Eliseo
Inspection history, citations, penalties and survey trends for this long-term care facility in Tacoma, Washington.
- Location
- 1301 N Highlands Parkway, Tacoma, Washington 98406
- CMS Provider Number
- 505435
- Inspections on file
- 36
- Latest survey
- April 22, 2026
- Citations (last 12 mo.)
- 5
Citation history
Health deficiencies cited at Eliseo during CMS and state inspections, most recent first.
A resident with PAD, diabetes, and chronic toe wounds had a long-standing relationship with a podiatrist whose hospital consult specified detailed wound care with betadine, gauze between toes, and protective wrapping, and the MDS indicated it was very important for family to be involved in care discussions. On admission, initial wound care orders including dressing were quickly discontinued and replaced by a wound consultant’s order to paint the toes with betadine and leave them open to air, without documented consultation or notification of the resident or representatives. Family members repeatedly told nursing staff they wanted the resident’s podiatrist involved and the podiatrist’s wound care regimen followed, reported seeing the foot without wrapping despite prior instructions, and expressed frustration that staff did not listen until the wounds became infected. The DON later acknowledged that the hospital podiatry recommendations and family concerns were not documented as being considered and that there was no documentation that the resident or representatives were consulted when wound care orders were changed.
The facility failed to provide complete medical records when two residents' legal representatives requested the residents' entire records. A family member reported missing documents and lack of staff identification in the records received. The Medical Records Assistant indicated that records were downloaded from the Point Click Care EMR to a flash drive as the "entire" record, but review showed missing orders, progress notes, provider notes, assessments, and other documents, and a documentation report without authentication of nursing assistant entries. The Director of Health Information and the DON both confirmed that the records provided were incomplete and that the documentation lacked identification of the staff who provided care and services.
Two residents experienced lapses in care when staff failed to follow physician orders and facility procedures. A resident with diabetes received daily glipizide but had blood sugars checked only during the first week after admission, despite several days of nausea, vomiting, poor PO intake, and meal refusals, and was later hospitalized with documented hypoglycemia attributed to glipizide and no PO intake. Another resident with peripheral arterial disease, diabetes, and moderate cognitive impairment developed a large, facility-acquired skin tear on the arm, but the record contained only an initial wound summary with no treatment orders, no investigation into how the injury occurred, and no documented communication with the resident or family, even though family involvement in care discussions was identified as very important.
Two residents had their meal intake inaccurately and prematurely documented by CNAs, including one case where a resident who ate only a few bites was recorded as having consumed more than half of the meal, and another where a resident still actively eating more than half of their tray was documented as having eaten only 25–50% while the meal was ongoing. A family collateral contact also reported that recorded intake did not match what they observed during meals, and the DON confirmed that staff are expected to document accurate intake only after meals are completed.
A resident with chronic respiratory failure, heart failure, and dementia had no documented bowel movement during their stay despite facility policy and provider orders requiring a stepwise bowel protocol. Admission information showed the last BM occurred prior to arrival, and the EHR contained no BM entries for the entire stay. The eMAR showed MOM was given, but there was no documentation of a digital rectal exam, rectal suppository, enema, or provider notification as required when MOM was ineffective. CNAs and LPNs described expectations to document BMs and follow the constipation protocol, and leadership acknowledged the protocol and orders were not followed. The resident’s family reported the resident was in pain, had no BM while at the facility, and was later found to have a fecal impaction at the hospital with additional complications.
Three residents requiring 15-minute monitoring for suicide risk or post-fall observation did not have complete or accurate documentation of their checks. In one case, a resident at risk for suicide was left unobserved during required intervals, and staff later documented checks they did not perform. For two other residents, monitoring logs were incomplete, with gaps in documentation, while the MARs indicated checks were done. The RCM confirmed that staff failed to follow documentation protocols.
A resident and their representative were not informed of specific charges for services not covered by insurance or private pay agreements. Only the daily room and board rate was disclosed, and additional service costs, such as therapy, were not communicated before the resident incurred them. This resulted in confusion and unmet expectations when services were discontinued and charges were not clearly explained.
The facility did not develop or implement complete care plans for five residents, resulting in unmet needs in areas such as activities, pain management, edema, and personal hygiene. Residents with dementia, chronic pain, edema, and dependence for personal care were observed or reported to have needs that were not addressed in their care plans, and staff confirmed that care planning was incomplete or missing for these issues.
The facility did not provide care as ordered for several residents, including not administering as-needed medications for loose stools, failing to monitor and document edema or apply compression stockings as ordered, and not repositioning a dependent resident as required. These actions were confirmed by staff interviews and direct observations.
Two residents with fluid restrictions were not properly monitored or provided fluids according to provider orders. Staff were unaware of the restrictions, documentation of fluid intake was inaccurate, and meal tickets instructed staff to provide more fluids than allowed. The process for totaling and monitoring fluid intake was not followed, resulting in residents receiving incorrect amounts of fluids.
The facility did not ensure that oxygen tubing and respiratory care equipment were properly dated and changed weekly as required by policy for three residents with significant respiratory and cardiac conditions. Observations found undated and improperly maintained equipment, and staff interviews revealed inconsistent knowledge and adherence to procedures for respiratory care equipment maintenance.
A resident with COPD and muscle weakness was moved between rooms multiple times and was not given the opportunity to view the new room or choose prior to one of the moves. The resident expressed concerns about the new room's size and the placement of personal belongings, and staff confirmed that the expected process of allowing a room viewing and follow-up on concerns did not occur.
The facility did not obtain or maintain required advanced directive (AD) and guardianship documentation for two residents, including one with dementia and another with a history of stroke. In both cases, the electronic health record lacked evidence of a durable power of attorney (DPOA) for healthcare, and care conference reports failed to document or review the residents' decision-making status as required.
A resident with dementia and depression continued to receive Seroquel and Depakote despite documentation that Seroquel was mostly ineffective and the resident had not exhibited behaviors for about a month. Staff observations noted the resident was frequently sleepy, and no dose reduction was attempted after starting Depakote, resulting in the continued use of unnecessary psychotropic medication and potential chemical restraint.
A resident with COPD and muscle weakness was involved in repeated verbal and physical altercations with a roommate, including items being thrown and shouting matches. Despite documentation of these incidents and facility policy requiring immediate investigation and reporting, no incident report was filed and the state was not notified. Staff interviews confirmed the reporting failure.
The facility did not conduct or document timely care conferences for two residents, one with diabetes and hypertension and another with heart failure, arthritis, and depression. Both residents either did not attend or could not recall attending a care conference, and required documentation was missing from the EHR, as confirmed by staff interviews and record review.
A resident with vascular dementia and depression was frequently documented by nursing staff as exhibiting continuous agitation and aggression, despite multiple observations and staff interviews indicating the resident was calm, asleep, or pleasantly conversive. This inconsistency between documentation and actual resident behavior reflects a failure to accurately monitor and record behaviors in line with professional standards.
A resident with diabetes and depression did not receive new glasses as prescribed following a neuro-ophthalmology consultation. Despite staff awareness and the prescription being available, a lack of communication and follow-up between nursing and health information staff led to a delay in obtaining the corrective lenses.
A resident with impaired mobility and a history of declining therapy services later requested to start a restorative therapy program. However, due to a lack of communication and follow-up among staff, the resident's request was not addressed, and no assessment or referral for restorative therapy was completed.
Two residents with chronic pain conditions did not receive appropriate pain assessment and monitoring. One resident on hospice care experienced daily pain but had inconsistent documentation and an improperly discontinued pain monitor. Another resident with multiple pain diagnoses reported ongoing pain and ineffective medication, with no ongoing pain monitoring or documentation in the EHR. Staff confirmed that pain assessments were not consistently performed or recorded as expected.
A resident with vascular dementia and depression did not receive person-centered, individualized interventions for dementia-related behaviors. The care plan included only general strategies and lacked documentation of the resident's preferences or specific approaches, despite ongoing behavioral issues such as aggression and resistance to care. Staff responses were limited to reapproaching, distraction, and redirection, without evidence of tailored interventions.
The facility did not post the required scheduled and actual nursing staff hours for each shift over several days. Staff responsible for staffing postings tracked the information but did not display it, and the Administrator was unaware of the incomplete postings.
A resident's grievances regarding missing property and communication issues were not promptly resolved by the facility. The grievance policy was not followed, as the Personal Possession Record was incomplete, and the investigation into missing items was inadequately documented. The resident's family reported dissatisfaction with a Social Services Assistant's involvement and faced communication challenges with the facility, leading to unresolved grievances and frustration.
A resident at risk for pressure ulcers due to peripheral vascular disease and diabetes mellitus did not receive adequate care to prevent ulcer development. Despite reporting heel pain, the facility failed to identify or treat a pressure ulcer, which was later discovered upon the resident's admission to another facility.
A resident at high risk for falls experienced multiple incidents, including a severe fall resulting in a neck fracture, due to the facility's failure to evaluate and adjust fall prevention interventions. The resident's bed was positioned diagonally, creating a hazardous environment, and staff did not document risk assessments or care deviations despite acknowledging the risks.
