Enumclaw Health And Rehabilitation
Inspection history, citations, penalties and survey trends for this long-term care facility in Enumclaw, Washington.
- Location
- 2323 Jensen Street, Enumclaw, Washington 98022
- CMS Provider Number
- 505400
- Inspections on file
- 27
- Latest survey
- April 23, 2026
- Citations (last 12 mo.)
- 4
Citation history
Health deficiencies cited at Enumclaw Health And Rehabilitation during CMS and state inspections, most recent first.
Two residents at increased risk for pressure injuries, as identified by Braden assessments and a wound specialist, did not receive timely pressure offloading interventions or appropriate care planning, leading to facility-acquired DTPIs on both heels for one resident and a Stage 3 sacral PI for another. Despite clear recommendations for repositioning, heel floating, and use of a low air loss mattress, the baseline care plan for one resident omitted PI prevention measures, and both residents remained on standard mattresses without the ordered or requested air mattresses. One resident was observed lying in bed for prolonged periods without repositioning and was later seen in a wheelchair without proper footrests, while the other reported a painful bedsore, difficulty sleeping, and a damaged, caved-in mattress that staff had been told about weeks earlier. The DON and other staff confirmed that air mattresses were discussed and documented as ordered but were never obtained or implemented, and there was no follow-up to ensure these pressure-relieving devices were provided.
Several residents submitted grievances regarding issues such as equipment malfunction, staff behavior, and inadequate hygiene assistance, but these grievances were not entered into the facility's log, investigated, or resolved according to policy. Staff interviews and record reviews confirmed that the grievance log was not current, and residents did not receive timely responses or notifications about their complaints.
A resident who was dependent on staff for bathing and personal hygiene did not consistently receive scheduled showers and grooming assistance as outlined in their care plan. Observations and interviews revealed the resident often had unkempt hair and reported irregular shower schedules, while staff confirmed that shower aides were sometimes reassigned, leading to missed care. Documentation showed only two bed baths and three refusals over an 18-day period, with incomplete records for the rest of the month.
A resident with complex medical needs did not consistently receive the physician-ordered frequency of OT and PT sessions. Therapy staff missed sessions without proper documentation or explanation, and staff could not provide records of refusals or reasons for missed treatments.
Surveyors observed expired and unlabeled food items, improper storage of chemicals near food, and staff failing to follow hand hygiene and sanitation protocols during food preparation and service. Cold foods were held above safe temperatures, and utensils were not properly sanitized between uses. These deficiencies in food storage, preparation, and service practices increased the risk of food-borne illness for residents.
Surveyors found that the facility failed to maintain a clean and homelike environment, with observations of stained carpets, broken and missing window blinds, and debris buildup on air vents in multiple areas. Staff interviews confirmed expectations for prompt housekeeping and maintenance, but documentation of regular facility reviews was not available.
Several residents with complex medical needs and a history of falls experienced incidents where the facility failed to complete thorough investigations and documentation. Incident reports lacked details on environmental factors, timely assistance, and required assessments such as neurological and skin checks. Staff interviews confirmed that important sections of reports were left incomplete and necessary evaluations were not performed, resulting in incomplete investigations for multiple residents.
Surveyors found that staff failed to document required transfer reports to hospitals, did not provide written discharge notices to residents or their representatives, and did not notify the LTCO as required. Additionally, the facility did not offer or document bed holds for residents transferred to hospitals, with staff interviews confirming these omissions and confusion over departmental responsibilities.
The facility did not ensure that care conferences included the resident, their representative, and all required IDT members. Instead, only limited staff attended, and care conferences were not completed collaboratively or within required timeframes. Residents with complex needs were not included in their care planning, and their representatives were not invited, contrary to facility policy.
Three residents receiving IV antibiotics did not have their central IV dressings changed as ordered by physicians and as documented in the TARs. Observations showed the dressings had not been changed since an earlier date, despite records indicating otherwise. The Regional Director of Clinical Operations confirmed the discrepancy and the expectation for weekly dressing changes.
The facility did not ensure accurate reconciliation of controlled substances, as required by policy, resulting in missing medication cards and incomplete documentation in Narcotic Ledgers. Nursing staff failed to verify each page of the ledger and did not obtain the required signatures during medication transfers, leading to discrepancies in the accounting of narcotics.
Surveyors observed that staff failed to properly administer 5 out of 28 medications for two residents, resulting in a medication error rate of 17.86%. Errors included administering a pain patch to the wrong site, giving a chewable instead of an enteric-coated medication, incorrect dosages of blood pressure and antidepressant medications, and failing to apply a prescribed pain gel. The DON confirmed staff are expected to follow the seven rights of medication administration and physician orders.
Staff failed to properly store and label medications and supplies, with multiple instances of undated or expired medications found in medication carts and the medication room. Several residents had medications and medical supplies left unsecured at their bedsides without physician orders, and some items were not labeled as required. Nursing staff and leadership confirmed these actions did not follow facility policy or professional standards.
Staff did not consistently provide or document required assistance with ADLs such as bathing, shaving, nail care, and grooming for several dependent residents. Multiple residents were observed with poor hygiene, including untrimmed facial hair, dirty nails, and matted hair, and reported not receiving scheduled showers or grooming. Staff interviews confirmed expectations for care and documentation were not met.
Two residents experienced a lack of dignity when an LPN administered medications in a public hallway and when staff had to use towels or pillowcases for personal hygiene care due to a prolonged shortage of washcloths. Staff and residents reported ongoing issues with supply availability, and the DON acknowledged that these practices did not meet facility expectations for resident dignity.
The facility did not transfer trust fund balances for two residents to the state Office of Financial Recovery within the required 30-day period after discharge or death. One resident's funds were delayed by over three months, while another's were transferred four days late, contrary to facility policy and state regulations.
Multiple residents had inaccurate MDS assessments, including errors in documenting dental status, medication use, mental health diagnoses, bowel continence for a resident with a colostomy, and discharge status. Staff confirmed these inaccuracies after reviewing clinical records and resident interviews.
The facility did not ensure that Level II PASRR evaluation recommendations were incorporated into the care plans for two residents with serious mental health needs. Despite receiving notifications and recommendations for specialized behavioral health services, the required evaluations and care plan updates were not completed as per policy.
Staff did not administer antihypertensive medications according to prescribed parameters for two residents, failed to follow proper resident identification and medication labeling procedures during med pass, and did not complete or clarify physician orders for weights, pain management, and bowel protocols. These actions were not in line with facility policy or professional standards.
A resident with bilateral hearing loss and a history of using hearing aids was left without a replacement after one device broke. Despite documentation of the incident and notification of nursing leadership, there was no evidence of follow-up or assistance to obtain a new hearing aid, and staff interviews revealed a lack of awareness regarding the resident's needs.
Multiple residents with known fall risks experienced repeated falls due to the facility's failure to update and implement individualized fall prevention interventions. For example, a resident with complex medical needs was left alone in their room despite care plan instructions, and another resident's bed was not positioned as directed for safety. Additional residents did not have new interventions added after actual falls, and staff confirmed that care plans were not revised as required.
A resident with severe right-sided weakness and cognitive impairment did not receive required therapy evaluations or treatments as ordered by a physician. Despite facility policy mandating timely therapy evaluation and confirmation from the business office that no insurance pre-authorization was needed, the therapy department failed to evaluate or treat the resident, resulting in a lack of specialized rehabilitative services.
Nursing staff left nurse run sheets containing PHI, including names, room numbers, and diagnoses, unattended and visible on medication carts in two units. Staff confirmed these documents should have been protected and not visible to unauthorized individuals, in accordance with facility policy and resident rights.
Staff failed to consistently perform hand hygiene, use appropriate PPE, and follow posted transmission-based precautions when caring for residents with infectious diseases. Observations included a CNA delivering meal trays and a nurse administering medications without performing hand hygiene, as well as staff entering isolation rooms without required PPE or proper glove use. These actions were not in accordance with facility policy or posted instructions.
A resident with a seizure disorder and brain damage was injured during a transfer due to the use of an incorrect sling. The care plan lacked documentation on the appropriate sling type, and two new CNAs used a split sling instead of the required medium whole-body sling. The resident fell and sustained spinal fractures after the wheelchair bumped the lift, highlighting confusion over sling assessment responsibilities.
The facility failed to provide adequate nutrition and hydration for three residents, resulting in significant weight loss. A resident with severe memory impairment experienced over 11% weight loss in 21 days due to inconsistent meal documentation and lack of assistance. Another resident with diabetes and dementia lost 10 pounds, with meals often out of reach and unrecorded. A third resident with cancer and heart failure also faced significant weight loss, with meals left out of reach and weights not monitored. These issues indicate a systemic failure in supporting residents' nutritional needs.
The facility failed to serve meals within the posted timeframes for residents eating in their rooms on the 100 and 200 Hall Dining Carts. Observations showed significant delays in meal delivery, with breakfast and lunch trays arriving late. Staff interviews revealed no process to address late deliveries, and residents expressed dissatisfaction with the delays affecting their meal schedules and digestion. The Dietary Manager expected timely service, but this was not consistently achieved.
The facility failed to maintain food safety standards, with staff not wearing hairnets, uncovered and undated food in the kitchen, incomplete temperature logs, and uncovered desserts being delivered through hallways, posing risks of contamination.
The facility failed to maintain dignity during meal assistance for three residents. A resident with complex medical needs experienced delays in receiving help with meals, while another was fed by a CNA standing in protective gear. A third resident was assisted by a CNA standing at their bedside, contrary to the facility's expectations for promoting dignity.
A resident with complex medical diagnoses, including a hip fracture and dementia, was observed multiple times with their feet pressed against the footboard of their bed, unable to straighten their legs. Staff confirmed the bed was too short, failing to accommodate the resident's needs.
The facility failed to provide required written transfer notices to two residents during hospitalizations. One resident, with severely impaired memory, was hospitalized multiple times without receiving the necessary notices. Another resident was transferred for medical reasons without receiving a written notification or information about their rights. Staff confirmed the absence of a process for issuing these notices.
