Fir Lane Care
Inspection history, citations, penalties and survey trends for this long-term care facility in Shelton, Washington.
- Location
- 2430 North 13th Street, Shelton, Washington 98584
- CMS Provider Number
- 505230
- Inspections on file
- 56
- Latest survey
- April 30, 2026
- Citations (last 12 mo.)
- 10
Citation history
Health deficiencies cited at Fir Lane Care during CMS and state inspections, most recent first.
A resident with severe cognitive impairment and wandering behaviors repeatedly entered other residents' rooms, while another resident with dementia, poor impulse control, and a history of physical behaviors frequently targeted them in the hallway and in shared areas. Staff reported often having to physically block the aggressive resident from approaching the vulnerable resident. Despite prior documented incidents where the aggressive resident had pushed another resident down and had previously pushed this same vulnerable resident causing a fall with head impact, the aggressive resident again shoved the vulnerable resident in their room, requiring staff to lower the victim to the floor. An incident report later described the action as guiding the resident out, but staff and the administrator confirmed it was a deliberate shove and the second such episode between these two residents.
A resident with an ankle infection, mood disorder, substance abuse history, and recent NWB status was discharged to a homeless shelter without an effectively developed discharge plan or sufficient time and orientation. Care plans and managed care discharge plans identified barriers such as non‑weight‑bearing status, lack of housing, and need for placement, with LTC listed as a back‑up, but placement with DSHS was not pursued before the resident was told they had to leave. Staff reported escalating verbally aggressive behavior and suspected alcohol use, yet behavior care plans were not updated until the day police were called, and no documented behavioral health or substance abuse referrals were made. The resident stated they believed they were going to another facility or transitional housing with a bed, but was instead transported by facility van to a street‑level shelter where no bed was available, while staff and the administrator gave conflicting reasons for the discharge and acknowledged that placement options should have been explored earlier.
A cognitively intact resident with an ankle infection, mood disorder, and substance abuse history was issued an involuntary discharge notice after a verbal altercation and concerns about aggression and alcohol use, and was discharged to a homeless shelter. The resident reported being told by the Social Service Director that they had to leave, believed the discharge was not optional, and thought they were going to another facility or senior housing, only to be dropped at a shelter with no available beds. Record review showed no documentation that the LTC Ombudsman was notified of the discharge, and the Social Service Director stated they had not sent the transfer and discharge notice to the Ombudsman, instead sending such notices at the end of the month.
A resident with Alzheimer’s dementia, quadriplegia, severe cognitive impairment, and an existing hospital POLST indicating DNR and selective treatment, as well as a documented DPOA-HC, was admitted with these documents uploaded into the EMR. Facility staff did not recognize or use the existing POLST and instead completed a new POLST with the resident, changing the status to full code/CPR and full treatment, despite the resident’s severe cognitive impairment and reported inability to sign legibly. Later, another nurse completed yet another POLST by phone with the resident’s POA, again unaware of the prior forms, and documentation from a care conference reflected full code without disclosure to the POA that a new POLST had been executed. The DNS acknowledged staff failed to adequately review hospital records and involve the resident’s representative in CPR and POLST decisions as required by policy.
A resident with severe cognitive impairment, paraplegia, dementia, and cancer had a care plan identifying nutritional risk and requiring monitoring of mealtime circumstances, analysis of causes of low intake, and implementation of diet modifications including minced and moist food, mildly thick (MT2) liquids, no straws, upright positioning, and 1:1 assist for PO. Despite repeated 0–25% meal intakes and documented low intake with weight loss, the record showed no documentation that staff attempted to determine patterns or causes of poor intake. After SLP changed the resident to thickened liquids and instructed nursing to remove thin liquids, staff continued to provide family-supplied Ensure without thickening in a sippy cup, sometimes with a straw, and the RD did not direct staff to track intake from home snacks or supplements. CNAs and an LPN reported the resident was fully dependent for eating and that staffing limitations made providing needed assistance difficult, while the DON confirmed that Ensure as given was not MT2 and that staff were expected to follow the care plan.
A resident with paraplegia, dementia, and severe cognitive impairment was admitted with a documented Stage 2 coccyx/sacral pressure ulcer and orders to be repositioned and have skin integrity monitored, but no wound care orders or weekly skin assessments were documented for nearly two weeks. Later notes described a Stage 2 sacral pressure ulcer and referenced a healed Stage 4 ulcer in the same area, while a wound consultant subsequently assessed a separate buttock wound as MASD and was unaware of any coccyx/sacral wound or prior Stage 4 history. Staff interviews confirmed missed weekly skin assessments, unclear documentation about whether the sacral and buttock wounds were the same, and that the resident had an open wound on the bottom since admission and often refused repositioning.