A resident with dementia frequently yelled and accused their cognitively intact roommate of theft, leading to verbal altercations. Despite staff interventions like 15-minute checks and redirection, the facility failed to adequately separate the residents or protect the roommate from ongoing verbal abuse, resulting in a deficiency.
The facility failed to properly label insulin pens in a medication cart, as observed during a survey. Two multi-dose insulin pens were found without an open date or expiration date. An LPN confirmed the oversight, and the DON stated that the expectation was for insulins to be dated with both the open and expiration dates.
The facility failed to maintain sanitary food storage in both the kitchen and resident refrigerators, with observations of undated, expired, and spoiled food items. Staff interviews confirmed that these practices did not meet the facility's expectations, posing a risk of contamination.
The facility failed to obtain signed consents for psychotropic medications before administration for three residents. One resident had their risperidone dosage increased without guardian consent, another was prescribed citalopram without consent documentation, and a third received multiple medications without documented consent or education on risks and benefits. Staff interviews revealed that the expectation was for LNs to obtain consents and document them, but this was not followed, risking adverse side effects and diminished quality of life.
The facility failed to maintain a safe environment for three residents. A resident had unsecured medications accessible, another experienced multiple falls without proper reassessment of a transfer pole, and a third had loose bedrails posing a safety risk. Staff interviews highlighted lapses in medication security, fall investigation, and bedrail inspection protocols.
The facility failed to offer, educate, and obtain consent for influenza and pneumococcal vaccinations for five residents, as required by their policy. A review of the EHRs showed no documentation of education or consent for these vaccinations. Interviews with staff revealed a lack of a consistent process for educating and obtaining consent, despite expectations set by the Director of Nursing Services.
The facility failed to offer, educate, and obtain consent for COVID-19 vaccinations for five residents, as required by their policy. A review of the residents' electronic health records showed no documentation of education on the risks and benefits of the vaccine. Interviews revealed that there was no process in place for educating and obtaining consent, as confirmed by the Infection Preventionist/RN and the DON.
The facility failed to maintain a griddle/oven combo unit and a freestanding refrigerator in safe working order. Observations revealed the refrigerator had standing water and condensation, while the griddle/oven unit had leaking grease. Staff interviews indicated the refrigerator was not in working order and should not have been used, and the Maintenance Director was unaware of the issues until later.
The facility did not have a regular maintenance program for inspecting bedrails, leading to potential risks for residents. Staff were expected to notice and report loose bedrails, but there was no formal system in place. The Maintenance Director confirmed this, and the Administrator acknowledged the need for regular inspections.
The facility failed to provide appropriate care for several residents, including delayed wound infection management for a resident with a femur fracture, inadequate monitoring of edema for a resident with CHF, and failure to report respiratory changes for a resident with COPD. Additionally, a resident with edema did not receive prescribed medication, and a resident with Parkinson's disease was improperly positioned without a care plan.
The facility failed to ensure that a resident was free from physical restraints, as evidenced by the use of a tilt in space wheelchair with a pressure alarm. The resident, with diagnoses including Parkinson's disease, was observed leaning in the wheelchair without proper documentation or a restraint assessment. The care plan lacked instructions for the wheelchair's use, and a nurse confirmed improper positioning and absence of markings for the correct tilt angle.
A facility failed to accurately assess a resident's pressure ulcers, which were incorrectly documented as present on admission. The resident, who had Alzheimer's and was unable to communicate needs, developed the ulcers after admission. The MDS Nurse admitted the error, and the DON confirmed the expectation for accurate assessments.
The facility failed to meet professional standards of practice for three residents regarding anticoagulant use and indwelling urinary catheter (IUC) care. A resident on Eliquis had no documentation of monitoring for bleeding, despite visible bruising. Two residents with IUCs had conflicting or unclear provider orders regarding catheter size and change schedules, leading to inadequate care. Staff interviews confirmed these deficiencies in documentation and order clarity.
A resident with Alzheimer's and other conditions did not receive a scheduled dressing change for a pressure ulcer, as observed during a dressing change. The LPN confirmed the missed change, and the treatment record showed missing documentation. The DON stated that nurses are expected to follow dressing change orders.
A facility failed to properly monitor a resident's fluid restriction, leading to the resident receiving more fluid than prescribed. The resident, with pulmonary edema and kidney failure, was supposed to have a 1500 ml fluid limit, but the MAR lacked clear instructions and a method to total daily intake. Staff acknowledged the documentation was confusing and inadequate for accurate monitoring.
A resident with dementia and anxiety was prescribed lorazepam PRN without a stop date, contrary to pharmacy recommendations to limit use to 14 days. The resident received the medication multiple times beyond the recommended period. The DON acknowledged the failure to adhere to pharmacy guidelines.
Failure to Incorporate Family Wound Care Preferences and Podiatry Oversight Into Plan of Care
Penalty
Summary
The deficiency involves the facility’s failure to incorporate a resident’s and resident representatives’ preferences for medical oversight and wound care into the person-centered plan of care. Resident 2 was admitted with peripheral arterial disease and diabetes, with a history of diabetic toe ulcerations that had been managed by an outpatient podiatrist. The admission MDS documented moderate cognitive impairment and that it was very important for the resident’s family to be involved in care discussions. The hospital podiatry consult specified a detailed wound care regimen, including betadine application to all toes and stable eschars, gauze in the web spaces, a sponge over the toes, and Kerlix wrap to protect the foot, with continuation of outpatient podiatry care after discharge. On admission, physician orders directed staff to apply betadine to the toes, place a dressing between toes 4 and 5, and cover with a light gauze dressing, but this order was discontinued the next day. A wound consultant then ordered the toes to be painted with betadine and left open to air, which differed from the hospital podiatrist’s wrapping instructions. There was no documentation that the resident or their representatives were consulted or notified when the original wound care orders were discontinued and the new open-to-air treatment was initiated. The DON later acknowledged that the hospital podiatry recommendations should have been considered on admission and when the family raised concerns, and that there was no documentation of consultation or notification regarding the change in wound care orders. Collateral contacts reported repeatedly expressing concerns and preferences for continued involvement of the resident’s long-standing podiatrist and adherence to that podiatrist’s wound care regimen. One family member stated the resident had been admitted with strict podiatry instructions and that the facility would not allow the podiatrist to treat the resident or follow the recommendations until the toe wounds deteriorated, describing significant frustration with nursing staff not listening. Another family member reported seeing the resident’s foot without wrapping despite prior instructions from the podiatrist to avoid sheet contact with the wounds, and stated they asked staff to involve the podiatrist and follow their treatment orders but felt they were ignored until the wounds became infected. Facility medical providers later stated they did not recall being aware of the long-standing podiatry relationship at the time of changing orders, and there was no documentation that the family’s expressed preferences for podiatry involvement and specific wound care were incorporated into the plan of care.
Incomplete Medical Records Provided to Resident Representatives
Penalty
Summary
The facility failed to provide complete medical records upon request for two residents whose legal representatives had requested the residents' entire records. A collateral contact reported that the family had requested and received the complete medical records for both residents but found that documents were missing and that some care staff were not identified in the records. Authorization to Disclose Health Information forms for both residents showed that their legal representatives had requested the residents' entire records from the facility. The Medical Records Assistant stated that when a resident or representative requested records, the facility sent the entire record by downloading it from the Point Click Care electronic medical record system onto a flash drive. However, review of the files sent showed incomplete medical records and a Documentation Survey Report with no authentication of nursing assistant documentation. The Director of Health Information confirmed that the records sent were missing orders, progress notes, medical provider notes, assessments, and other records, and explained that the software had been configured in a way that did not download the complete medical record. The DON also acknowledged that the entire medical records were not sent and that the documentation report did not identify who completed the care and service documentation.
Failure to Monitor Diabetic Resident and Investigate/Document Skin Tear
Penalty
Summary
The deficiency involves the facility’s failure to provide appropriate treatment and care according to physician orders and resident needs for a resident with diabetes. The resident was admitted with diabetes and a physician order for daily glipizide and daily blood sugar checks for seven days after admission. After the first week, staff stopped checking blood sugars despite ongoing administration of glipizide. Collateral contact reported the resident was not eating and appeared unwell, and that staff stated they had only checked blood sugars for a few days after admission and did not think further checks were necessary. Medical provider notes over several days documented persistent nausea, vomiting, and poor PO intake, as well as refusals of meals with minimal nutritional supplement intake. The resident was ultimately transferred to the hospital at the family’s request, where an emergency room note showed a glucose level of 47 and treatment with IV D50, and the hospital history and physical documented hypoglycemia due to glipizide and no PO intake. The DNS and the nurse practitioner later acknowledged that blood sugars had not been checked after the first week and that they should have advocated for or ordered blood sugar monitoring while the resident was on glipizide and not eating well. The deficiency also includes the facility’s failure to determine and document the cause and treatment for a skin tear in another resident. This resident had peripheral arterial disease, diabetes, moderate cognitive impairment, and required substantial assistance with dressing, bed mobility, and transfers, and it was very important for the family to be involved in care discussions. The resident’s family member reported learning of a large skin tear on the resident’s arm only after the resident was sent to the hospital and expressed concern about not knowing how the injury occurred. The facility’s wound summary documented a facility-acquired skin tear on the resident’s arm measuring 6.0 cm by 4.0 cm with light, bloody exudate. The DNS stated they had no idea how the skin tear occurred and that review of the medical record showed no documentation beyond the initial wound summary, with no treatment orders, no investigation into the cause of the skin tear, and no documented discussion with the resident or their representative.