A resident with complex medical conditions experienced significant weight loss and developed a new pressure injury, but the facility failed to complete a Significant Change in Status Assessment (SCSA) within the required timeframe. Despite the resident's deteriorating condition, the necessary assessment to address care needs was not conducted, as acknowledged by the MDS Coordinator.
The facility failed to ensure accurate and timely PASRR assessments for two residents. One resident's PASRR Level 1 was not obtained until over two months after admission, while another resident's PASRR Level 1 was incomplete, missing key diagnoses such as dementia and a psychotic disorder. Staff acknowledged the deficiencies and the need for accurate and updated assessments.
The facility failed to develop comprehensive care plans for three residents, leading to unmet care needs. A resident with a spinal cord injury lacked an updated smoking safety evaluation, another on antipsychotic medication had an incomplete care plan, and a third resident did not have a care plan for recommended range of motion exercises.
The facility failed to update CPs for four residents, leading to discrepancies between documented care needs and actual resident conditions. A resident with dementia had no medications ordered despite CP instructions, while another resident's CP inaccurately required moderate assistance with meals despite their independence. Additionally, a resident's discontinued restorative program was not reflected in their CP, and another resident's ability to self-feed was not updated in their CP. The DON acknowledged the need for CP revisions.
The facility failed to follow POs and ensure accurate documentation for several residents. A resident received narcotic pain medication outside ordered parameters, while another used an ace bandage instead of a prescribed compression stocking without order clarification. Additionally, staff inaccurately documented the use of a moon boot and knee splint, which were not worn as ordered.
The facility failed to assist three residents with ADLs, including personal hygiene, dressing, and meal setup. One resident had long, untrimmed nails despite orders for weekly care. Another resident remained in a hospital gown for days and struggled to eat due to improper meal tray positioning. A third resident wore the same gown for multiple days and did not receive needed dressing assistance.
A facility failed to follow its BG monitoring protocol for a diabetic resident, leading to the administration of insulin despite a low BG reading of 70 mg/dl. The resident, with multiple health diagnoses, was not monitored for three days due to a leave of absence, increasing their risk. The DON confirmed the protocol breach and the associated risk.
A resident with hearing impairment was not consistently assisted with their hearing aids, leading to ineffective communication. Observations showed the resident without hearing aids and, when worn, they were not charged. The care plan lacked specific instructions for hearing aid use, and staff failed to ensure proper maintenance and assistance.
The facility failed to provide restorative programs for residents with mobility limitations, including a resident with a progressive neurological condition and another with severe obesity. Despite therapy recommendations, programs were not initiated timely or documented properly, placing residents at risk for declines in ROM and mobility.
The facility failed to document a failed Gradual Dose Reduction (GDR) for a resident's antianxiety medication and did not obtain informed consent for another resident's antidepressant medication. Despite no documented anxious behaviors, the GDR was discontinued without justification, and the medication was increased. Additionally, informed consent was not obtained for an antidepressant, and target behavior monitoring was not established.
The facility failed to dispose of expired medications timely and ensure secure storage, as observed in two medication carts and the central supply room. Expired medications were found on the 100 and 500 Hall medication carts and in the central supply room. Additionally, a treatment cart on the 500 Hall was left unlocked, containing various medical supplies. Staff interviews confirmed these deficiencies.
The facility failed to provide timely dental services for two residents, leading to unmet dental needs. One resident had not seen a dentist for many years despite having broken teeth, and staff did not facilitate a dental appointment until much later. Another resident was without dentures for over 19 months, with staff failing to document the issue or follow up on recommendations for new dentures. Interviews revealed that staff did not meet expectations for timely dental consultations and follow-ups.
The facility failed to accommodate the food preferences of three residents, leading to dissatisfaction and potential risks. One resident with dental issues was served meals they couldn't chew, another received incorrect meal orders despite filling out a weekly menu, and a third was served a disliked vegetable. Staff acknowledged these errors, indicating a lapse in following documented preferences.
The facility failed to maintain comprehensive medical records for three residents, leading to incomplete documentation and potential delays in treatment. A resident's medication change recommendation was delayed over three months, hospice notes for another resident were not updated for several months, and a third resident's pharmacy recommendation was found unscanned. Staff interviews revealed inconsistencies in following the facility's policy for timely document uploads.
The facility failed to maintain infection control practices, with staff not wearing PPE when entering rooms of residents under contact precautions, such as a resident with antibiotic-resistant bacteria and another with a severe intestinal infection. Additionally, urinals were improperly stored next to food trays for two residents, and a cracked floor mat was noted for another resident, posing infection risks.
Failure to Implement Pressure Injury Prevention and Offloading Interventions for At-Risk Residents
Penalty
Summary
The deficiency involves the facility’s failure to provide timely pressure offloading interventions and preventive care for residents identified as being at increased risk for pressure injuries (PIs), resulting in the development of new facility-acquired PIs. Facility policy required that residents admitted without PIs would not develop them, that PI risk would be assessed on admission, that a care plan would be established based on identified risk factors, and that new PIs would trigger assessment, documentation, and implementation of interventions. Despite this, residents who were assessed as at risk did not have appropriate preventive interventions or care plans implemented, and recommended pressure-relieving equipment was not provided. For one resident, the admission assessment documented dependence on staff for bed mobility, need for two-person assistance in bed, and no heel skin impairment at admission. A Braden assessment identified this resident as at risk for PIs due to very limited mobility, inability to change position independently, need for staff assistance into a chair, and risk of friction and shear. A wound specialist consultation on the day after admission confirmed no heel skin impairment, noted muscle weakness in both feet, and recommended repositioning every two hours, skin care with lotion to the feet, and floating the heels off the mattress using pillows or a wedge. However, the baseline care plan created several days after admission did not include a PI prevention care plan, did not incorporate the Braden risk findings, and did not include the wound specialist’s recommended interventions. Subsequently, nursing notes documented the development of deep tissue pressure injuries (DTPIs) on both heels, described as dark red/purple, non-blanching, tender to touch, and worsening. The wound specialist later noted that the right heel DTPI had increased in size and was deteriorating, and recommended a low air loss mattress on two separate visits. Observations showed the resident remained on a standard mattress, and the DON confirmed there was no PI prevention care plan on admission and that, although an air mattress was documented as ordered, it was never obtained or implemented and there was no staff follow-up. For another resident, an admission Braden assessment identified risk for PIs due to limited mobility, confinement to bed, increased skin moisture, and risk of friction and shear from sliding against bed sheets. A nurse progress note later documented that the resident reported a sore on the buttocks, initially described as a friction tear. Within days, a wound specialist documented a facility-acquired Stage 3 PI on the sacrum, with specific measurements, and recommended treatment including a low air loss mattress. A late entry nurse note recorded that an air mattress was ordered to assist with healing. On observation, the resident was found lying on a standard mattress with only a sheet, and reported that the bedsore was not present on admission, that it caused pain and interfered with sleep and comfort, and that the mattress was caved in with a hole from prior use. The resident stated they had reported the mattress problem to staff weeks earlier and had been told they would receive a new mattress, but this had not occurred. The admissions coordinator stated that the facility owned air mattresses and could rent additional units the same day if needed, but no rental air mattresses were ordered or obtained for either resident. The DON and resident care manager acknowledged that there had been team discussion and a request from the administrator to obtain an air mattress for this resident, but there was no follow-up to ensure it was ordered or implemented.
Failure to Initiate, Investigate, and Resolve Resident Grievances
Penalty
Summary
The facility failed to initiate, investigate, and resolve grievances for six of twelve sampled residents, as required by its grievance policy. The Administrator, who is designated as the Grievance Official, did not maintain an up-to-date grievance log, and several grievances submitted by residents were not entered into the log or followed up with complete documentation of resolution, actions, recommendations, or notification to the residents. For example, one resident reported a malfunctioning mechanical lift that caused pain and submitted two grievances, but did not receive a timely response, and the grievance was not logged or resolved. Another resident filed a grievance about staff behavior that triggered their anxiety, but there was no entry in the log or evidence of resolution or notification. Additional residents reported grievances related to inadequate hygiene assistance and other concerns, which were similarly not documented or resolved according to policy. Interviews with staff confirmed that the grievance log was not current and that grievances were not being tracked or managed as required. The Maintenance Director also stated there was no log for mechanical lift inspections. Review of the grievance forms for the affected residents showed incomplete documentation and lack of follow-up. The facility's failure to follow its own grievance procedures resulted in unresolved grievances and lack of communication with residents regarding the status or outcome of their complaints.
Failure to Provide Consistent ADL Assistance for Dependent Resident
Penalty
Summary
The facility failed to provide required assistance with Activities of Daily Living (ADLs) for a resident who was dependent on staff for bathing, personal hygiene, and grooming. According to the resident's most recent MDS and Baseline Plan of Care, the resident required substantial to maximum support for bathing and was dependent on staff for hair care and personal hygiene, with a care plan specifying showers twice weekly. However, observations on multiple occasions found the resident in bed with unkempt hair, and the resident reported that scheduled showers were not consistently provided as planned, with shower days appearing random and hair becoming so matted that it had to be cut. Interviews with staff revealed that shower aides were sometimes reassigned to other duties, resulting in missed showers. Review of shower task sheets over an 18-day period showed only two bed baths and three documented refusals, with no additional refusals or completed showers documented for the remainder of the 30-day period. Requested documentation for the remaining days was not provided. The lack of consistent ADL assistance was confirmed by both staff and documentation review.
Failure to Provide Ordered Rehabilitative Services
Penalty
Summary
The facility failed to provide specialized rehabilitative services as ordered by the physician for one resident who required assistance with position and mobility. The resident, who had multiple medically complex conditions, was dependent on staff for all mobility and required substantial to maximal assistance with daily activities such as dressing, transfers, and wheelchair mobility. Physician orders specified occupational therapy (OT) five times per week and physical therapy (PT) three times per week. However, therapy calendars and documentation showed that the resident did not consistently receive the ordered frequency of therapy sessions, with some weeks showing reduced numbers of sessions for both OT and PT. During interviews and observations, the resident reported missing therapy sessions, sometimes due to dialysis appointments, but also noted that therapists occasionally did not show up without explanation. The Therapy Director confirmed that missed therapy sessions should have been documented with reasons for absence or refusal, but such documentation was not available. Staff were unable to provide records of refusals or explanations for the missed sessions, indicating a lack of adherence to the prescribed therapy regimen.