The facility failed to maintain accurate clinical documentation for a resident with severe cognitive impairment and multiple comorbidities. Despite an order for a suprapubic catheter, nursing assistant records and the MDS coded the resident as always incontinent of urine, and a wound consultant note also documented urinary incontinence based on assumption rather than confirmed information. Provider notes repeatedly listed PEG tube feeds as part of SNF recommendations even though the resident did not receive PEG feeds; these entries were carried over from hospital records via AI and not corrected. Wound records were inconsistent, with differing descriptions of a Stage 2 pressure ulcer on the coccyx/sacrum and a partial-thickness MASD wound on the buttocks, and staff were unable to clearly determine whether these referred to the same wound, reflecting unclear and inaccurate wound documentation.
A resident with severe cognitive impairment and hemiplegia experienced multiple falls, but the resident's representative was only notified of one incident. Incident reports showed inconsistent or delayed documentation of family and physician notifications, and staff relied on assumptions rather than direct communication to confirm notifications had occurred.
Two residents experienced failures in the accurate documentation and reconciliation of controlled substances, including missing entries, incomplete records, and improper shift change counts. Staff did not consistently follow procedures for logging medication administration and counting controlled substances, resulting in discrepancies in the Controlled Substance Record Book.
Staff failed to perform hand hygiene during medication administration, including before and after resident contact, after glove removal, and after touching the resident's environment. A nurse administered medications and handled personal and medical equipment without cleaning their hands, while another nurse did not perform hand hygiene after removing protective equipment and before accessing the medication cart. A family member also reported that nurses did not wash their hands or use gloves when administering eye drops.
The facility did not consistently inform or provide documentation to residents about their right to formulate an advance directive, including a POA for health care. Several cognitively intact and impaired residents were not offered this information upon admission, and staff interviews confirmed that the process for offering and documenting advance directives was not followed as required.
The facility did not ensure that grievances voiced by residents during Resident Council meetings were properly logged, investigated, or resolved, despite repeated complaints about issues such as missing beverages with meals, delayed call light response, loud TVs, and privacy concerns. Residents reported that staff failed to follow up or communicate actions taken, and the DON confirmed that required grievance procedures were not followed.
The facility did not notify the State Long-Term Care Ombudsman when two residents were transferred to the hospital on multiple occasions. Staff interviews confirmed that required notifications had not been sent for these hospitalizations, and the Social Services Director acknowledged that no notifications had been made for several months.
The facility did not consistently complete or update PASRR screenings to accurately reflect residents' mental health diagnoses, resulting in several residents with conditions such as anxiety, schizophrenia, delusional disorder, and psychosis not being properly identified or referred for further evaluation. Staff interviews confirmed that PASRR forms were often inaccurate or not updated when new diagnoses were made, and required referrals for Level II evaluations were not always documented or completed.
The facility did not follow physician orders or facility protocols for bowel management, failed to maintain and document coordinated hospice plans of care, and did not routinely assess or monitor non-pressure skin conditions. Several residents went extended periods without bowel movements without receiving ordered PRN medications, hospice documentation was missing for two residents, and a resident with self-inflicted abrasions did not receive recommended treatments or monitoring.
Staff failed to consistently and accurately document and calculate fluid intake for a resident on a fluid restriction, with incomplete and inaccurate records over a two-week period. Additionally, significant weight loss in another resident went unrecognized, and no further nutritional interventions were implemented or evaluated, despite care plan requirements. These failures placed residents at risk for adverse health outcomes.
Two residents with cognitive impairment and limited range of motion did not receive restorative nursing services, despite therapy recommendations and referrals, because the facility lacked sufficient qualified staff. Therapy and nursing staff confirmed that restorative programs were not implemented or initiated, resulting in unmet care needs for these residents.
The facility did not ensure that binding arbitration agreements were clearly explained to three residents or their legal representatives, including two who were cognitively intact and one with a POA due to severe cognitive impairment. Residents and a POA reported not understanding the agreement, the rights being waived, or the voluntary nature of signing. Staff interviews revealed inconsistent explanations, with key information such as the 30-day revocation period and the fact that signing was not a condition of admission not being communicated.
A resident who was cognitively intact missed a scheduled neurology appointment for diagnostic testing after facility staff failed to arrange transportation, leading to the appointment's cancellation. The resident was not informed by the facility and only learned of the cancellation through their own email, resulting in emotional distress and a delay in care. The DON confirmed this did not meet expectations.