Inaccurate and Premature Documentation of Meal Intake
Penalty
Summary
The deficiency involves inaccurate and premature documentation of meal intake for two residents, resulting in medical records that did not reflect actual food consumption. A collateral contact reported that when they assisted their family member with meals and later asked staff what had been recorded, the documented intake did not match what they had personally observed, and stated that staff "lied." During a lunch observation, one resident ate only two bites of the main dish and took a few sips of a supplement before indicating they were finished and leaving the dining room with assistance from a CNA. However, the Meal Monitor for that lunch documented that the resident had consumed 51–75% of the meal, and the record showed it was completed by another CNA. When interviewed, the CNA who completed the documentation for this resident stated they determined intake by looking at the tray after the meal and acknowledged that documenting 51–75% was likely due to looking at the wrong tray or making a mistake. In a separate observation, another resident was still actively eating and had already consumed all of their potatoes, about 75% of their chicken, and 50% of their green beans when their Meal Monitor showed only 25–50% intake, with the entry time-stamped while the resident was still eating. The CNA involved confirmed they did not know why the documentation had been completed before the resident finished the meal and acknowledged that intake should not be charted until the meal is completed. The DON stated that staff are expected to document the amount of food consumed at the end of the meal and to do so accurately, underscoring that the observed practices did not align with facility expectations.
Failure to Follow Bowel Management Protocol and Provider Orders
Penalty
Summary
The deficiency involves the facility’s failure to follow its bowel management protocol and provider orders for a resident with documented constipation risk. The facility’s undated "Management of Constipation" policy required daily documentation of bowel patterns and initiation of a bowel protocol if no bowel movement (BM) occurred in 48 hours, including administration of Milk of Magnesia (MOM) on the morning of the third day, a digital rectal exam 8–10 hours later if still no BM, a rectal suppository if soft stool was present, and provider notification for enema orders if there was no result within four hours of the suppository. Admission documentation showed the resident’s last BM was on 12/28/2025, and the electronic health record contained no documented BM for the entire facility stay. Provider orders dated 12/29/2025 mirrored the bowel protocol steps. Review of the eMAR showed the resident received MOM on 12/31/2025, and staff later reported an additional MOM dose on 1/2/2026, but there was no documentation of a digital rectal exam, rectal suppository, enema, or provider notification despite the continued absence of a BM. Interviews with CNAs and LPNs confirmed that CNAs were responsible for documenting BMs in the electronic system and notifying nurses if a resident had no BM in three days, and that nurses were expected to administer MOM, then a suppository, and then contact the provider for an enema if needed. The Resident Care Manager and the Director of Nursing acknowledged that the resident did not have a BM during the stay, that no digital exam or further constipation interventions were documented after MOM administration, and that the facility’s bowel protocol and provider orders were not followed. The resident’s daughter reported that the resident was in pain, had no BM during the facility stay, and was later found to have a fecal impaction requiring removal at the hospital, with further health complications noted there.
Incomplete and Inaccurate Documentation of 15-Minute Monitoring Checks
Penalty
Summary
The facility failed to ensure that medical records were complete and accurate for three residents who required 15-minute monitoring due to various clinical concerns, including suicide risk and post-fall observation. For one resident with a recent stroke and identified as being at moderate to high risk for suicide, staff failed to perform and document required 15-minute checks during a period when the assigned CNA was on break. Despite this, the monitoring log was later found to have documentation for the missed times, indicating inaccurate recordkeeping. The Resident Care Manager confirmed that staff are expected to document only the tasks they personally complete, and that this expectation was not met. For two other residents, both of whom were placed on 15-minute checks following falls, the monitoring logs showed incomplete documentation for required observation periods. In one case, the log was blank for a significant portion of the day, while the MAR indicated the checks had been completed. In the other case, there was a gap of several hours with no documentation of checks. The Resident Care Manager acknowledged these discrepancies and stated that it was not acceptable to document checks that were not performed or to leave required checks incomplete.
Failure to Disclose Charges for Non-Covered Services
Penalty
Summary
The facility failed to notify a resident and their representative of the specific charges for services not covered under their Medicare Managed Care or private pay agreements. Upon admission, the resident received information about daily room rates and a list of potentially chargeable services, but the actual costs for these services were not provided. Staff confirmed that only the daily room and board charges and beauty salon fees were reviewed with residents, and that costs for medical supplies or therapy were not disclosed. When the resident's insurance coverage ended, an Advance Beneficiary Notice of Non-coverage (ABN) was issued, indicating the resident would be responsible for a daily rate, but did not specify charges for additional services such as therapy or medical supplies. The resident and their financial representative believed all previously received services, including therapy, would continue under private pay, as no separate charges were communicated. However, therapy services were discontinued after insurance authorization ended, and the facility did not provide advance notice of separate charges for these services. Staff interviews confirmed that residents only received information about additional charges after incurring them, and that the ABN did not clarify what was included in the daily rate. This lack of transparency led to confusion and unmet expectations regarding the continuation and cost of services.
Failure to Develop and Implement Comprehensive Care Plans
Penalty
Summary
The facility failed to develop and implement comprehensive care plans for five residents, resulting in unmet needs related to activities, pain management, edema, and personal hygiene. For one resident with dementia, diabetes, and hypertension, the care plan documented preferences for music and reading, but observations showed the resident was left unengaged at the nurses' station, and staff interviews confirmed that appropriate activities were not consistently offered after a unit transfer. Another resident with fibromyalgia, arthritis, and colon cancer reported daily pain, but the care plan lacked specific pain monitoring interventions, and no pain monitoring documentation was found in the electronic health record. A third resident with back pain, sciatica, and arthritis reported severe pain that was not effectively managed, and although pain medication was administered, there was no care plan addressing pain. Staff confirmed that residents with ongoing pain complaints should have individualized pain care plans, but these were missing. For a resident with chronic kidney disease and edema, observations revealed significant swelling in the lower extremities, yet no care plan was initiated to address edema, contrary to staff expectations for accurate care planning. Additionally, a resident with multiple conditions including intracerebral hemorrhage, chronic kidney disease, and hemiplegia was observed with unshaved facial hair and long nails. The care plan did not specify the level of assistance or frequency for shaving and nail care, nor did it include the resident's preferences. Staff interviews indicated the resident was dependent on staff for these tasks and often refused care, but the lack of care planning for personal hygiene needs did not meet facility expectations.
Failure to Provide Ordered Care for Bowel Management, Edema, and Positioning
Penalty
Summary
The facility failed to provide appropriate treatment and care according to provider orders and residents' needs in several areas, including bowel management, edema management, and positioning. For bowel management, a resident with a history of congestive heart failure had provider orders for as-needed medications to address loose stools. Despite multiple documented episodes of loose stools, there was no evidence that the ordered medications were administered on those occasions. Staff interviews confirmed that the resident should have received the medications as ordered, but this did not occur. In the area of edema management, two residents with conditions such as congestive heart failure, respiratory failure, chronic kidney disease, and dependence on dialysis were not properly monitored or treated for edema. One resident had a care plan requiring daily assessment for edema, but there was no documentation of daily monitoring. Another resident had orders for daily use of compression stockings to manage edema, but observations showed the resident was often not wearing the stockings as ordered, and when worn, they were not properly applied. Additionally, nursing documentation did not accurately reflect the presence of edema, despite visible swelling observed during the survey. For positioning, a resident with significant physical impairments, including hemiplegia and dependence on staff for all care, was observed lying on their back in bed for extended periods across multiple observations. Staff interviews indicated the expectation that the resident should be turned every two hours, but there was no evidence this was occurring. The resident was also on hospice care and unable to consistently voice their needs, further emphasizing the importance of staff adherence to positioning protocols.
Failure to Monitor and Provide Fluids per Provider Orders for Residents with Fluid Restrictions
Penalty
Summary
The facility failed to properly monitor and provide fluids according to provider orders for two residents with fluid restrictions. For one resident with a history of spinal fracture, chronic kidney disease, and diabetes, provider orders specified a 1200 cc fluid restriction, with specific amounts to be provided by nursing and dietary staff. Observations revealed that the resident was given more fluids than allowed, and staff were unaware of the fluid restriction. Documentation of fluid intake was inconsistent and inaccurate, with daily totals not matching the amounts provided by nursing and dietary staff. Additionally, required signage indicating the fluid restriction was not posted at the resident's bedside, and meal trays contained more fluid than permitted by the restriction. For the second resident, who had dementia and diabetes, provider orders indicated a 2000 cc fluid restriction. Observations showed a full water pitcher at the bedside, and documentation of fluid intake was again inconsistent and inaccurate, with daily totals not aligning with the actual amounts provided. Meal tickets for both residents instructed staff to provide more fluid than the restrictions allowed, and the registered dietician confirmed that the meal tickets did not reflect the correct fluid restrictions. Interviews with staff, including a CNA, unit manager/LPN, registered dietician, and the DON, revealed a lack of awareness and adherence to the fluid restriction orders. Staff were unclear about which residents were on fluid restrictions, and the process for totaling and monitoring fluid intake was not followed as ordered. The facility did not ensure that residents with fluid restrictions received the correct amount of fluids as prescribed by their providers.