Deficient Food Storage, Preparation, and Sanitation Practices
Penalty
Summary
The facility failed to store, prepare, and serve food under sanitary conditions as required by policy and professional standards. During multiple observations, surveyors found expired and improperly labeled food items in the walk-in refrigerator, including a bag of cut carrots past its use-by date, unsealed and undated packages of cheese, chicken, pork, ham loaf, and boiled eggs, as well as sealed roast beef without a use-by date. Staff interviews confirmed that food should be sealed and labeled with open and use-by dates, but staff were unable to determine how long some items had been stored. Additionally, chemicals such as surface sanitizer were stored next to food products, and staff were observed entering the kitchen without appropriate hair coverings beyond designated areas. Food preparation practices were also found to be unsanitary. Staff were observed handling food and food-contact surfaces with soiled hands or gloves, failing to wash hands after touching their faces or other potentially contaminated surfaces, and placing raw meat near clean trays, resulting in cross-contamination. Staff did not consistently sanitize surfaces or utensils after contact with raw meat, and food was sometimes placed next to dirty items on counters. Staff interviews confirmed that these actions were not in line with facility expectations for food safety and sanitation. During food service, cold foods were repeatedly found to be held at temperatures above the facility's policy of 41°F or lower, with milk, juice, desserts, and salads measured at unsafe temperatures. Staff failed to properly sanitize thermometers between uses, and utensils previously touched with soiled hands were placed back into food containers. Staff also entered the kitchen and handled food without washing hands or donning hairnets as required. These actions and inactions placed residents at risk for consuming expired or contaminated foods and potential exposure to food-borne illness.
Failure to Maintain Clean and Homelike Environment
Penalty
Summary
Surveyors observed multiple deficiencies in the facility's maintenance and housekeeping practices across three units and the main dining room. Over several days, a large carpet stain was noted in the hallway across from a resident room, and staff interviews confirmed that housekeeping was expected to address such stains promptly. Additionally, missing and broken window blinds were observed at the ends of two hallways, with broken blinds found on the floor. Staff acknowledged the need for repairs and replacements to maintain a clean and functional environment for residents. Further observations revealed a buildup of debris on ceiling air vents in the main dining room, as well as on bathroom ceiling vents in several resident rooms and on a wall-mounted heater vent. The maintenance supervisor confirmed that these vents required cleaning and emphasized the importance of a clean, homelike environment. However, the facility was unable to provide documentation of regular facility reviews as required by their own policies. These findings indicate a failure to maintain the environment in a safe, clean, and comfortable condition as outlined in facility policies and resident rights documentation.
Failure to Conduct Thorough Fall Investigations and Assessments
Penalty
Summary
The facility failed to conduct thorough and complete investigations for multiple residents who experienced falls. For several residents with complex medical histories and high fall risk, incident reports and investigations were incomplete. Specifically, documentation was missing regarding environmental factors such as room clutter, wheelchair safety, and whether residents had their needs met or received timely assistance prior to the falls. In some cases, there was no information about when the last assistance was provided or if care plan interventions, such as toileting schedules, were followed. Incident reports for residents who sustained injuries from falls did not consistently include required assessments. For example, neurological assessments were initiated but not documented, and skin assessments for injuries were not completed or lacked details such as measurements and descriptions. Environmental assessments were often left blank, failing to identify potential causes like wet floors, inappropriate footwear, or room hazards. Additionally, there was a lack of documentation regarding whether staff assessed blood sugar levels for residents with diabetes after a fall, as required by their care plans. Interviews with staff, including the DON and regional clinical leadership, confirmed that incident reports and investigations were not thorough and did not meet facility policy expectations. Staff acknowledged that important sections of the incident reports were left incomplete, and necessary assessments were not performed or documented. These deficiencies were observed for multiple residents, including those with a history of falls, complex medical needs, and those dependent on staff for transfers and toileting.
Failure to Provide Required Transfer Documentation and Notifications
Penalty
Summary
Surveyors identified multiple deficiencies related to the facility's failure to provide required documentation and notifications during resident transfers and discharges. Specifically, staff did not document that reports were given to receiving hospitals regarding residents' conditions at the time of transfer, and e-interact forms were not completed for several residents transferred to acute care hospitals. Additionally, there was no evidence that written notifications of discharge were provided to residents or their representatives as required by facility policy and regulatory standards. The review also found that the facility did not notify the Office of the State Long Term Care Ombudsman (LTCO) when residents were transferred to hospitals or discharged to the community. Staff interviews revealed confusion regarding departmental responsibilities for LTCO notification, with both nursing and social services staff indicating the other was responsible. In several cases, staff were unable to provide documentation that notifications or reports had been completed, despite facility policies requiring these actions. Furthermore, the facility failed to offer or document the offer of bed holds to residents or their representatives upon transfer to the hospital, as required by the facility's bed hold policy. This deficiency was noted for at least one resident, with staff unable to produce documentation of the offer. The lack of documentation and communication was confirmed through record reviews and staff interviews, which consistently showed that required notifications and reports were not completed or documented for multiple residents during the review period.
Failure to Conduct Interdisciplinary Care Conferences with Resident and Representative Involvement
Penalty
Summary
The facility failed to conduct care conferences with the required participation of the resident, their representative, and the full interdisciplinary team (IDT) for multiple residents. Documentation and interviews revealed that care conferences were routinely attended only by the Resident Care Manager (RCM) and Social Services staff, with other vital IDT members such as nursing, therapy, dietary, and activities staff not present. In several instances, care conference forms were completed by different staff members on separate dates, rather than as a collaborative team meeting with the resident and their representative. Residents reported not being included in their care planning process and not receiving care conferences that involved all relevant departments. For example, one resident stated they had not had a care conference with nursing, therapy, social services, dietary, and activities, and had not received a copy of their care plan. Another resident expressed that their power of attorney or representative was not involved in their care planning, despite being listed in their records. These findings were corroborated by staff interviews, which confirmed that only limited staff attended care conferences and that other departments, though invited, did not participate. Record reviews showed that care conferences were not completed within the required timeframes, such as within 72 hours of admission, and that resident representatives were not invited as required by facility policy and admission agreements. The lack of full IDT participation and resident or representative involvement in care conferences was observed for several residents, including those with complex medical needs such as tube feeding, neurological disorders, and recent admissions requiring therapy services.
Failure to Change Central IV Dressings as Ordered and Documented
Penalty
Summary
The facility failed to ensure that intravenous (IV) dressings for three residents receiving IV antibiotic therapy were changed as ordered by physicians and as documented by staff. For each resident, physician orders and facility policy required central IV dressings to be changed every seven days and as needed. Treatment Administration Records (TARs) indicated that the dressings were signed as changed on specific dates; however, direct observation revealed that the actual last changed date on the dressings was earlier than documented, indicating that the dressings had not been changed according to orders or documentation. Specifically, one resident with a bone infection, another with sepsis, and a third with an infection of the heart chambers and valves all had central IV access and were receiving IV antibiotics. Despite TARs showing that dressings were changed on two occasions, observations showed the dressings had not been changed since an earlier date. The Regional Director of Clinical Operations confirmed the discrepancy between the documented and observed dressing change dates and acknowledged the expectation for weekly dressing changes as per policy and physician orders.
Failure to Accurately Account for Controlled Substances in Narcotic Ledgers
Penalty
Summary
The facility failed to ensure the accuracy of Narcotic Ledgers for two medication carts, resulting in discrepancies in the accounting of controlled substances. According to facility policy, a physical inventory of controlled medications was to be conducted by two licensed staff at each shift change, with documentation on the record and immediate reporting of any discrepancies to the Director of Nursing. However, observations and record reviews revealed that the required procedures were not consistently followed. On one cart, a review of the Narcotic Ledger showed 21 tablets remaining on a page, but the corresponding medication card was missing from the cart. A registered nurse admitted to not catching the missing card during the shift count and stated that only the physical cards in the lock box were counted, rather than verifying each page of the ledger as required. On another cart, multiple pages in the Narcotic Ledger showed transfers of controlled medications to other units with only one nurse's initials, rather than the required signatures of both the releasing and receiving nurse. Several pages also lacked medication names, prescription numbers, or proper identification of the medication form, and some pages had no nurse signature for medication card transfers. Interviews with nursing staff confirmed that the expected process of going page by page in the Narcotic Ledger to ensure all controlled medications were accounted for was not followed. Staff acknowledged the importance of this process in preventing narcotic diversion and ensuring accurate accounting of controlled substances, but admitted to not adhering to the established procedures. The Director of Nursing also confirmed the expectation for both nurses to sign the ledger during transfers and for staff to verify each page during counts.
Medication Error Rate Exceeds 5% Due to Multiple Administration Errors
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, as required by policy and regulation. During observed medication passes, staff administered 5 out of 28 medications incorrectly for two residents. For one resident, a pain medication patch was applied to the left hip instead of the right shoulder as ordered by the physician. The nurse involved acknowledged not clarifying the order before administering the medication to a different site than prescribed. For another resident, multiple errors were observed: a chewable form of a medication was given instead of the prescribed enteric-coated form, a blood pressure medication was administered at 25 mg instead of the ordered 75 mg, and an antidepressant was given at 30 mg instead of the prescribed 60 mg. Additionally, a pain medication gel was not applied as required, despite being documented as administered. The DON confirmed that staff are expected to follow the seven rights of medication administration and adhere to physician orders.