Two residents received psychotropic medications before proper consent was obtained. One cognitively intact resident was given an antidepressant prior to signing a consent form, and another resident with a court-appointed guardian was administered multiple psychotropic medications before the guardian was notified and consented. Staff confirmed that consent should have been secured before medication administration.
Two residents receiving psychotropic medications did not have required monitoring or documentation of side effects and behaviors, and pharmacist recommendations for monitoring were not acted upon in a timely manner. Staff confirmed that these monitoring and documentation practices did not meet expectations.
A resident with severe cognitive impairment reported being hit, and the facility did not notify the State Agency of the abuse allegation within the required timeframe, instead reporting it three days later. The DON confirmed this delay did not meet expectations for timely reporting.
The facility did not ensure that care plans were fully developed and updated for three residents, including one with pressure injuries and an indwelling catheter, another with nutritional risk, and a third with anemia and visual impairment. Care plans lacked documentation of catheter justification, nutritional interventions, anemia management, transfusion history, and vision needs, as confirmed by staff interviews.
Multiple residents experienced deficiencies in medication administration, including late administration of thyroid medication, lack of provider follow-up for a resident's blood pressure medication concerns, improper handling of a chewable medication, and failure to promptly waste a controlled substance. Nursing staff did not consistently follow professional standards or physician orders, leading to deviations in medication timing, form, and documentation.
A resident with multiple pressure injuries was not consistently assessed, and ordered pressure redistribution equipment was not functional for several days. The resident reported discomfort and the need for pillows due to a malfunctioning low air loss mattress, which staff did not address promptly. Documentation and wound care consults failed to consistently assess or monitor a pressure injury on the resident's right heel, despite ongoing wound care and previous documentation of the wound.
A resident with a history of Stage 3 and 4 pressure injuries was admitted with an indwelling urinary catheter, initially justified by the presence of these wounds. After the wounds had healed, staff did not reassess or seek provider orders for catheter removal, and no ongoing medical justification for continued catheter use was documented, contrary to facility policy.
Several residents received pain medications, including opioids and acetaminophen, without documented attempts to use non-pharmacological interventions (NPIs) as required by facility policy. In one case, a resident was also given a medication for GERD without an active diagnosis, and staff did not reassess the necessity of this medication on admission. Staff interviews confirmed that NPIs should have been offered and documented, but this was not done.
Surveyors found that two medication carts contained expired medications, unlabeled creams, and multiple bottles of nystatin powder without resident identifiers. An LPN and RN confirmed that medications were left unattended, expired, or lacked proper labeling, which did not meet facility expectations.
The facility did not consistently document refrigerator and freezer temperatures for multiple food storage units, as required by professional standards. Numerous dates were missing from temperature logs, and the Dietary Manager confirmed that staff were responsible for daily checks but acknowledged the gaps in records.
Staff did not consistently follow infection control protocols during wound care, as a nurse failed to perform hand hygiene before donning gloves and did not change gloves after direct contact with a resident's leg. During meal tray delivery, a CNA did not perform hand hygiene between resident rooms or after assisting residents, despite facility expectations. Additionally, laundry staff did not consistently document washer temperature checks, resulting in incomplete records necessary for ensuring proper sanitation.
A resident with severe cognitive impairment, multiple sclerosis, diabetes, and a stage III pressure ulcer did not receive care as outlined in their plan, including frequent repositioning, assistance with meals, and personal hygiene. The resident was repeatedly observed in uncomfortable positions in bed, unable to access meals, and without proper grooming or clothing, while staff interviews and documentation indicated inconsistent adherence to the care plan.
A resident with dementia and a seizure disorder did not receive prescribed seizure medications due to unavailability and refusals, and the facility failed to notify the physician or the resident's representative. This led to the resident becoming unresponsive, requiring CPR, and hospitalization. Hospital records showed subtherapeutic levels of anticonvulsant medications, likely causing a seizure.
Three staff members failed to adhere to CDC guidelines for PPE use when caring for residents with COVID-19. An LPN and two CNAs did not remove their N95 respirators and eye protection after exiting rooms of COVID-19 positive residents, continuing to interact with others in the facility. The Acting DON confirmed that staff did not follow infection control procedures, placing residents and staff at risk.
Two residents in an LTC facility did not receive adequate assistance with daily living activities, such as bathing and dressing, despite being cognitively intact and requiring substantial help. One resident received only one shower 11 days after admission, while the other was left in bed for extended periods without regular hygiene care. Staff were too busy to provide the necessary assistance, contrary to the care plans.