Failure to Date and Change Oxygen Tubing and Equipment as Required
Penalty
Summary
The facility failed to ensure that oxygen tubing and related respiratory care equipment were properly dated and changed according to policy for three residents who required respiratory support. Facility policy required that oxygen tubing, cannulas, masks, and small volume nebulizer (SVN) equipment be changed weekly and appropriately dated by nursing staff. However, observations revealed undated oxygen tubing and equipment in the rooms of all three residents reviewed, and in some cases, equipment was left uncovered or contained unknown liquid residue. One resident with a history of congestive heart failure, asthma, and pleural effusions was observed with uncovered SVN equipment on their bedside table, with undated tubing and a reservoir containing an unknown clear liquid. This resident had orders for SVN treatments as needed for shortness of breath and had received these treatments multiple times in the review period. Another resident with heart failure, dyspnea, and pulmonary hypertension was found with an undated oxygen mask and tubing, which the resident reported having brought from a previous hospital stay. Staff interviews revealed a lack of knowledge or adherence to the facility's policy regarding the dating and changing of oxygen equipment. A third resident with heart failure and acute respiratory failure with hypoxia was observed using an oxygen concentrator with a humidifier, but the tubing was not dated, and the resident was unsure how often the humidifier was changed. Review of this resident's records showed no specific order for changing the oxygen tubing or humidifier. Interviews with facility staff, including the Director of Nursing Services and unit managers, confirmed that the expectation was for weekly changes and dating of equipment, but this was not consistently implemented.
Resident Not Provided Opportunity to View New Room Prior to Move
Penalty
Summary
A resident with chronic obstructive pulmonary disease (COPD) and generalized muscle weakness, who was able to make their needs known, experienced multiple room changes within a few months. The resident reported dissatisfaction with a particular room move, stating they were not given a choice in the move and were not shown the new room prior to relocation. Documentation in the electronic health record confirmed room moves on three separate occasions, and a progress note indicated the resident expressed concerns about the new room being too small and issues with the placement of personal belongings. Social services staff were notified of these concerns. Interviews with facility staff revealed that the move in question was considered an emergency due to ongoing roommate issues, and the resident was not shown the new room beforehand, contrary to facility expectations. The Social Services Director acknowledged that the resident should have been given the opportunity to view the new room and that there should have been follow-up on the resident's concerns. The Administrator also confirmed that the lack of follow-up and failure to offer a room viewing did not meet facility expectations.
Failure to Obtain and Review Advanced Directives and Guardianship Documentation
Penalty
Summary
The facility failed to obtain and maintain appropriate legal documentation regarding advanced directives (AD) and guardianship for two residents. For one resident with a history of dementia, bipolar disorder, and psychotic disorder, the electronic health record (EHR) did not contain documentation of a durable power of attorney (DPOA) for healthcare, despite a physician's statement from several years prior indicating the resident lacked capacity to make their own healthcare decisions. The resident was unable to confirm if the facility had the necessary legal paperwork, and staff interviews confirmed that the AD was not present in the EHR and had not been reviewed as required during care conferences or the previous quarter. For another resident with a history of high blood pressure and stroke, there was no documentation of an AD for healthcare in the EHR, and care conference reports repeatedly indicated that no AD or DPOA was in place, with relevant sections left blank or marked as not applicable. The resident stated they did not have an AD, and staff were unable to locate any such documentation or explain the lack of follow-up. The facility's failure to obtain, document, and periodically review these legal documents did not meet expectations and was confirmed by both the Social Services Director and the Administrator.
Failure to Reduce Unnecessary Psychotropic Medication Use
Penalty
Summary
The facility failed to prevent the use of chemical restraints for one resident with vascular dementia and depression, who was prescribed Seroquel, Depakote, and Mirtazapine. Despite documentation that Seroquel was mostly ineffective and provider notes indicating a goal to discontinue it due to medication class risk, no dose reduction was attempted after Depakote was initiated. Observations over several days showed the resident was often sleepy or had eyes closed, and staff interviews confirmed the resident had not exhibited behaviors for about a month and was redirectable when behaviors had occurred. Staff also reported the resident was frequently sleepy during activities and sometimes did not attend due to this sleepiness. Review of records showed that although monthly psychoactive monitoring summaries documented Seroquel as mostly ineffective, the rationale for not reducing the dose was to continue the current plan of care. Interviews with nursing and social services staff confirmed that no dose reduction was attempted after starting Depakote, and the psychiatric nurse practitioner stated it was clinically contraindicated due to ongoing behaviors, despite staff observations to the contrary. The lack of timely dose reduction and continued use of Seroquel without clear evidence of ongoing behaviors led to the use of unnecessary psychotropic medication and potential chemical restraint.
Failure to Identify and Report Resident-to-Resident Abuse Allegation
Penalty
Summary
The facility failed to identify and report an allegation of abuse involving a resident who had recently been moved to a new room following an altercation with a roommate. The resident, who had diagnoses including COPD and generalized muscle weakness and was able to communicate needs, reported that their roommate had thrown items at them and that there had been several shouting matches. Despite these incidents, a review of the facility's incident logs showed no abuse allegation was logged for this resident. Progress notes documented verbal altercations and behavioral monitoring, but no formal incident report or state notification was made. Interviews with facility staff confirmed that an incident report should have been completed and the allegation reported to the state, but this did not occur. The facility's policy required immediate investigation and reporting of all alleged violations of abuse, including resident-to-resident altercations, within specified timeframes. The failure to follow these procedures resulted in the deficiency cited by surveyors.
Failure to Document and Conduct Timely Care Conferences
Penalty
Summary
The facility failed to provide and/or maintain timely documentation of care conferences for two of three sampled residents during care planning review. For one resident with diabetes and high blood pressure, there was no evidence in the electronic health record (EHR) that a care conference had occurred following admission, and the resident confirmed not having attended such a meeting. For another resident with heart failure, arthritis, and depression, although a social services progress note indicated a care conference was completed and was to be uploaded to the EHR, there was no documentation in the EHR to confirm this occurred, and the resident did not recall attending a care conference. Interviews with facility staff, including the Social Services Director and the Administrator, confirmed that care conferences had not been conducted or properly documented as required. Staff acknowledged that care conferences should have been held and documented within the initial assessment period and that the lack of documentation did not meet facility expectations. The absence of timely and documented care conferences was verified through both resident interviews and EHR review.
Inaccurate Behavior Monitoring Documentation for Dementia Care
Penalty
Summary
The facility failed to ensure that services provided met professional standards of practice by not accurately documenting behavior monitoring for a resident with vascular dementia and depression. The resident was assessed as confused and dependent on staff for care. Multiple observations over several days showed the resident was often calm, asleep, or pleasantly conversive, with no signs of agitation or aggression. However, the behavior monitoring documentation by nursing staff indicated continuous behaviors of agitation and aggression on several days and shifts, which was inconsistent with direct observations and staff interviews. Interviews with CNAs, an RN, and Life Enrichment staff confirmed that the resident had not exhibited aggressive or agitated behaviors recently, and was often calm or asleep during their shifts. The Director of Nursing Services stated that it was their expectation that behavior monitoring would be documented accurately. The discrepancy between the documented behaviors and actual observations/interviews demonstrates a failure to maintain accurate records in accordance with professional standards.
Failure to Provide Timely Vision Services
Penalty
Summary
A deficiency occurred when the facility failed to provide prompt vision services to a resident who required new corrective lenses. The resident, who had a history of diabetes and depression, was readmitted to the facility and had a neuro-ophthalmology consultation that resulted in a new prescription for glasses. Despite the prescription being available in early February, the resident reported in May that they had not received the new glasses, and staff were aware of this issue. The resident's electronic health record indicated adequate vision with corrective lenses, but the recommended new glasses were not obtained in a timely manner. Interviews with facility staff revealed a breakdown in communication and follow-up regarding the prescription. The Unit Manager/RN acknowledged that the prescription should have been addressed sooner, and the Health Information Clerk stated they never received the prescription from nursing, which prevented them from processing it with the in-house optometrist. The Director of Nursing Services was also unaware that the prescription had not been filled and noted that proper communication between nursing and health information/medical records was lacking. This failure resulted in the resident not receiving necessary vision services as recommended by their provider.
Failure to Provide Restorative Therapy Services After Resident Request
Penalty
Summary
A resident with chronic obstructive pulmonary disease, generalized muscle weakness, and impaired lower extremity function was admitted to the facility and identified as having an activities of daily living (ADL) self-care performance deficit related to impaired balance. The resident initially refused physical therapy services, expressing a preference to remain in bed and engage in leisure activities, and as a result, no restorative program was recommended at that time. Documentation indicated that the resident limited their own range of motion beyond what they could perform independently. Subsequently, the resident communicated a desire to begin a restorative therapy program during a social services check-in. However, there was no documentation of follow-up with nursing regarding this request, and the unit manager was unaware of the resident's interest in restorative therapy. The director of nursing services confirmed that a referral and assessment should have been completed but were not, due to a lack of communication. This failure resulted in the resident not receiving necessary services to maintain or improve their range of motion and mobility.