Improper Storage and Labeling of Medications and Supplies
Penalty
Summary
Facility staff failed to ensure proper storage and labeling of medications and biologicals across multiple units, medication carts, and the medication room. Observations revealed that medications, including nasal sprays and insulin pens, were not dated upon opening, and expired medications and supplies were not removed from storage areas. For example, one medication cart contained nasal sprays and an insulin pen without documented open dates, and another cart had expired blood pressure medications and medicated creams stored alongside inhaled medications. The medication room also contained expired vitamins, syringes, needles, and an intravenous device stabilizer. Additionally, staff did not follow facility policy or physician orders regarding the storage of medications at residents' bedsides. Several residents were observed with medications and medical supplies, such as topical pain-relieving patches, anti-fungal creams, powders, and tube feeding formula, left unsecured in their rooms or on their nightstands. In these cases, there were no physician orders permitting bedside storage, and some items were not labeled with the resident's name or the date and time of opening, as required by policy. Interviews with nursing staff and facility leadership confirmed that these practices were inconsistent with facility policies and professional standards. Staff acknowledged that medications and supplies should be dated, stored in locked carts or rooms, and removed upon expiration. They also stated that wound care supplies and medications should not be left in resident rooms to prevent contamination and ensure resident safety.
Failure to Provide Assistance with ADLs and Personal Hygiene
Penalty
Summary
Facility staff failed to provide necessary assistance with activities of daily living (ADLs), including bathing, shaving, nail care, and grooming, for seven dependent residents. Multiple residents who required substantial or total staff assistance for personal hygiene were observed with untrimmed facial hair, long and dirty fingernails, and uncombed or matted hair. Documentation revealed that scheduled showers and personal hygiene care were frequently missed, with staff either not offering care, not documenting refusals, or leaving records blank or marked as 'Not Applicable.' Several residents reported not receiving showers or assistance with grooming as care planned, despite expressing preferences for more frequent bathing and personal hygiene. For example, one resident stated they had not been shaved or had their nails trimmed for weeks, and another reported only receiving bed baths once a week despite preferring more frequent bathing. Other residents, including those with cognitive or physical impairments, were not offered showers as scheduled, and documentation did not reflect refusals or alternative care provided. In some cases, residents were given baby wipes and told to clean themselves, contrary to their care plans requiring staff assistance. Interviews with staff, including the Director of Nursing and Resident Care Managers, confirmed that the expectation was for staff to follow care plans, offer and assist with ADLs as scheduled, and document any refusals or care provided. However, observations and record reviews demonstrated that these expectations were not consistently met, resulting in unmet care needs and poor hygiene for the affected residents.
Failure to Promote Resident Dignity During Medication Administration and Personal Care
Penalty
Summary
The facility failed to provide care in a manner that promoted dignity for two residents. For one resident, a Licensed Practical Nurse (LPN) administered medications, including eye drops and an inhaler, in the hallway while other residents were present. The Director of Nursing (DON) confirmed that it was the facility's expectation that medication administration should not occur in the hallway and should be offered in private to promote resident dignity. Another resident reported frustration and embarrassment due to the facility frequently running out of washcloths, resulting in staff using pillowcases or towels for personal hygiene care. Multiple observations confirmed that washcloths were not available in various linen closets and the laundry department over several days. Staff interviews corroborated the ongoing shortage, with staff expressing difficulty in providing care and residents voicing concerns about the lack of appropriate supplies for personal hygiene.
Delayed Transfer of Resident Trust Funds After Discharge
Penalty
Summary
The facility failed to ensure that resident trust fund balances were reimbursed to the state Office of Financial Recovery (OFR) within 30 days of discharge or death, as required by policy and regulation. Specifically, one resident's trust fund balance of $229.61 was not transferred to the OFR until over three months after discharge, and another resident's balance of $55.84 was transferred four days past the 30-day requirement. These delays were confirmed by the Business Office Manager during an interview and were identified through record review. The facility's policy states that resident personal funds must be returned to the resident, responsible party, or as directed by state regulation upon discharge or death.
Inaccurate MDS Assessments for Multiple Residents
Penalty
Summary
The facility failed to ensure the Minimum Data Set (MDS) assessments accurately reflected the clinical status and care needs of multiple residents. For one resident, the annual MDS indicated no dental concerns, despite the resident reporting broken teeth and documentation showing decayed and broken teeth requiring dental intervention. Another resident's significant change MDS failed to indicate the use of diuretic and antipsychotic medications, even though medication records confirmed daily administration of both. A third resident's MDS did not reflect a serious mental illness diagnosis, despite behavioral health documentation supporting the presence of such a condition and the need for specialized services. Additional deficiencies included a resident with a colostomy being incorrectly coded as occasionally incontinent of bowel on the MDS, rather than indicating the presence of an ostomy. Another resident's discharge MDS was inaccurately coded, failing to reflect that the resident left the facility against medical advice. In each case, staff interviews confirmed the inaccuracies in the MDS coding, and the need for modifications to ensure accurate assessments as required by facility policy and regulatory standards.
Failure to Incorporate PASRR Level II Recommendations into Care Plans
Penalty
Summary
The facility failed to ensure that recommendations from Level II Preadmission Screening and Resident Review (PASRR) evaluations were incorporated into the care plans for two of five sampled residents. For one resident with multiple complex diagnoses, including anxiety, depression, and a mental health condition related to trauma, staff completed a Level I PASRR indicating the need for a Level II evaluation. Although a Notice of Determination was received confirming the need for specialized behavioral health services, the Level II evaluation was not found in the resident's records, and its recommendations were not integrated into the care plan. The Social Services Director confirmed that the evaluation and its recommendations were received via email but were not implemented as required by facility policy. Similarly, another resident with dementia and depression, who was receiving antipsychotic, antianxiety, and antidepressant medications, was identified as needing a Level II PASRR evaluation following a Level I screen. However, no Level II evaluation was found in this resident's records. The Social Services Director acknowledged that such evaluations should be obtained and included in the resident's records when a serious mental illness is identified. These omissions were in direct violation of the facility's policy and state regulations.
Failure to Follow Medication Administration Parameters and Physician Orders
Penalty
Summary
Staff failed to administer antihypertensive medications according to prescribed parameters for two residents with complex medical histories, including hypertension. For one resident, medications were given on multiple occasions despite blood pressure readings below the ordered threshold. Similarly, another resident received blood pressure medications outside of the specified heart rate and systolic blood pressure parameters on several occasions across two months. These actions were not in accordance with the medication administration records and physician orders. During medication pass observations, an agency LPN did not follow facility policy for resident identification, administering medications without confirming the resident’s identity using two identifiers. The same LPN was also observed storing pre-poured, unlabeled medication cups in the medication cart, and was unable to identify the contents of one of the cups. Facility policy required medications to be administered at the time they are prepared and for medication cups to be labeled if not immediately administered. Additionally, staff did not follow or clarify physician orders for two residents. One resident’s order for monthly weights was not completed for two consecutive months, with documentation either missing or incomplete. Another resident had conflicting as-needed pain medication orders and unclear bowel protocol orders, with no clarification provided to guide staff on which medications to administer first. These failures were confirmed by interviews with facility leadership, who stated that staff were expected to follow physician orders and facility policies.
Failure to Assist Resident in Obtaining Replacement Hearing Aid
Penalty
Summary
The facility failed to ensure that a resident received proper assistance in obtaining a replacement hearing aid after their original device was broken. The resident, who had a history of being hard of hearing in both ears and used hearing aids for both ears, reported that their right hearing aid broke after falling out and being stepped on. Although the incident was documented by social services, and both the resident care manager and director of nursing were notified, there was no further documentation or evidence that an appointment was set up or assistance was provided to replace the broken hearing aid. Interviews with facility staff revealed a lack of awareness and follow-up regarding the resident's need for hearing aid services. The Social Services Director was unaware of any residents requiring referrals for broken hearing aids and did not believe the resident wore hearing aids. Similarly, the Resident Care Manager was unaware of any referrals for the resident's hearing aids, and the Regional Director of Clinical Operations stated that it was their expectation that appointment referrals be followed up on by staff. Observations confirmed that the resident was only wearing a hearing aid in one ear, and records did not show any further action taken to address the broken device.
Failure to Update and Implement Fall Prevention Interventions
Penalty
Summary
The facility failed to implement and update appropriate interventions to prevent continued falls among multiple residents with known fall risks and histories of previous falls. For one resident with multiple complex diagnoses and a history of falls, staff were instructed not to leave the resident alone in their room and to keep them near the nurse's station, but the resident experienced repeated falls in their room, indicating that interventions were not consistently followed or updated. Another resident with a history of repeated falls and a recent fall with injury was observed with their bed positioned away from the wall, contrary to their care plan instructions for safety, and staff acknowledged that the care plan interventions needed revision. Additional residents with fall histories did not have new interventions added to their care plans after experiencing actual falls. One resident fell after attempting to close window blinds without staff assistance, despite being at moderate risk for falls and requiring appropriate footwear. Another resident, dependent on staff for transfers and with paralysis, fell after being placed incorrectly in a wheelchair, resulting in the wheelchair tipping over. In both cases, staff confirmed that no new interventions were documented following the falls, contrary to facility policy requiring evaluation and modification of plans after such incidents.
Failure to Provide Timely Rehabilitative Services per Physician Orders
Penalty
Summary
The facility failed to provide specialized rehabilitative services as required by physician orders for one resident who was reviewed for position and mobility needs. The resident, who had a diagnosis of a brain bleed and severe right-sided weakness, was admitted with moderate cognitive impairment and required significant assistance with activities of daily living. Despite a physician's order for physical, occupational, and speech therapy evaluation and treatment, there was no documentation that the resident was evaluated or treated by the therapy department. The facility's policy required therapy evaluations to occur within 48 hours of receiving a physician's order, but this was not followed. Observations and interviews revealed that the resident did not receive any therapy or exercise program and expressed concerns about not being able to improve mobility. Staff interviews indicated a misunderstanding regarding insurance pre-authorization requirements, which led to a delay in therapy evaluation. The business office confirmed that pre-authorization was not needed and that the resident was eligible for therapy evaluation since admission, but the therapy department did not act on this information, resulting in the resident not receiving the ordered rehabilitative services.