A facility failed to ensure residents were free from physical restraints, using Velcro straps and tilt-in-space wheelchairs improperly. A resident's arm was secured to a wheelchair without proper documentation, while two residents were tilted back excessively in wheelchairs to prevent movement, contrary to care plans. Staff were unaware of the need for proper documentation and the correct use of these devices.
A resident with a history of pressure ulcers and at risk due to developmental delay, diabetes, and morbid obesity developed severe pressure ulcers on both heels, leading to hospitalization and a below-the-knee amputation. The facility failed to accurately assess and document the resident's condition, resulting in a lack of timely intervention. Staff interviews revealed poor communication and awareness of the resident's deteriorating condition, contributing to the delay in treatment.
The facility failed to implement care plan interventions for two residents, leading to deficiencies in their care. One resident, with dementia and depression, was not provided with hearing aids or TED hose as per their care plan and remained in bed without proper hygiene assistance. Another resident, who required assistance with bathing, did not receive a shower or bed bath during their first week of admission. The Director of Nursing acknowledged the inconsistency in implementing care plans.
A resident in a dementia unit sustained a second-degree burn after being found unsupervised on a baseboard heater. The resident, with cognitive impairments and wandering behaviors, was able to access the heater due to inadequate supervision. Staff reported difficulty regulating heater temperatures, and the facility's thermometer was malfunctioning, contributing to the unsafe environment.
A resident with cognitive impairment and a history of elopement left the facility unattended, highlighting a failure to follow the elopement prevention policy. The resident's care plan did not indicate a risk for elopement, and there was no physician's order for a wander guard, which was applied after the initial incident. The facility's logs lacked documentation of the elopement, and the wander guard alarm was not functioning properly.
A resident admitted with a fractured femur and on a pain medication regimen did not receive prescribed medications due to a new LPN's lack of access to the Omnicell and insufficient training on admissions. The resident experienced significant pain overnight without relief, as the LPN was unaware of the procedure to obtain medication or whom to contact for assistance.
A resident was transferred to the hospital from a scheduled appointment without receiving the required written notice of transfer. The facility did not notify the resident, their representative, or the Office of the State Long-Term Care Ombudsman, as the transfer did not occur directly from the facility. The resident, who required moderate to total dependence on staff, was admitted to the ICU without proper notification.
A resident with chronic inflammatory demyelinating polyneuritis was not re-admitted to the facility after hospitalization due to the facility's inability to provide necessary care. The resident required infusions and mobility assistance, but the facility failed to communicate or document discharge plans, leaving the resident without proper support.
The facility did not provide quarterly personal fund statements to residents, including a resident with a neurological condition. The Business Office Manager admitted to inconsistencies in issuing these statements, and the Administrator was unaware of the issue, despite expectations for quarterly distribution.
The facility failed to meet professional standards for two residents. One resident received incorrect pain medication orders and unauthorized oxygen therapy due to transcription errors. Another resident missed doses of an antibiotic because the nurse couldn't locate it, and alert charting was not completed. The DON acknowledged these issues.
The facility failed to provide timely vision services for two residents, leading to a deficiency in maintaining their vision. One resident with diabetes and kidney failure waited several months for an eye appointment that was not scheduled. Another resident with depression and a recent MI experienced vision issues and did not receive a timely eye exam due to poor communication and scheduling issues.
The facility experienced staffing shortages, resulting in unmet resident needs for ADLs such as showers and nail care. Residents reported long wait times for assistance and pain medication, while staff confirmed the inability to complete tasks due to insufficient staffing. The Director of Nursing and Administrator acknowledged the ongoing staffing issues and lack of RN coverage.
The facility failed to record refrigerator temperatures for one of the two refrigerators in the locked medication rooms. An RN and the DNS were unable to locate the temperature log, which should have been recorded by the night shift staff. The DNS confirmed that the log is usually placed on top of the refrigerator and should be started anew if missing.
The facility failed to store and serve food under safe and sanitary conditions, with uncovered food items exposed to dust and debris, and improperly sealed and dated items in the refrigerator and freezer. The Dietary Manager acknowledged the issues, and the Administrator confirmed the expectation for compliance with guidelines.
The facility failed to honor the bathing preferences of a resident with a neurological condition, missing scheduled showers without proper documentation. Additionally, another resident with anxiety, depression, and PTSD was not returned to their original room post-quarantine, despite expressing dissatisfaction and staff acknowledgment.