Failure to Accurately Assess and Monitor Pain Management
Penalty
Summary
The facility failed to accurately assess and monitor pain for two residents who required pain management services. One resident, with chronic kidney disease, heart failure, and on hospice care, reported daily pain in multiple areas but stated that they only requested pain medication when the pain was unbearable due to staff being too busy. Documentation showed discrepancies in the number of as-needed pain medications administered and a lack of monitoring of pain characteristics as required by the resident's care plan. The pain monitor for this resident was discontinued in error, and there was no documentation of ongoing pain assessment in the electronic health record (EHR). Another resident with multiple chronic pain conditions, including spinal stenosis, degenerative disc disease, and fibromyalgia, reported chronic pain and ineffective pain management, particularly overnight. There was no provider order to monitor this resident's pain level, and no documentation of pain assessment was found in the progress notes. Staff interviews confirmed that pain monitoring was discontinued after seven days, and the DON stated that it was expected for staff to assess and document pain at least daily for residents experiencing pain.
Failure to Provide Individualized Dementia Care Interventions
Penalty
Summary
The facility failed to provide person-centered, individualized interventions for a resident diagnosed with vascular dementia and depression. The resident was admitted with significant cognitive impairment, as evidenced by confusion and dependence on staff for care. The care plan included general interventions such as administering medications, maintaining a consistent routine, and engaging the resident in structured activities, but did not specify resident preferences or individualized approaches. The care plan lacked documentation of specific activities the resident preferred and did not include tailored interventions to address the resident's unique needs and behaviors. Record review and staff interviews revealed that the resident exhibited frequent behavioral disturbances, including aggression and resistance to care, such as becoming combative and striking staff during care. Staff responses to these behaviors included leaving and reapproaching the resident later, as well as attempting distraction and redirection. Despite these efforts, the care plan did not reflect the resident's preferences or document personalized strategies, and staff confirmed that behaviors were ongoing and often triggered during care. The lack of individualized, person-centered interventions placed the resident at risk of unmet care needs and diminished quality of life.
Failure to Post Daily Nurse Staffing Information
Penalty
Summary
The facility failed to post the scheduled and actual hours worked for nursing staff each day during the survey period, as required. Observations over four consecutive days revealed that the posted nurse staffing information did not include the necessary details for each discipline on each shift. Interviews with the Staffing Coordinator confirmed that while the schedule and actual hours were tracked, they were not posted, and once posted, the information was rarely updated for the remainder of the day. The Administrator was unaware that the postings were incomplete and not updated as required, acknowledging that this did not meet expectations.
Failure to Resolve Grievances and Missing Property Issues
Penalty
Summary
The facility failed to promptly resolve grievances for a resident concerning missing property and communication issues. The facility's grievance policy, which requires grievances to be recorded and resolved promptly, was not adequately followed. The resident's missing items, including a belt and glasses, were reported, but the facility did not document a thorough investigation or resolution. The grievance log indicated the issue was referred to environmental services and nursing, but there was no evidence of a satisfactory resolution or communication with the resident or their family. The facility's policies on handling personal belongings were not adhered to, as the Personal Possession Record was not completed for the resident upon admission. This oversight contributed to the inability to resolve the grievance regarding the missing items. Interviews with staff revealed that the inventory list was not completed, and the grievance form's back side, which should have documented the investigation and actions taken, was missing. The Social Services Director acknowledged receiving only one grievance and stated that the missing items were not found, but could not provide documentation of the investigation. Communication issues were also a significant concern, as the resident's family reported multiple grievances that were not addressed. The family expressed dissatisfaction with the involvement of a Social Services Assistant in the resident's care and requested their removal. Despite repeated attempts to communicate with the facility, including emails and phone calls, the family did not receive adequate responses. The facility's responses to the family's inquiries were insufficient, and the grievances remained unresolved, leading to frustration and a diminished quality of life for the resident.
Failure to Prevent and Identify Pressure Ulcer
Penalty
Summary
The facility failed to provide necessary care and services to prevent the development of pressure ulcers for a resident who was at risk due to conditions such as peripheral vascular disease and diabetes mellitus. Despite being assessed as at risk for pressure ulcers, the resident did not have any documented pressure ulcers upon admission. The care plan included interventions to keep the feet clean and dry and to monitor and document any skin injuries. However, the facility did not consistently perform skin checks as ordered, with documentation showing a significant gap in performing these checks. The resident began reporting heel pain to staff, but no treatment was provided other than the application of lotion. The resident's family noted the pain, and an alert note later documented swelling and pain in the left heel. Despite these reports, no heel wounds were identified in the resident's records before discharge. Upon admission to another facility, the resident was found to have a Stage II pressure ulcer on the left heel, which was not disclosed by the original facility. This indicates a failure to identify and treat the pressure ulcer, leading to its development and progression.
Failure to Mitigate Fall Risks for High-Risk Resident
Penalty
Summary
The facility failed to evaluate the effectiveness of fall prevention interventions and did not adequately address environmental modifications that posed a risk to Resident 1, who was at high risk for falls. Resident 1, who was cognitively intact and required substantial assistance with mobility and toileting, experienced multiple falls, including two with injuries, over several months. Despite being assessed as high risk for falls, the facility did not implement a toileting program or adequately adjust the resident's environment to mitigate fall risks. Resident 1's bed was positioned diagonally in their room, as per their preference, which created a hazardous environment. This arrangement left limited space between the bed, dresser, and wall, increasing the risk of entrapment and falls. Staff interviews revealed that the resident's preference for bed placement was honored without a documented review of the associated risks and benefits, and no deviation of care was recorded. The resident experienced several falls, including a severe incident where they fell out of bed and sustained a neck fracture, among other injuries. The facility's failure to reassess and adjust the resident's care plan and environment, despite repeated falls and the resident's high-risk status, contributed to the incident. Staff acknowledged the hazardous room setup but did not take corrective action due to the resident's preferences. The lack of proactive measures and failure to document risk assessments and care deviations resulted in harm to Resident 1 and placed them at continued risk for falls and injury.
Failure to Protect Resident from Verbal Abuse
Penalty
Summary
The facility failed to protect a resident's right to be free from mental and verbal abuse, as evidenced by a resident-to-resident altercation involving two residents sharing a room. Resident 1, who was admitted with a diagnosis of dementia and severely impaired cognitive skills, exhibited behaviors of wandering and was noted to yell and scream at Resident 2, accusing them of stealing personal items. Despite staff interventions, Resident 1 continued to display aggressive verbal behavior towards Resident 2, who was cognitively intact and attempted to de-escalate the situation by leaving the room or going to the Bistro. The facility's policy on abuse, neglect, and exploitation required the implementation of procedures to prevent abuse and protect residents from harm. However, the facility's response to the altercation was inadequate, as staff failed to effectively separate the residents or provide a safe environment for Resident 2. Although staff conducted 15-minute checks and attempted to redirect Resident 1, these measures were insufficient in preventing ongoing verbal abuse. Interviews with staff revealed that the altercations were a frequent occurrence, yet no significant actions were taken to protect Resident 2 from the distress caused by Resident 1's behavior. The facility's inaction in addressing the conflict between the residents resulted in a deficiency, as they did not ensure the safety and well-being of Resident 2. Despite being aware of the situation, the facility did not take adequate steps to separate the residents or provide alternative accommodations, such as moving one of the residents to a different room. The failure to implement effective interventions and protect Resident 2 from verbal and mental abuse highlights a significant lapse in the facility's duty to safeguard its residents.
Improper Labeling of Insulin Pens in Medication Cart
Penalty
Summary
The facility failed to ensure proper labeling of insulin medications in one of the medication carts, specifically the 700-hall medication cart. During an observation, two multi-dose insulin pens were found without an open date or expiration date. This was confirmed during an interview with a Licensed Practical Nurse, who acknowledged the presence of two undated insulin pens in the cart. The Director of Nursing Services stated that the expectation was for open insulins to be dated with both the open date and expiration date, which was not adhered to in this instance.
Unsanitary Food Storage Practices
Penalty
Summary
The facility failed to ensure that food was stored and handled in a sanitary manner, as observed in both the kitchen and resident refrigerators. In the kitchen, the walk-in refrigerator contained four bags of raw chicken sitting in bloodied water, undated containers of minced garlic and pudding, a package of bacon with an expired use-by date, and uncovered, undated trays of raw fish. The walk-in freezer had a rack of exposed, dried-out raw meat. Additionally, dry storage contained a container of granola with no date. Staff interviews revealed that these items were recognized as needing disposal, and the storage practices did not meet the facility's expectations. In the resident dining areas, the Narrows, Mountain, and Ocean refrigerators contained various undated and expired food items, some with visible white growth indicating spoilage. The Mountain refrigerator had a Styrofoam container with foul-smelling, unidentifiable food and a bag of raspberries with white growth. The Ocean refrigerator contained a sandwich with an expired use-by date and several plates of food with white growth. Staff interviews confirmed that expired foods should not be present in resident refrigerators, and some items belonged to staff, which was against policy. The facility's adherence to the 2024 Food Code was acknowledged, but the storage of resident foods was not up to standard.