Failure to Protect Resident PHI on Medication Carts
Penalty
Summary
Nursing staff on two separate units failed to safeguard resident-identifiable information by leaving nurse run sheets containing protected health information (PHI) unattended and visible on medication carts. On Unit 500, a nurse run sheet listing residents' names, room numbers, and diagnoses was observed left in plain view on the medication cart without staff present. Staff interviews confirmed that the run sheet should have been protected and not visible to unauthorized individuals, and staff acknowledged the importance of maintaining PHI confidentiality for resident rights. Similarly, on Units 200 and 300, a printed nurse run sheet with full names, room numbers, and diagnoses for 15 residents was left unattended and visible on a medication cart, with no nursing staff nearby. Staff confirmed the document was left unattended and agreed that PHI should not be visible to unauthorized individuals. Facility policy and admission agreements reviewed indicated an expectation to protect and maintain the confidentiality of all residents' PHI.
Failure to Follow Infection Control Protocols and Transmission-Based Precautions
Penalty
Summary
Multiple staff members failed to adhere to infection prevention and control protocols, including hand hygiene (HH), use of personal protective equipment (PPE), and proper medication handling. During meal tray delivery, a staff member was observed touching items in resident rooms, wiping their face, and delivering trays to multiple residents, including one on transmission-based precautions (TBP), without performing HH at any point. Similarly, during a medication pass, a nurse handled medications with bare hands, touched various surfaces, administered medications, and used personal items such as a cell phone, all without performing HH between tasks or after glove removal. The nurse also failed to follow the facility's policy of placing medications directly into cups and not handling them directly. Staff also failed to follow posted TBP signage and PPE requirements for residents on isolation precautions. For example, two staff members entered a room with a posted Contact Precautions sign without donning the required gown and gloves, despite the signage instructing all entrants to do so. Another staff member entered a room requiring Special Droplet/Contact Precautions without wearing the required eye protection. Additional observations showed staff not performing HH before donning gloves, wearing damaged gloves during resident care, and failing to perform HH after glove removal and before exiting isolation rooms. The facility's policies required strict adherence to HH before and after resident contact, after glove removal, and when entering or exiting isolation rooms, as well as the use of appropriate PPE as indicated by posted signage. Staff interviews confirmed that expectations for HH and PPE use were known, but staff did not consistently follow these protocols. These lapses were observed in the care of residents with active infectious diseases who were on TBP, as well as during routine care and medication administration.
Incorrect Sling Use Leads to Resident Injury
Penalty
Summary
The facility failed to ensure the correct type of sling was used for a resident during mechanical lift transfers, resulting in harm. The resident, who had a history of brain damage, seizure disorder, and was totally dependent on staff for transfers, was transferred using an incorrect sling type. The care plan did not specify the size or type of sling required, and there was no documented assessment to determine the appropriate sling for the resident. During a transfer, the resident fell from the sling and sustained a spinal injury. The incident occurred when two newly hired CNAs used a split sling instead of the medium whole-body sling that the resident was assessed to require. The resident experienced discomfort and felt the sling was not applied correctly. During the transfer, the resident began to have tremors and slid through the sling after the wheelchair bumped the lift, resulting in a fall to the floor. The resident was later diagnosed with compression fractures to the T4 and T5 vertebrae. Interviews revealed confusion regarding the responsibility for assessing and documenting the appropriate sling type. The Director of Nursing believed the therapy department was responsible, while the Director of Rehabilitation stated that the therapy department did not handle sling assessments. This lack of clarity and documentation contributed to the use of an incorrect sling, leading to the resident's injury.
Failure to Ensure Adequate Nutrition and Hydration
Penalty
Summary
The facility failed to ensure adequate nutrition and hydration for three residents, leading to significant weight loss and potential health risks. Resident 218, who had severe memory impairment and required a pureed diet, experienced a weight loss of over 11% within 21 days. The facility did not consistently document meal intake, and observations showed that meals were often left out of reach, preventing the resident from eating. Staff were unaware of the resident's need for mealtime assistance, and inaccurate meal intake documentation was noted. Resident 15, with complex medical diagnoses including diabetes and dementia, was not weighed upon admission as per facility policy and experienced a 10-pound weight loss. Observations revealed that meals were not positioned to facilitate eating, and the resident struggled to access food. Meal intake documentation was inconsistent, with several meals unrecorded, indicating a lack of monitoring and support for the resident's nutritional needs. Resident 57, with diagnoses including cancer and heart failure, also experienced significant weight loss. The facility failed to document meal intake on numerous occasions, and observations showed meals were left out of reach. Staff did not obtain weekly weights despite the resident's weight loss, and there was a lack of communication and documentation regarding the resident's nutritional status. These deficiencies highlight a systemic failure in monitoring and supporting residents' nutritional needs.
Delayed Meal Service in Resident Rooms
Penalty
Summary
The facility failed to consistently serve meals within the posted timeframes for residents who ate in their rooms on the 100 and 200 Hall Dining Carts. Observations showed that breakfast trays on the 200 Hall were delayed by 74 minutes, and lunch trays on the 100 Hall were delayed by up to 63 minutes. Staff interviews revealed a lack of a process to address late meal deliveries, and some staff trusted the kitchen to resolve delays without inquiry. Residents expressed dissatisfaction with the late meal deliveries, noting that it affected their meal schedules and digestion. The Dietary Manager stated that meals were expected to be served at the posted times and trays should be passed out within five minutes of the carts arriving on the hall. However, observations indicated that this expectation was not met, as meal carts were often delayed, and trays were not delivered promptly. This inconsistency in meal service times placed residents at risk of receiving meals at undesired temperatures and experiencing hunger due to delayed meal delivery.
Food Safety and Storage Deficiencies
Penalty
Summary
The facility failed to adhere to professional standards of food safety in its kitchen and unit refrigerators, leading to potential risks of food contamination and foodborne illnesses. Observations revealed that dietary staff, including the Dietary Manager and a Cook, were not wearing hairnets as required by the facility's Personal Hygiene Standards policy. Additionally, the kitchen freezer contained uncovered bowls of ice cream without any date labels, and the refrigerator had opened jugs of milk that were not marked with a date to indicate when they were opened or should be used by. These lapses in food safety practices were acknowledged by the Dietary Manager, who admitted that the items were stored incorrectly and needed to be discarded. Further deficiencies were noted in the unit refrigerators, where temperature logs were incomplete, and the cleanliness of the refrigerators was compromised by sticky stains. The 500 Hall resident snack refrigerator had not been monitored for temperature for several days, and a container of food brought by a visitor was not dated, leading to its disposal. Additionally, staff were observed delivering lunch trays with uncovered desserts through hallways, increasing the risk of food contamination. The Dietary Manager expressed frustration over these practices, emphasizing the importance of maintaining food safety standards.
Failure to Maintain Dignity During Meal Assistance
Penalty
Summary
The facility failed to provide care and services that maintained and promoted dignity during meal assistance for three residents. Resident 29, who had complex medical diagnoses including cancer, anxiety, depression, and weakness, required substantial assistance with eating. However, during multiple meal services, staff delayed assisting Resident 29, leaving the resident to watch others eat and wait for extended periods before receiving help. On one occasion, Resident 29 had to use the call light twice before receiving assistance, highlighting a lack of timely support. Resident 5, who was dependent on staff for eating due to the loss of ability to move their arms and legs, was fed by a CNA who stood while wearing a protective gown and gloves, which did not align with the facility's expectations for promoting dignity. Similarly, Resident 12, who required setup help with eating, was fed by a CNA standing at their bedside. The Director of Nursing stated that staff were expected to sit next to residents while assisting with feeding, indicating a deviation from the facility's standards during these observations.
Inadequate Bed Accommodation for Resident
Penalty
Summary
The facility failed to provide a comfortable and appropriately sized bed for a resident, identified as Resident 15, who was reviewed for accommodation of needs. Resident 15 had multiple medically complex diagnoses, including a hip fracture and dementia, and was assessed to have functional limitations in their range of motion in both arms and legs, requiring substantial assistance from staff to roll or sit up in bed. Observations on multiple occasions showed Resident 15 lying in bed with both feet pushed up against the footboard, unable to straighten their legs, which was confirmed by the resident's complaint of sore knees. Staff confirmed that the bed was not long enough for the resident to straighten their legs, indicating a failure to accommodate the resident's needs appropriately.
Failure to Provide Written Transfer Notices
Penalty
Summary
The facility failed to provide required written notices to residents at the time of transfer or discharge, as evidenced by the cases of two residents. Resident 23, who had severely impaired memory and was dependent on staff for daily activities, was hospitalized on three occasions due to medical conditions such as seizures and a urinary tract infection. However, there was no record of the facility providing the necessary written transfer notices for any of these hospitalizations. The Director of Nursing confirmed the absence of these notices during an interview. Similarly, Resident 28 was transferred to the hospital for low blood pressure and low blood-oxygen levels, but neither the resident nor their representative received a written notification explaining the reason for the transfer, contact information for the State Long-Term Care Ombudsman, or an explanation of the resident's rights regarding the transfer. Staff confirmed that there was no process in place for providing such written notices at the time of the incident.
Failure to Complete SCSA for Resident with Decline in Condition
Penalty
Summary
The facility failed to complete a Significant Change in Status Assessment (SCSA) within 14 days for a resident who experienced a decline in nutritional intake and a change in skin integrity. The resident, who had complex medical diagnoses including cancer, heart failure, and kidney failure, was admitted with no significant weight loss or pressure injuries. However, the resident later reported weight loss and a wound on their foot, which was observed during an interview. Documentation showed a weight loss of 6.79% between February and March, and a new deep tissue injury was identified on the resident's left heel. Despite these changes, the facility did not complete the required SCSA. The Nutrition Hydration Skin Committee reviewed the resident's condition due to significant weight loss and a new pressure injury, and a wound care consult noted the deteriorating condition of the pressure injury with poor healing potential. The MDS Coordinator acknowledged that a SCSA should have been completed to address the resident's changing condition, but it was not done as required, placing the resident at risk for unmet care needs.
