for this resident was found to be blank, and there was no documentation in the electronic health record. The Social Services Director confirmed that the resident's representative was the POA but could not provide evidence that the advance directive was requested or discussed. The facility's administrator stated that advance directives should be discussed upon admission and during care conferences, and the forms should not be left blank.
Failure to Address Resident Grievance Regarding Missing Property
Penalty
Summary
The facility failed to properly handle a grievance reported by a resident, identified as Resident 76, regarding a missing personal cell phone. Despite the resident having intact cognition and reporting the missing phone to staff members, including the Maintenance Director and a Laundry Aide, the grievance was not logged or investigated according to the facility's policy. The facility's grievance policy, revised in February 2024, mandates that grievances be reviewed within five business days and that a Resident Grievance Report be initiated for all concerns. However, the grievance was not documented in the facility's grievance log, and no formal grievance report was completed. Interviews with staff revealed that the Maintenance Director informed the Social Services Director about the missing phone, but no further action was taken to document or resolve the grievance. The Social Services Director acknowledged the oversight and confirmed that the resident's inventory list indicated two cell phones, which was not initially considered. The missing phone was eventually found in the resident's closet, but the failure to follow the grievance process placed the resident at risk for unmet care needs and a diminished quality of life.
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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Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release June 24, 2026) and official state health department websites — never guesswork.
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