Failure to Obtain Consent for Psychotropic Medications
Penalty
Summary
The facility failed to obtain signed consents for psychotropic medications before administration for three out of five residents reviewed. Resident 40, who was readmitted with multiple diagnoses including heart disease, dementia, anxiety, and a psychotic disorder, had their risperidone dosage increased without obtaining consent from the resident's guardian. Resident 78, admitted with Parkinson's disease, dementia, and depression, was prescribed citalopram for major depressive disorder without any consent documentation upon admission. Resident 119, diagnosed with dementia, was receiving multiple medications including donepezil, olanzapine, mirtazapine, and risperidone without documented consent or education on the risks and benefits provided to the resident or their representative. Interviews with facility staff, including a Registered Nurse/Unit Manager and the Director of Nursing Services, revealed that the expectation was for licensed nurses to obtain consents from residents or their representatives before administering psychotropic medications and to document this in the medical records. However, this procedure was not followed, placing the residents at risk for adverse side effects and diminished quality of life. The facility's document on informed consent, dated December 1998, outlines the necessity for residents to receive appropriate and meaningful information regarding their healthcare decisions, which was not adhered to in these cases.
Failure to Ensure Safe Environment and Supervision
Penalty
Summary
The facility failed to ensure a safe environment free from accident hazards for three residents. For Resident 121, medications were not secured properly. A lidocaine patch was found in a refrigerator accessible to residents and on the resident's bedside table, despite the resident not being assessed to self-administer medications. Staff interviews confirmed that medications should be locked away, indicating a lapse in following medication security protocols. Resident 68 experienced multiple falls, yet the facility did not adequately investigate or reassess the use of a transfer pole, which may have contributed to the falls. The resident, who had a history of impulsivity and required substantial assistance for transfers, fell several times while attempting to self-exit the bed. Despite these incidents, the transfer pole's safety was not reassessed, and there was a lack of communication between nursing staff and physical therapy regarding the need for reassessment. For Resident 4, bedrails were observed to be loose, posing a risk of entrapment. Staff interviews revealed that there was no regular system for inspecting bedrails, and maintenance was only notified if staff noticed the issue. This lack of a systematic approach to ensuring bedrail safety resulted in the resident's bedrails being inadequately secured, which did not meet safety expectations.
Failure to Educate and Obtain Consent for Vaccinations
Penalty
Summary
The facility failed to offer, educate, and obtain consent for influenza and pneumococcal vaccinations for five residents, as required by their policy. The policy, dated January 28, 2022, mandates that all residents be offered vaccines to prevent infectious diseases, with prior education on the benefits and potential side effects documented in the resident's medical record. However, a review of the electronic health records (EHR) for Residents 74, 90, 102, 108, and 120 revealed no documentation that staff provided the necessary education or obtained consent for these vaccinations. Interviews with facility staff further highlighted the deficiency. Staff H, the Infection Preventionist/Registered Nurse, admitted to the absence of a consistent process for educating and obtaining consent for the vaccines. Additionally, Staff B, the Director of Nursing Services, confirmed that it was expected for staff to provide education on the risks and benefits before offering and obtaining consent for the vaccines. This lack of adherence to the facility's policy denied residents the opportunity to make informed decisions regarding their immunizations, potentially placing them at risk for communicable diseases.
Failure to Educate and Document COVID-19 Vaccination for Residents
Penalty
Summary
The facility failed to offer, educate, and obtain consent for COVID-19 vaccinations for five residents, as identified in the report. The facility's policy, dated January 28, 2022, mandates that all residents be offered vaccines to prevent infectious diseases, with prior education on the benefits and potential side effects documented in the resident's medical record. However, a review of the electronic health records (EHR) for Residents 74, 90, 102, 108, and 120 revealed no documentation indicating that staff had offered or provided education on the risks and benefits of the COVID-19 vaccine. Interviews conducted during the investigation further highlighted the deficiency. Staff H, the Infection Preventionist/Registered Nurse, admitted that there was no process in place for educating and obtaining consent for resident COVID-19 vaccines. Additionally, Staff B, the Director of Nursing Services, stated that it was their expectation for staff to provide education on risks and benefits before offering and obtaining consent for all resident COVID-19 vaccines. This lack of process and documentation denied residents the opportunity to make informed decisions regarding the COVID-19 vaccine.
Failure to Maintain Kitchen Equipment in Safe Working Order
Penalty
Summary
The facility failed to maintain essential kitchen equipment in safe working order, specifically a griddle/oven combo unit and one of four freestanding refrigerators. Observations on June 2, 2024, revealed a freestanding refrigerator containing a tray of sandwiches with standing water at the bottom and condensation droplets on the ceiling. A metal container with approximately two inches of water, a small screwdriver, and screws was found inside the refrigerator. Additionally, the griddle/oven combo unit was observed with a grease trap protruding about one and a half inches, with dried grease on the side of the unit and on the ground beneath it. Further observations on June 4, 2024, showed the refrigerator still had water on the floor and droplets on the ceiling, with a rack of resident foods inside. The container with water, screwdriver, and screws remained on the crossbar. The griddle/oven combo unit was observed with brown grease actively leaking down its side, and accumulated grease below the grease trap. Interviews with staff revealed that the refrigerator was not in working order and should not have been used to store resident foods. The Maintenance Director was only made aware of the issues on June 4, 2024, and there were no open work orders for the kitchen at that time.
Lack of Regular Bedrail Inspection Poses Risks
Penalty
Summary
The facility failed to implement a regular maintenance program for inspecting bedrails, which placed residents at risk of falling, entrapment, avoidable injury, and a diminished quality of life. During interviews, it was revealed that there was no established system for regular inspection of bedrails. Staff C, a Registered Nurse/Unit Manager, and Staff B, the Director of Nursing Services, both stated that staff were expected to notice loose bedrails and notify maintenance. Staff M, the Maintenance Director, confirmed the absence of a regular inspection system, indicating that maintenance was only informed of bedrails needing tightening as they were discovered. Staff A, the Administrator, acknowledged that bedrail inspection should be part of a regular preventative maintenance schedule.
Deficiencies in Resident Care and Treatment
Penalty
Summary
The facility failed to provide appropriate treatment and care according to professional standards for several residents, leading to deficiencies in their care. Resident 42, who was admitted with a fracture of the left femur and subsequent surgical intervention, experienced a delay in the management of a surgical wound infection. Despite obtaining a wound culture, there was a significant delay in receiving the results and initiating antibiotic treatment. The facility's staff did not promptly contact the orthopedic surgeon, resulting in a delay of more than nine days before appropriate treatment was administered. Resident 107, diagnosed with congestive heart failure, did not receive consistent monitoring and documentation of edema as outlined in their care plan. The resident's family expressed concerns about the lack of care, including the failure to elevate the resident's legs and monitor fluid accumulation. An investigation revealed that the licensed nursing staff did not follow the care plan, and there was no documentation of edema assessment in the resident's electronic health record. Resident 2, with chronic obstructive pulmonary disease and congestive heart failure, experienced a change in respiratory status that was not promptly reported to the provider. Despite the resident's complaints of chest congestion and pain, and visible symptoms such as coughing up yellow mucus, the staff failed to notify the provider or document the change in the resident's condition. Additionally, Resident 30, who had edema and acute kidney failure, did not receive prescribed medication for edema management, and there was no care plan addressing this condition. Resident 78, with Parkinson's disease, was observed inappropriately positioned in a wheelchair without a care plan for mobility and positioning, leading to discomfort.
Failure to Ensure Residents are Free from Physical Restraints
Penalty
Summary
The facility failed to ensure that residents were free from physical restraints, as evidenced by the use of a tilt in space wheelchair with a pressure alarm for Resident 78. Resident 78, who was admitted with diagnoses including Parkinson's disease, asthma, and depression, was observed leaning to the front right in the wheelchair, which was then repositioned by a staff member. There was no documentation of a restraint assessment or provider order for the use of the tilt in space wheelchair in Resident 78's electronic health record. Additionally, the care plan initiated in March 2023 did not include instructions regarding the use of the tilt in space wheelchair or the positioning of Resident 78. During an interview and observation, a registered nurse confirmed that Resident 78 was not positioned appropriately and that there were no markings on the wheelchair to indicate the correct angle of tilt as per the provider order and care plan.
Inaccurate Assessment of Pressure Ulcers
Penalty
Summary
The facility failed to accurately assess a pressure ulcer/skin condition for one resident, identified as Resident 7, who was reviewed for pressure injury. Resident 7 was admitted with multiple diagnoses, including Alzheimer's disease, adult failure to thrive, and abnormal weight loss, and was unable to communicate needs. A quarterly Minimum Data Set (MDS) assessment dated May 20, 2024, inaccurately recorded that Resident 7 had two unstageable pressure ulcers present on admission. However, during an interview on June 5, 2024, the MDS Nurse, Staff K, acknowledged that the pressure ulcers developed after the resident's admission to the facility. The Director of Nursing Services, Staff B, confirmed that the expectation was for the MDS assessment to accurately reflect the resident's condition.