Failure to Ensure Accurate and Timely PASRR Assessments
Penalty
Summary
The facility failed to ensure that a Pre-Admission Screening and Resident Review (PASRR) assessment was obtained, accurate, and available in the records for two residents, which is a requirement to determine if residents have mental health or intellectual disability needs that require further assessment or treatment. For Resident 61, the PASRR Level 1 assessment was not available in the records upon admission, and it was only located and added to the records over two months later. Staff M confirmed the absence of the PASRR Level 1 in the records and acknowledged that it should have been obtained at the time of admission. The Divisional Director of Social Services stated that the expectation was for the PASRR Level 1 to be obtained prior to admission. For Resident 29, the PASRR Level 1 assessment was initially incomplete, failing to identify the resident's dementia and psychotic disorder, despite the resident having multiple medically complex diagnoses, including psychosis, anxiety, and depression, and requiring the use of related medications. The PASRR Level 1 was later updated to include the psychotic disorder but still did not reflect the dementia diagnosis. Staff R, the Social Services Director, acknowledged that the PASRR Level 1 forms should be updated and accurate to reflect the resident's current condition and should be readily available in the resident's records.
Deficiencies in Comprehensive Care Planning for Residents
Penalty
Summary
The facility failed to develop comprehensive care plans for three residents, leading to deficiencies in meeting their care needs. Resident 5, who had a traumatic spinal cord injury and was dependent on staff for all self-care and mobility, had a care plan for smoking safety that was not updated with a recent evaluation. The last smoking safety evaluation was completed several months prior, and staff could not confirm if a more recent evaluation had been conducted. This lack of updated assessment placed Resident 5 at risk for injuries related to smoking. Resident 34, diagnosed with anxiety and depression, exhibited physical behavior towards others and was on antipsychotic medication. However, the care plan did not specify the medication or the symptoms it was intended to treat, nor did it include resident-specific goals. The care plan was developed over five months after the medication was first prescribed, rather than at the time of administration. Additionally, Resident 8, who was discharged from occupational therapy with a recommendation for a restorative nursing program, did not have a care plan developed to address the recommended range of motion exercises. This oversight meant that staff did not identify the need for assistance with these exercises.
Failure to Update Care Plans for Residents
Penalty
Summary
The facility failed to ensure that Care Plans (CPs) were updated and revised as needed to reflect person-centered care for four residents. Resident 34, who had severe memory impairment and dementia, had a CP that included administering and monitoring dementia medications. However, the Medication Administration Record showed no medications were ordered for dementia, and no monitoring was conducted. The Director of Nursing acknowledged that the CP needed revision. Resident 53, who had no memory impairment and required minimal assistance with meals, had a CP indicating moderate assistance was needed. Observations showed the resident feeding themselves independently, and the Director of Nursing confirmed the CP was outdated. Resident 9, with moderate memory loss, had a CP that included a restorative nursing program, which was discontinued due to the resident's refusal to participate. The CP was not updated to reflect this change, and observations showed the resident eating in bed, contrary to CP instructions. The Director of Nursing confirmed the CP was outdated. Resident 28's CP required substantial assistance with meals, but progress notes indicated the resident could feed themselves. Staff confirmed the resident's ability to eat independently, but the CP was not updated. The Director of Nursing emphasized the importance of keeping CPs current to ensure appropriate care.
Failure to Follow Physician's Orders and Inaccurate Documentation
Penalty
Summary
The facility failed to ensure that physician's orders (POs) were followed and/or clarified for several residents, leading to potential risks for unmet care needs and unnecessary treatments. For Resident 50, the facility administered narcotic pain medication outside the ordered parameters, providing the medication for pain levels lower than specified in the order. This was confirmed by the Director of Nursing, who acknowledged the medication was given outside the ordered parameters. Resident 19, who had end-stage kidney failure, was supposed to have a specialty compression stocking applied to their left lower leg daily. However, observations and interviews revealed that the resident was using an ace bandage wrap instead, and staff had not clarified or updated the order to reflect this change in practice. Staff interviews indicated that the resident sometimes refused the stocking, but no clarification of the order was sought. Additionally, the facility failed to ensure that nurses signed only for tasks completed. For Resident 57, staff documented that a moon boot was worn as ordered, but observations showed the resident was not wearing it. Similarly, Resident 29 had orders for a knee splint that was not being worn, yet staff documented monitoring of the splint. Interviews confirmed these discrepancies, indicating that staff signed for tasks that were not completed.
Failure to Assist Residents with ADLs
Penalty
Summary
The facility failed to provide necessary assistance with Activities of Daily Living (ADLs) for three residents who were dependent on staff for such care. Resident 25, who had complex medical diagnoses including kidney failure and Alzheimer's disease, was observed with long, jagged fingernails despite physician orders for weekly nail care. Staff confirmed that the required nail care was not provided as ordered. Resident 15, with a history of hip fracture and dementia, required substantial assistance for personal hygiene, dressing, and meal setup. Observations showed that Resident 15 remained in a hospital gown over several days, and staff failed to assist with dressing or provide appropriate meal setup, leaving the resident struggling to eat. Staff confirmed that Resident 15's fingernails were not trimmed as ordered, and the resident's meal tray was not positioned correctly to facilitate eating. Resident 218, who had impaired memory and medical conditions including facial paralysis and a recent knee fracture, required substantial assistance with dressing. Observations revealed that Resident 218 wore the same gown for multiple days and expressed a need for assistance with changing clothes. Staff acknowledged the expectation to assist Resident 218 with dressing due to their limited mobility, but this assistance was not provided as required.
Failure to Follow Blood Glucose Monitoring Protocol for Diabetic Resident
Penalty
Summary
The facility failed to provide appropriate care for a resident with Diabetes Mellitus by not adhering to the established blood glucose (BG) monitoring protocol. The resident, who had intact memory and diagnoses including heart failure, diabetes, high cholesterol, and a heart blockage, was receiving daily insulin injections. On May 10, 2024, the resident's BG was documented at 70 mg/dl, which was below the threshold requiring physician notification and withholding of insulin as per the facility's protocol. However, the fast-acting insulin was administered at noon without notifying the physician, contrary to the protocol. Additionally, the resident took a leave of absence from the facility four hours after the low BG was recorded and three hours after the insulin was administered, leaving the facility unable to monitor or provide necessary care for three days. The Director of Nursing acknowledged that the nurses should have notified the physician and held the insulin, recognizing that the resident was placed at risk during their absence. The facility's failure to follow the medication administration parameters contributed to the deficiency.
Failure to Assist Resident with Hearing Aids
Penalty
Summary
The facility failed to ensure that a resident with hearing deficits was provided the necessary assistance with their hearing aids, as assessed. Resident 218, who had a hearing impairment and used hearing aids, was observed multiple times without their hearing aids in place. The resident's Care Area Assessment indicated that staff should ensure the use of hearing aids for effective communication, yet the care plan did not specify this need. Observations showed that the resident was unable to understand questions from staff when not wearing the hearing aids, indicating a lack of effective communication. Further observations revealed that when Resident 218 did wear their hearing aids, they were not functioning properly due to not being charged. Staff K confirmed that the hearing aids were not charged and found the charger under the resident's bed, suggesting a lack of proper maintenance and assistance with the hearing aids. The Director of Nursing acknowledged that care staff should assist the resident with their hearing aids during morning routines, but this was not consistently done, leading to the deficiency.
Failure to Provide Restorative Programs for Residents with Mobility Limitations
Penalty
Summary
The facility failed to provide a restorative program for four residents with mobility limitations, as identified by staff and reviewed for Range of Motion (ROM). Resident 1, with a progressive neurological condition and functional limitations in both legs, was supposed to receive lower extremity ROM exercises three times a week. However, documentation showed that the program was only provided on 5 out of 10 opportunities, with no records of the program being offered or refused. Resident 22, with multiple complex diagnoses including lymphedema and severe obesity, was assessed to require moderate assistance for mobility. Despite a physician's order for therapy evaluation and treatment, and the resident's agreement to participate in a restorative program, no interventions were established in the care plan. The restorative program was initiated over two weeks after recommendations were made, contrary to the facility's expectations for timely initiation. Resident 8, who was referred for a restorative therapy program for shoulder exercises five times a week, only received assistance on 14 out of 22 opportunities. The sole restorative aide was unable to complete the program as scheduled due to workload. Resident 29, with a diagnosis of weakness, was recommended for an arm ROM program, but the care plan was not updated to reflect this, and no program was established. The facility's failure to provide these restorative programs as directed placed residents at risk for declines in ROM and mobility.
Failure to Document GDR and Obtain Informed Consent for Psychotropic Medications
Penalty
Summary
The facility failed to ensure that two residents were free from unnecessary psychotropic drugs, as evidenced by the lack of documentation and informed consent. For Resident 9, the facility did not document the rationale for discontinuing a Gradual Dose Reduction (GDR) of an antianxiety medication. Despite the absence of documented anxious behaviors in June, July, and August 2023, the GDR was discontinued in September 2023, and the medication was increased back to the original dose without justification from the physician or documentation of the failed GDR. Interviews with staff confirmed the lack of documentation regarding the resident's behaviors and the decision to revert to the original medication dosage. For Resident 118, the facility failed to obtain informed consent before administering an antidepressant medication. The resident, who was oriented and had intact memory, was prescribed the medication without evidence of a discussion about the risks and benefits. Additionally, there was no monitoring of target behaviors at the start of the antidepressant treatment. The Director of Nursing acknowledged the failure to obtain informed consent and establish behavior monitoring for the medication.
Expired Medications and Unsecured Treatment Cart
Penalty
Summary
The facility failed to ensure the timely disposal of expired medications and secure storage of medications, as observed in two medication carts and the central supply room. On the 100 Hall medication cart, an opened bottle of non-narcotic pain medication was found with an expiration date of the previous month. Similarly, the 500 Hall medication cart contained expired liquid calcium, Vitamin E, and non-narcotic pain medications. In the central supply room, numerous expired medications, including iron medication, non-steroidal anti-inflammatory medication, Vitamin E, digestion enzyme supplements, liquid calcium, calcium tablets, fiber liquid, and protein powder, were found. Staff interviews confirmed that these medications were expired and should have been removed from stock. Additionally, the facility failed to secure a treatment cart on the 500 Hall. The treatment cart was observed unlocked while a nurse prepared medication at a separate medication cart across the hallway. The unlocked cart contained dressings, hydrocortisone cream, iodine, and an antiseptic solution. Staff interviews indicated that the treatment cart should have been locked, and it was the responsibility of the nurses to ensure the security of treatment carts.