Deficiencies in Anticoagulant Monitoring and Catheter Care
Penalty
Summary
The facility failed to ensure that services provided met professional standards of practice for three residents concerning anticoagulant use and indwelling urinary catheter (IUC) care. Resident 2, who was admitted with atrial fibrillation, was receiving Eliquis to prevent blood clots. Despite having bruising on their arms and legs, there was no documentation in the electronic health record (EHR) regarding monitoring for abnormal bleeding or bruising, which was expected as part of the care plan. Interviews with staff revealed that there was no order in the medication administration record (MAR) to monitor for adverse side effects of the anticoagulant medication, which was acknowledged as an oversight by the Director of Nursing Services. For Residents 88 and 28, the facility failed to ensure accurate and clear provider orders for IUC care. Resident 88, who had diagnoses including Parkinson's disease and benign prostate hypertrophy, experienced severe lower abdominal pain due to the catheter. The EHR contained conflicting orders regarding the IUC size and change schedule, and the care plan lacked specific details about the catheter type and size. Similarly, Resident 28 had conflicting provider orders regarding the IUC size and type, which needed clarification. Staff interviews confirmed that the orders did not meet expectations for clarity and accuracy, which are necessary for proper catheter management.
Failure to Follow Pressure Ulcer Treatment Orders
Penalty
Summary
The facility failed to provide necessary treatment to heal pressure injuries for a resident, identified as Resident 7, who was reviewed for pressure injuries. Resident 7 was admitted to the facility with multiple diagnoses, including Alzheimer's disease, adult failure to thrive, and abnormal weight loss, and was unable to communicate needs. During an observation and interview on June 5, 2024, it was noted that a dressing on Resident 7's right outer ankle, dated May 31, 2024, had not been changed as ordered on June 3, 2024. Staff L, an LPN, confirmed the dressing change was missed. A review of the treatment administration record for June 2024 showed missing documentation for multiple orders on June 3, 2024, during the day shift. During an interview, Staff B, the Director of Nursing Services, stated that the expectation was for nurses to follow orders for dressing changes.
Failure to Monitor Fluid Restriction
Penalty
Summary
The facility failed to ensure proper fluid restriction for Resident 54, who was admitted with pulmonary edema and kidney failure. The provider's orders specified a fluid restriction of 1500 ml, with 600 ml to be provided by nursing and 900 ml by dietary. However, the medication administration record (MAR) lacked a clear method to total daily fluid intake and did not specify how much liquid to give per section. This resulted in Resident 54 receiving more than the prescribed 1500 ml of fluid on multiple days in May and June 2024. Interviews with staff revealed that the documentation was confusing and did not allow for accurate monitoring of fluid intake, which did not meet the facility's expectations.
Failure to Limit PRN Psychotropic Medication Use
Penalty
Summary
The facility failed to ensure that as-needed (PRN) psychotropic medications were limited to 14 days for one of the sampled residents, identified as Resident 6. Resident 6, who was admitted with multiple diagnoses including dementia, anxiety, and congestive heart failure, had an order for lorazepam, an antianxiety medication, to be administered every 2 hours as needed, starting on May 4, 2024, without a specified stop date. Despite pharmacy recommendations on May 14, 2024, to discontinue the lorazepam PRN after 14 days, the medication administration record showed that Resident 6 received lorazepam nine times in May 2024 and once in June 2024. During an interview, the Director of Nursing Services acknowledged that the expectation was for staff to follow pharmacy recommendations, which was not met in this case.
Latest citations in Washington
Inaccurate PASARR screening affected two residents. One resident with vascular dementia, depression, and adjustment disorder had a PASARR level one that did not reflect mental health diagnoses, and staff stated it was inaccurate. Another resident with PTSD had a PASARR level one that did not include the PTSD diagnosis, with no additional PASARR level one or level two found in the EHR; staff stated the screening was not accurate and should have been repeated.
Undated open meds were found on 2 medication carts, including an open insulin vial and multiple open eye drop bottles with no dates. An LPN and an RN both stated the items should have been dated when opened, and the DON stated open multidose vials or bottles found without a date should be discarded immediately.
A resident with respiratory failure, HTN, and anxiety became SOB and diaphoretic, received a breathing tx, and was sent by EMS to the hospital. The facility could not locate the required SNF/NF to Hospital Transfer form or other transfer records showing what information was communicated to the receiving provider.
Care plans for two residents were not updated to match their current status and care needs. One resident had PTSD and generalized anxiety disorder and was receiving a psychotropic medication, but the care plan listed monitoring for antipsychotic and anticonvulsant meds that were not prescribed and did not include the anxiety diagnosis or related behaviors and interventions. Another resident had new upper and lower dentures, but the oral/dental care plan only noted edentulous status and difficulty chewing, with no mention of dentures or denture-related interventions.
Failure to Provide Individualized Activities: A resident with anxiety, depression, and weakness was cognitively intact but said they could not attend group activities because of leg problems and wanted more in-room activities. The resident mostly stayed in bed watching TV, and staff documentation showed only limited room visits with no consistent activity documentation despite a care plan goal for participation two to three times per week.
Failure to maintain heel offloading for a resident with a reopened DFU. A resident with dementia and dependence for mobility had a left heel wound that had healed and then reopened; the wound care provider recommended heel floating and pressure relieving boots at all times, but observations showed the resident in bed with heels on the mattress and later reclined in a wheelchair with the heel resting on the footrest strap and no boots in place. Staff stated the resident had not refused the boots or heel floating, and the care plan was not updated after the wound reopened.
Failure to Address Hearing and Vision Services for a Resident: A resident with dementia, bilateral hearing loss, and impaired vision was observed without eyeglasses or a hearing device, despite records showing admission with eyeglasses and a personal sound amplifier. The care plan addressed vision only and did not include hearing-related interventions, while staff interviews confirmed the resident’s hearing was strained and that the resident’s device use and vision needs were not fully reflected in the plan of care.
Respiratory care was not provided consistently for two residents receiving O2. One resident with COPD and chronic respiratory failure had an O2 order missing the indication for use and Sats parameters, no MAR documentation of O2 therapy, and inconsistent Sats charting. Another resident with respiratory failure was observed on continuous O2 via NC, but provider orders for O2 therapy and tubing changes were not present after readmission, despite the care plan stating the resident was dependent on O2.
A resident with dementia, hearing loss, and missing lower teeth had an MDS showing obvious or likely cavities or broken natural teeth, and the care plan identified oral/dental health problems with an intervention to coordinate dental care and transportation. Staff stated the resident’s dental needs were captured on the MDS, but no referral was made for dental services or follow-up with the dentist, and the DON said the lack of referral did not meet expectations.
Inaccurate Meal Intake Documentation: A resident with DM, dysphagia, and protein-calorie malnutrition was observed eating less than 25% of a meal, but the POC documented 76-100% intake. The CNA said the resident usually ate only 25-50% of meals and that intake was sometimes documented based on what a coworker reported. The LPN/RCM and DON stated meal intake should be documented accurately.
Inaccurate PASARR Screening for Two Residents
Penalty
Summary
The facility failed to ensure that two residents were screened for additional mental health supports through the PASARR process. Resident 97 was admitted with diagnoses including vascular dementia, depression, and adjustment disorder, and was able to make needs known. Review of the PASARR level one dated 04/10/2026 showed no mental health diagnoses and no need for a PASARR level two, even though the resident’s record included mental health diagnoses. During interview, the Regional Social Services staff and the Administrator stated the PASARR was inaccurate, needed modifications, and did not meet expectations. Resident 6 was admitted with diagnoses including heart failure, respiratory failure, and PTSD, and was able to make needs known. Review of the PASARR level one dated 03/30/2026 showed no serious mental illness indicators marked and no PASARR level two indicated, and the EHR contained no other documented PASARR level one or level two. The Social Services Director stated the hospital-provided PASARR was reviewed for accuracy and, if inaccurate, another level one would be completed, and stated this resident’s PASARR did not include PTSD and should have had another level one completed. The Administrator also stated the PASARR was not accurate and another level one needed to be conducted, but none could be located in the EHR.
Undated Open Medications on Medication Carts
Penalty
Summary
The facility failed to ensure proper storage and labeling of medications for 2 of 3 sampled medication carts reviewed for medication storage and labeling, including carts on the 400 and 500 halls. On the 500 hall medication cart, an open vial of insulin and an open bottle of eye drops were observed with no dates. During interview, an LPN stated that when an insulin vial or bottle of eye drops is opened, it should be dated immediately and said both items should have been dated upon opening; the LPN stated they would dispose of the undated vial and bottle. On the 400 hall medication cart, two open bottles of eye drops were observed with no dates. During interview, an RN stated both bottles should have been dated as soon as they were opened and said they would get new eye drops and dispose of the undated bottles. The DNS/RN stated that if an eye drop was opened it should have been dated immediately and that any open multidose vial or bottle found without a date should be discarded immediately.
Missing Hospital Transfer Documentation
Penalty
Summary
The facility failed to ensure hospital transfer documentation was completed for one resident who was transferred to the hospital after complaining of not being able to breathe and appearing diaphoretic. The resident had diagnoses of respiratory failure, high blood pressure, and anxiety disorder, and was able to make needs known. A breathing treatment was provided, and the provider agreed to send the resident out for further evaluation, after which emergency transportation took the resident to the hospital. Record review found no documentation showing what information was provided or communicated to the receiving facility for the transfer. Staff stated that transfer documentation should have included a SNF/NF to Hospital Transfer form, the resident's face sheet, and the medication and treatment administration records, but they were unable to locate documentation showing these items were completed or sent for the resident's hospital transfer.
Care plans did not reflect current diagnoses, medications, or denture status
Penalty
Summary
The facility failed to ensure that care plans were revised and accurately reflected residents’ current status and care needs for 2 of 21 sampled residents. Resident 6 was admitted with diagnoses including heart failure, respiratory failure, and PTSD, and was able to make needs known. The EHR showed Resident 6 also had generalized anxiety disorder and was receiving a psychotropic medication, but the current care plan dated 05/05/2026 documented monitoring for side effects of antipsychotic and anticonvulsant medications even though Resident 6 was not prescribed those medications. The care plan also identified PTSD but did not include generalized anxiety disorder or behaviors to monitor and interventions related to PTSD or anxiety disorder. Staff F, LPN/CC, stated the care plan did not accurately reflect the resident’s current status or prescribed medications, and Staff B, DNS, stated it did not meet expectations because it did not address the anxiety disorder or target behaviors and interventions. Resident 71 was admitted with diagnoses including PTSD, high blood pressure, and depression and was able to make needs known. Observation on 05/06/2026 showed a denture cup by the sink with the resident’s name on the lid and new upper and lower dentures dated 01/12/26. The resident stated the lower dentures did not fit well and that denture adhesive had been provided, but the dentures still did not fit right and the resident had not told staff yet. The focused oral/dental care plan, initiated on 06/23/2026, identified the resident as edentulous and having difficulty chewing, but did not show that the resident had dentures or include interventions related to denture use or maintenance. Staff E, CNA, stated they had not seen the resident wear dentures and were unaware of the new dentures, Staff C, LPN/CC, stated the care plan should have been updated when the dentures were obtained, and Staff B, DNS, stated the care plan should have reflected the dentures and interventions.
Failure to Provide Individualized Activities
Penalty
Summary
The facility failed to provide individualized activities for Resident 5, who was admitted with diagnoses including anxiety disorder, depression, and weakness. The admission MDS dated 01/14/2026 showed the resident was cognitively intact. During interviews on 05/03/2026 and 05/06/2026, Resident 5 stated they could not attend in-person activities because of their legs, wanted more activities to occupy them, mostly stayed in bed watching TV, and did not remember the last time activities staff visited to offer activities. The resident also stated activities staff would need to offer something they were able to do because they had difficulty doing some activities. The activities care plan dated 12/26/2026 showed a goal for Resident 5 to participate in activities two to three times per week. Progress notes documented one visit on 12/22/2026 to provide a welcome packet and encourage participation in daily activities, but no further activity documentation was found in the progress notes. Staff H stated room visits should include puzzles, arts and crafts, visiting, and chatting, and that documentation was placed in tasks, but the task record showed no documentation of activities for the past 30 days. Staff J stated paper documentation existed for room visits and that Resident 5 was on a list for room visits every Monday and Wednesday, while the room visit documentation showed only four visits on 01/26/2026, 02/06/2026, 03/10/2026, and 04/08/2026.
Failure to Maintain Heel Offloading for Reopened DFU
Penalty
Summary
The facility failed to consistently implement pressure reducing strategies for a resident with a left heel diabetic foot ulcer that had reopened. The resident was admitted with diagnoses including left hip fracture with surgical repair, a blood clot of the left lower leg, and dementia, and was dependent on staff for mobility and unable to make needs known. The baseline care plan and care plan both included heel offloading interventions, and the wound care provider initially recommended heel floating with pillows or wedge and pressure relieving boots. The wound later resolved, but a weekly skin assessment documented that the left heel wound reopened and was very painful to touch. After the wound reopened, the contracted wound care provider documented that the DFU to the left heel had reopened and recommended the resident wear pressure relieving boots at all times. The current care plan reviewed after the wound reopened did not include new interventions related to the reopened wound. Observations showed the resident seated in a reclined wheelchair with the left foot/heel resting on the footrest strap and no pressure relieving boots in place, and later lying in bed with both heels directly on the mattress without being floated and without boots. Staff interviews indicated the resident had not refused the boots or heel floating, and the LPN/CC and DON stated the resident should have been assessed and the plan of care updated when the wound reopened.
Failure to Address Resident Hearing and Vision Needs
Penalty
Summary
The facility failed to address one resident’s hearing and vision needs. Resident 112 was admitted with diagnoses including a leg fracture, dementia, and hearing loss in both ears, and was able to make needs known. The record showed the resident lost their glasses and was given readers, but the resident did not wear them because they were concerned that wearing glasses that were not their prescription would further degrade their vision. Observation did not show glasses in the resident’s room, and the resident stated they did not use a hearing aid. The resident was observed to be hard of hearing, requiring an elevated voice and repeated questions to understand. The admission MDS dated [DATE] documented adequate hearing with hearing aid and adequate vision with corrective lenses, while the significant change MDS dated [DATE] documented moderate difficulty hearing without a hearing aid and impaired vision without corrective lenses. The care plan initiated 02/24/2026 addressed impaired vision with interventions to arrange consultation with eye care practitioners as needed and remind the resident to wear glasses, but it did not include a focus area or interventions for hearing loss or use of hearing aids. A resident clothing list showed the resident admitted with one pair of eyeglasses and one Super Ear headset personal sound amplifier, yet observation and interview showed the resident in bed without eyeglasses or a hearing device, with the amplifier stored in the bedside table drawer. Staff interviews confirmed the resident’s hearing was strained, that the hearing device and glasses were not being used, and that the resident’s hearing device use should have been included in the plan of care and the resident should have been referred for eye care assessment.
Respiratory Care Orders and Documentation Not Maintained
Penalty
Summary
The facility failed to provide respiratory care consistent with professional standards of practice for two residents receiving oxygen therapy. One resident with COPD and chronic respiratory failure with hypoxia was observed multiple times lying in bed receiving oxygen at 2 L via nasal cannula. The resident’s oxygen order, dated 02/15/2026, allowed 1 to 4 L per minute continuously via nasal cannula, but it did not include an indication for use or oxygen saturation parameters. The April and May 2026 MARs did not show documentation of oxygen therapy being provided, and the TARs showed only an order to change oxygen tubing if damaged or visibly soiled, not an order for oxygen therapy. Oxygen saturations were not documented consistently daily from 04/01/2026 through 05/04/2026. A second resident with respiratory failure, high blood pressure, and anxiety disorder was observed in the room receiving oxygen at 6 L via nasal cannula on multiple occasions. The resident stated they needed oxygen therapy to breathe, and the care plan identified the resident as dependent on oxygen and to receive oxygen per provider orders. However, provider orders reviewed on 05/04/2026 showed no orders for oxygen therapy or for changing oxygen tubing. Staff stated the oxygen and tubing-change orders had been discontinued when the resident went to the hospital and were not added back to the MAR or TAR when the resident readmitted to the facility.
Failure to Refer Resident With Identified Dental Needs
Penalty
Summary
The facility failed to ensure that Resident 112 received needed dental care. Resident 112 was admitted with diagnoses including a leg fracture, dementia, and hearing loss in both ears. Observation on 05/03/2026 showed the resident had missing lower teeth. The admission MDS, dated [DATE], documented obvious or likely cavities or broken natural teeth, and the care plan dated 02/24/2026 identified oral/dental health problems related to likely cavities or broken teeth with an intervention to coordinate dental care and provide transportation. During interviews, Staff G, Regional Social Services, stated Resident 112's dental needs were captured on the 02/24/2026 MDS and the resident was not referred for dental services. Staff M, Social Services Director, stated residents with dental needs should be referred to social services to be scheduled for assessment by a dental care practitioner, and that Resident 112 should have been referred after the MDS assessment. Staff B, DON, stated residents with identified dental needs should be referred for follow-up with a dentist and that Resident 112 should have been referred to the in-house dental provider; Staff B stated the lack of referral did not meet expectations.
Inaccurate Meal Intake Documentation
Penalty
Summary
The facility failed to accurately document the amount of food eaten for Resident 13, who was admitted with diagnoses including diabetes mellitus, dysphagia, and protein-calorie malnutrition. The quarterly MDS dated 02/12/2026 showed the resident was moderately cognitively impaired. During observation on 05/05/2026 at 12:09 PM, a meal tray was delivered to the resident’s room, set up on a bedside table, and the resident was observed eating slowly, eating less than 25% of the meal, then laying back in bed and closing their eyes while the tray remained in the room. Staff later removed the tray, but the POC documentation for lunch on 05/05/2026 recorded that Resident 13 ate 76-100% of the meal. During interview, the CNA stated the resident typically ate 25-50% of meals and never ate all of the food, and that if they did not pick up a tray they would ask a coworker what the resident ate before documenting it. The CNA stated they were told the resident ate 75-100% of lunch, so that is what was entered. The LPN/RCM stated staff should document meal intake accurately in POC, and the RN/DNS stated it was their expectation that all staff document meal intake accurately.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release June 24, 2026) and official state health department websites — never guesswork.
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