Failure to Provide Timely Dental Services
Penalty
Summary
The facility failed to provide prompt dental services for two residents, leading to unmet dental needs and a diminished quality of life. Resident 45, who had no memory impairment and was able to communicate effectively, had not seen a dentist for many years despite having broken and rotting teeth. Although a dental consult was ordered in December 2022, staff did not facilitate a dental appointment until May 2024, nearly a year and a half later. During this period, Resident 45's dental issues were not addressed in care conferences, and staff failed to document any assistance provided to the resident for dental services. Resident 35, who had severe cognitive impairment and no natural teeth, was observed without dentures and reported waiting for new ones. Despite receiving dentures in September 2022, staff did not document the missing dentures for over 19 months. The facility's records showed that staff did not follow up on dental provider recommendations for new dentures, and no grievance form was filled out when the dentures were first noted missing. Staff failed to complete a referral for new dentures within the required three days. Interviews with facility staff revealed expectations for timely dental consultations and follow-ups, which were not met in these cases. Staff G, the Resident Care Manager, acknowledged the lack of documentation and assistance for Resident 45, while Staff O and Staff R confirmed the failure to provide timely assistance for Resident 35. These deficiencies highlight the facility's failure to adhere to its own policies and state regulations regarding dental care for residents.
Failure to Accommodate Resident Food Preferences
Penalty
Summary
The facility failed to provide meals that accommodated the food preferences of three residents, leading to dissatisfaction and potential risks to their well-being. Resident 8, who was admitted to the facility with no memory impairment, expressed dissatisfaction with the meals provided, as they were unable to chew certain foods due to dental issues. Despite a grievance filed by Resident 8 indicating their need for softer foods and a dislike for meat and seafood, the facility continued to serve meals that did not align with these preferences. The dietary manager, Staff F, acknowledged that the food preference form was not completed within the required timeframe and could not provide documentation of follow-ups with Resident 8. Resident 45, who also had no memory loss, reported that their food preferences were not being followed. Despite filling out a weekly menu, Resident 45 received meals that did not match their requests, such as being served fried eggs instead of scrambled eggs and not receiving cottage cheese as ordered. The facility's records did not document any preference for poached eggs, contradicting the meal served. Staff J confirmed that Resident 45 did not receive the requested cottage cheese and had to rectify the situation. Resident 55, who was understood and able to communicate, was served a meal containing zucchini, despite having a documented dislike for it. The tray card clearly highlighted Resident 55's dislike for zucchini, yet the meal was prepared and delivered with the disliked vegetable. Staff BB acknowledged the error and returned the meal to the kitchen. The dietary manager, Staff F, stated that the expectation was for dietary staff to adhere to the information on the resident's tray card, which was not followed in this instance.
Failure to Maintain Comprehensive Medical Records
Penalty
Summary
The facility failed to maintain comprehensive medical records for three residents, leading to incomplete documentation and potential delays in treatment. For Resident 50, a recommendation from the facility's consultant pharmacist to consider a medication change was not added to the medical record until over three months after the recommendation was made. This delay in updating the medical record could have impacted the resident's treatment plan, as the recommendation involved the use of two beta blockers for heart conditions. Resident 25's hospice notes from February, March, and April were not scanned into the resident's records until May, leaving a gap in the documentation of hospice care. Additionally, Resident 29's February pharmacy recommendation was found in a stack of papers waiting to be uploaded, indicating a delay in updating the resident's medical records. Interviews with staff revealed that the facility's policy required documents to be uploaded timely, but this was not consistently followed, resulting in incomplete and outdated records.
Infection Control Deficiencies in PPE Use and Equipment Storage
Penalty
Summary
The facility failed to maintain proper infection control practices, as evidenced by staff not adhering to the posted instructions for wearing Personal Protective Equipment (PPE) when entering rooms of residents under contact precautions. Specifically, Resident 36, who was on contact precautions due to an infection with antibiotic-resistant bacteria, had multiple instances where staff entered their room without donning the required PPE. Staff V, a Housekeeping Supervisor, and Staff W, a Certified Nursing Assistant (CNA), both entered Resident 36's room without PPE, despite the clear instructions on the door. Additionally, Staff X attempted to enter without PPE but was stopped by another staff member, and Staff Y was similarly stopped by a colleague before entering without PPE. Another deficiency was observed with Resident 16, who was on contact precautions for a severe intestinal infection. A provider was seen in Resident 16's room without wearing a gown or gloves, contrary to the facility's policy and expectations for infection control. The Infection Control Preventionist, Staff D, confirmed that staff were expected to don PPE before entering rooms with contact precautions and emphasized the importance of this practice to prevent the transmission of infections. The facility also failed to properly store resident urinals, as observed with Residents 46 and 57. Resident 46 had a urinal placed next to their breakfast tray on the overbed table while eating, and Resident 57 had a similar situation with a urinal next to their lunch tray. Staff G acknowledged that placing food next to urinals posed an infection control risk. Additionally, Resident 29 had a floor mat that was cracked and peeling, making it uncleanable, which was noted by Staff G as needing replacement.
Latest citations in Washington
Inaccurate PASARR screening affected two residents. One resident with vascular dementia, depression, and adjustment disorder had a PASARR level one that did not reflect mental health diagnoses, and staff stated it was inaccurate. Another resident with PTSD had a PASARR level one that did not include the PTSD diagnosis, with no additional PASARR level one or level two found in the EHR; staff stated the screening was not accurate and should have been repeated.
Undated open meds were found on 2 medication carts, including an open insulin vial and multiple open eye drop bottles with no dates. An LPN and an RN both stated the items should have been dated when opened, and the DON stated open multidose vials or bottles found without a date should be discarded immediately.
A resident with respiratory failure, HTN, and anxiety became SOB and diaphoretic, received a breathing tx, and was sent by EMS to the hospital. The facility could not locate the required SNF/NF to Hospital Transfer form or other transfer records showing what information was communicated to the receiving provider.
Care plans for two residents were not updated to match their current status and care needs. One resident had PTSD and generalized anxiety disorder and was receiving a psychotropic medication, but the care plan listed monitoring for antipsychotic and anticonvulsant meds that were not prescribed and did not include the anxiety diagnosis or related behaviors and interventions. Another resident had new upper and lower dentures, but the oral/dental care plan only noted edentulous status and difficulty chewing, with no mention of dentures or denture-related interventions.
Failure to Provide Individualized Activities: A resident with anxiety, depression, and weakness was cognitively intact but said they could not attend group activities because of leg problems and wanted more in-room activities. The resident mostly stayed in bed watching TV, and staff documentation showed only limited room visits with no consistent activity documentation despite a care plan goal for participation two to three times per week.
Failure to maintain heel offloading for a resident with a reopened DFU. A resident with dementia and dependence for mobility had a left heel wound that had healed and then reopened; the wound care provider recommended heel floating and pressure relieving boots at all times, but observations showed the resident in bed with heels on the mattress and later reclined in a wheelchair with the heel resting on the footrest strap and no boots in place. Staff stated the resident had not refused the boots or heel floating, and the care plan was not updated after the wound reopened.
Failure to Address Hearing and Vision Services for a Resident: A resident with dementia, bilateral hearing loss, and impaired vision was observed without eyeglasses or a hearing device, despite records showing admission with eyeglasses and a personal sound amplifier. The care plan addressed vision only and did not include hearing-related interventions, while staff interviews confirmed the resident’s hearing was strained and that the resident’s device use and vision needs were not fully reflected in the plan of care.
Respiratory care was not provided consistently for two residents receiving O2. One resident with COPD and chronic respiratory failure had an O2 order missing the indication for use and Sats parameters, no MAR documentation of O2 therapy, and inconsistent Sats charting. Another resident with respiratory failure was observed on continuous O2 via NC, but provider orders for O2 therapy and tubing changes were not present after readmission, despite the care plan stating the resident was dependent on O2.
A resident with dementia, hearing loss, and missing lower teeth had an MDS showing obvious or likely cavities or broken natural teeth, and the care plan identified oral/dental health problems with an intervention to coordinate dental care and transportation. Staff stated the resident’s dental needs were captured on the MDS, but no referral was made for dental services or follow-up with the dentist, and the DON said the lack of referral did not meet expectations.
Inaccurate Meal Intake Documentation: A resident with DM, dysphagia, and protein-calorie malnutrition was observed eating less than 25% of a meal, but the POC documented 76-100% intake. The CNA said the resident usually ate only 25-50% of meals and that intake was sometimes documented based on what a coworker reported. The LPN/RCM and DON stated meal intake should be documented accurately.
Inaccurate PASARR Screening for Two Residents
Penalty
Summary
The facility failed to ensure that two residents were screened for additional mental health supports through the PASARR process. Resident 97 was admitted with diagnoses including vascular dementia, depression, and adjustment disorder, and was able to make needs known. Review of the PASARR level one dated 04/10/2026 showed no mental health diagnoses and no need for a PASARR level two, even though the resident’s record included mental health diagnoses. During interview, the Regional Social Services staff and the Administrator stated the PASARR was inaccurate, needed modifications, and did not meet expectations. Resident 6 was admitted with diagnoses including heart failure, respiratory failure, and PTSD, and was able to make needs known. Review of the PASARR level one dated 03/30/2026 showed no serious mental illness indicators marked and no PASARR level two indicated, and the EHR contained no other documented PASARR level one or level two. The Social Services Director stated the hospital-provided PASARR was reviewed for accuracy and, if inaccurate, another level one would be completed, and stated this resident’s PASARR did not include PTSD and should have had another level one completed. The Administrator also stated the PASARR was not accurate and another level one needed to be conducted, but none could be located in the EHR.
Undated Open Medications on Medication Carts
Penalty
Summary
The facility failed to ensure proper storage and labeling of medications for 2 of 3 sampled medication carts reviewed for medication storage and labeling, including carts on the 400 and 500 halls. On the 500 hall medication cart, an open vial of insulin and an open bottle of eye drops were observed with no dates. During interview, an LPN stated that when an insulin vial or bottle of eye drops is opened, it should be dated immediately and said both items should have been dated upon opening; the LPN stated they would dispose of the undated vial and bottle. On the 400 hall medication cart, two open bottles of eye drops were observed with no dates. During interview, an RN stated both bottles should have been dated as soon as they were opened and said they would get new eye drops and dispose of the undated bottles. The DNS/RN stated that if an eye drop was opened it should have been dated immediately and that any open multidose vial or bottle found without a date should be discarded immediately.
Missing Hospital Transfer Documentation
Penalty
Summary
The facility failed to ensure hospital transfer documentation was completed for one resident who was transferred to the hospital after complaining of not being able to breathe and appearing diaphoretic. The resident had diagnoses of respiratory failure, high blood pressure, and anxiety disorder, and was able to make needs known. A breathing treatment was provided, and the provider agreed to send the resident out for further evaluation, after which emergency transportation took the resident to the hospital. Record review found no documentation showing what information was provided or communicated to the receiving facility for the transfer. Staff stated that transfer documentation should have included a SNF/NF to Hospital Transfer form, the resident's face sheet, and the medication and treatment administration records, but they were unable to locate documentation showing these items were completed or sent for the resident's hospital transfer.
Care plans did not reflect current diagnoses, medications, or denture status
Penalty
Summary
The facility failed to ensure that care plans were revised and accurately reflected residents’ current status and care needs for 2 of 21 sampled residents. Resident 6 was admitted with diagnoses including heart failure, respiratory failure, and PTSD, and was able to make needs known. The EHR showed Resident 6 also had generalized anxiety disorder and was receiving a psychotropic medication, but the current care plan dated 05/05/2026 documented monitoring for side effects of antipsychotic and anticonvulsant medications even though Resident 6 was not prescribed those medications. The care plan also identified PTSD but did not include generalized anxiety disorder or behaviors to monitor and interventions related to PTSD or anxiety disorder. Staff F, LPN/CC, stated the care plan did not accurately reflect the resident’s current status or prescribed medications, and Staff B, DNS, stated it did not meet expectations because it did not address the anxiety disorder or target behaviors and interventions. Resident 71 was admitted with diagnoses including PTSD, high blood pressure, and depression and was able to make needs known. Observation on 05/06/2026 showed a denture cup by the sink with the resident’s name on the lid and new upper and lower dentures dated 01/12/26. The resident stated the lower dentures did not fit well and that denture adhesive had been provided, but the dentures still did not fit right and the resident had not told staff yet. The focused oral/dental care plan, initiated on 06/23/2026, identified the resident as edentulous and having difficulty chewing, but did not show that the resident had dentures or include interventions related to denture use or maintenance. Staff E, CNA, stated they had not seen the resident wear dentures and were unaware of the new dentures, Staff C, LPN/CC, stated the care plan should have been updated when the dentures were obtained, and Staff B, DNS, stated the care plan should have reflected the dentures and interventions.
Failure to Provide Individualized Activities
Penalty
Summary
The facility failed to provide individualized activities for Resident 5, who was admitted with diagnoses including anxiety disorder, depression, and weakness. The admission MDS dated 01/14/2026 showed the resident was cognitively intact. During interviews on 05/03/2026 and 05/06/2026, Resident 5 stated they could not attend in-person activities because of their legs, wanted more activities to occupy them, mostly stayed in bed watching TV, and did not remember the last time activities staff visited to offer activities. The resident also stated activities staff would need to offer something they were able to do because they had difficulty doing some activities. The activities care plan dated 12/26/2026 showed a goal for Resident 5 to participate in activities two to three times per week. Progress notes documented one visit on 12/22/2026 to provide a welcome packet and encourage participation in daily activities, but no further activity documentation was found in the progress notes. Staff H stated room visits should include puzzles, arts and crafts, visiting, and chatting, and that documentation was placed in tasks, but the task record showed no documentation of activities for the past 30 days. Staff J stated paper documentation existed for room visits and that Resident 5 was on a list for room visits every Monday and Wednesday, while the room visit documentation showed only four visits on 01/26/2026, 02/06/2026, 03/10/2026, and 04/08/2026.
Failure to Maintain Heel Offloading for Reopened DFU
Penalty
Summary
The facility failed to consistently implement pressure reducing strategies for a resident with a left heel diabetic foot ulcer that had reopened. The resident was admitted with diagnoses including left hip fracture with surgical repair, a blood clot of the left lower leg, and dementia, and was dependent on staff for mobility and unable to make needs known. The baseline care plan and care plan both included heel offloading interventions, and the wound care provider initially recommended heel floating with pillows or wedge and pressure relieving boots. The wound later resolved, but a weekly skin assessment documented that the left heel wound reopened and was very painful to touch. After the wound reopened, the contracted wound care provider documented that the DFU to the left heel had reopened and recommended the resident wear pressure relieving boots at all times. The current care plan reviewed after the wound reopened did not include new interventions related to the reopened wound. Observations showed the resident seated in a reclined wheelchair with the left foot/heel resting on the footrest strap and no pressure relieving boots in place, and later lying in bed with both heels directly on the mattress without being floated and without boots. Staff interviews indicated the resident had not refused the boots or heel floating, and the LPN/CC and DON stated the resident should have been assessed and the plan of care updated when the wound reopened.
Failure to Address Resident Hearing and Vision Needs
Penalty
Summary
The facility failed to address one resident’s hearing and vision needs. Resident 112 was admitted with diagnoses including a leg fracture, dementia, and hearing loss in both ears, and was able to make needs known. The record showed the resident lost their glasses and was given readers, but the resident did not wear them because they were concerned that wearing glasses that were not their prescription would further degrade their vision. Observation did not show glasses in the resident’s room, and the resident stated they did not use a hearing aid. The resident was observed to be hard of hearing, requiring an elevated voice and repeated questions to understand. The admission MDS dated [DATE] documented adequate hearing with hearing aid and adequate vision with corrective lenses, while the significant change MDS dated [DATE] documented moderate difficulty hearing without a hearing aid and impaired vision without corrective lenses. The care plan initiated 02/24/2026 addressed impaired vision with interventions to arrange consultation with eye care practitioners as needed and remind the resident to wear glasses, but it did not include a focus area or interventions for hearing loss or use of hearing aids. A resident clothing list showed the resident admitted with one pair of eyeglasses and one Super Ear headset personal sound amplifier, yet observation and interview showed the resident in bed without eyeglasses or a hearing device, with the amplifier stored in the bedside table drawer. Staff interviews confirmed the resident’s hearing was strained, that the hearing device and glasses were not being used, and that the resident’s hearing device use should have been included in the plan of care and the resident should have been referred for eye care assessment.
Respiratory Care Orders and Documentation Not Maintained
Penalty
Summary
The facility failed to provide respiratory care consistent with professional standards of practice for two residents receiving oxygen therapy. One resident with COPD and chronic respiratory failure with hypoxia was observed multiple times lying in bed receiving oxygen at 2 L via nasal cannula. The resident’s oxygen order, dated 02/15/2026, allowed 1 to 4 L per minute continuously via nasal cannula, but it did not include an indication for use or oxygen saturation parameters. The April and May 2026 MARs did not show documentation of oxygen therapy being provided, and the TARs showed only an order to change oxygen tubing if damaged or visibly soiled, not an order for oxygen therapy. Oxygen saturations were not documented consistently daily from 04/01/2026 through 05/04/2026. A second resident with respiratory failure, high blood pressure, and anxiety disorder was observed in the room receiving oxygen at 6 L via nasal cannula on multiple occasions. The resident stated they needed oxygen therapy to breathe, and the care plan identified the resident as dependent on oxygen and to receive oxygen per provider orders. However, provider orders reviewed on 05/04/2026 showed no orders for oxygen therapy or for changing oxygen tubing. Staff stated the oxygen and tubing-change orders had been discontinued when the resident went to the hospital and were not added back to the MAR or TAR when the resident readmitted to the facility.
Failure to Refer Resident With Identified Dental Needs
Penalty
Summary
The facility failed to ensure that Resident 112 received needed dental care. Resident 112 was admitted with diagnoses including a leg fracture, dementia, and hearing loss in both ears. Observation on 05/03/2026 showed the resident had missing lower teeth. The admission MDS, dated [DATE], documented obvious or likely cavities or broken natural teeth, and the care plan dated 02/24/2026 identified oral/dental health problems related to likely cavities or broken teeth with an intervention to coordinate dental care and provide transportation. During interviews, Staff G, Regional Social Services, stated Resident 112's dental needs were captured on the 02/24/2026 MDS and the resident was not referred for dental services. Staff M, Social Services Director, stated residents with dental needs should be referred to social services to be scheduled for assessment by a dental care practitioner, and that Resident 112 should have been referred after the MDS assessment. Staff B, DON, stated residents with identified dental needs should be referred for follow-up with a dentist and that Resident 112 should have been referred to the in-house dental provider; Staff B stated the lack of referral did not meet expectations.
Inaccurate Meal Intake Documentation
Penalty
Summary
The facility failed to accurately document the amount of food eaten for Resident 13, who was admitted with diagnoses including diabetes mellitus, dysphagia, and protein-calorie malnutrition. The quarterly MDS dated 02/12/2026 showed the resident was moderately cognitively impaired. During observation on 05/05/2026 at 12:09 PM, a meal tray was delivered to the resident’s room, set up on a bedside table, and the resident was observed eating slowly, eating less than 25% of the meal, then laying back in bed and closing their eyes while the tray remained in the room. Staff later removed the tray, but the POC documentation for lunch on 05/05/2026 recorded that Resident 13 ate 76-100% of the meal. During interview, the CNA stated the resident typically ate 25-50% of meals and never ate all of the food, and that if they did not pick up a tray they would ask a coworker what the resident ate before documenting it. The CNA stated they were told the resident ate 75-100% of lunch, so that is what was entered. The LPN/RCM stated staff should document meal intake accurately in POC, and the RN/DNS stated it was their expectation that all staff document meal intake accurately.
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