A facility failed to notify a Medicaid recipient when their personal fund balance exceeded the $2,000 resource limit, risking their Medicaid coverage. The resident's balance had been over the limit for several months, and staff did not consistently provide quarterly fund statements or address the issue in a timely manner.
Failure to Prevent Repeated Resident-on-Resident Physical Abuse
Penalty
Summary
The facility failed to protect a resident from abuse by another resident when it did not prevent repeated physical aggression despite prior incidents and known behavioral risks. Resident 1, who had Alzheimer's disease and was assessed as severely cognitively impaired, had a care plan noting behavior issues related to confusion, pacing, and wandering, including entering other residents' rooms. Staff B, a CNA, reported that Resident 1 frequently ambulated in the hallway and entered other residents' rooms, while Resident 2, who was independent with ambulation and often stayed in their room, would quickly approach Resident 1 whenever they encountered them. Staff B stated they frequently had to physically block Resident 2 from getting close to Resident 1, including standing in doorways to prevent Resident 2 from entering areas where Resident 1 was present. Resident 2's care plan documented a history or potential for physical behaviors, including slamming doors and throwing an overbed table, related to anger and dementia with poor impulse control, with a goal that Resident 2 would not harm self or others. Medical provider notes for Resident 2 and Resident 1 dated 02/26/2026 showed that Resident 2 had previously walked up to another resident and pushed them down, unprovoked, and that Resident 1 had been pushed by another resident, resulting in a fall and head impact. On 04/17/2026, Staff B witnessed Resident 1 wandering into Resident 2's room, after which Resident 2 immediately entered the room and shoved Resident 1; Staff B caught and lowered Resident 1 to the floor. The facility incident report characterized Resident 2's actions as guiding Resident 1 out by placing hands on their shoulders, but Staff B later clarified that Resident 2 was not guiding Resident 1 out the door and instead pushed Resident 1 down to the floor. The Administrator acknowledged that Resident 2 deliberately shoved Resident 1 when finding them in their room and that this was the second time Resident 2 had shoved Resident 1.
Inadequate Discharge Planning and Orientation Prior to Shelter Discharge
Penalty
Summary
The deficiency involves the facility’s failure to communicate, develop, and implement an effective discharge plan and to provide sufficient time and orientation prior to discharge for one resident. The resident was admitted with an ankle infection, mood disorder, and substance abuse, and had limited mobility with non‑weight‑bearing restrictions on the right lower extremity for six weeks. The Discharge Care Plan noted that the resident wished to return to placement options and that there was potential for complications related to discharge planning, including health literacy and the possibility that the prior living environment was not available because the resident did not have a home. Early discharge evaluations documented that the discharge plan was unknown, and subsequent managed care discharge plans identified barriers such as placement needs and the foot injury, with a back‑up plan of LTC if preferred discharge locations were not attainable. Over the course of several weeks, managed care discharge plans projected discharge dates and contemplated discharge to home with the resident’s mother versus placement, while continuing to list barriers of non‑weight‑bearing status and placement. The facility’s social services staff reported they were waiting to explore placement with DSHS until the resident was able to bear weight, and acknowledged they did not have time to plan for placement with DSHS when the resident was later required to leave immediately. Although the resident’s behavior reportedly escalated in the two weeks prior to discharge, including derogatory comments toward other residents, a verbal altercation with a roommate, and threats to physically harm a nurse, the care plan related to these behaviors was not updated until the day police were called. Staff also reported suspected alcohol use, but there was no documentation of referrals to behavioral health or substance abuse programs, and the behavioral consultant was not re‑engaged when behavior escalated. The resident stated that the Social Service Director told them they had to leave after a verbal altercation with a nurse and that they did not believe remaining at the facility was an option. The resident reported being told they would be discharged to a shelter and believed this would be a transitional housing setting with a bed, not a street‑level homeless shelter. The Transfer and Discharge notice cited endangerment to the safety of others as the reason for discharge and listed a specific shelter as the discharge location, with only two days between notice and discharge. The resident reported being surprised when the facility van dropped them off outside a homeless shelter, finding the doors locked and no bed available for the night, and having to travel a distance using a knee scooter to contact family. Facility leadership later stated that the resident was discharged because they no longer needed services and were independent with ADLs, and that they believed the resident wanted to go to a homeless shelter, while also acknowledging that exploring placement options should have occurred prior to discharge and that they were unaware at the time that the shelter did not guarantee overnight beds. Documentation on the day before and day of discharge showed the resident was on behavior alert but did not record significant behaviors other than talking loudly, and staff described the resident as anxious about discharge and attempting to delay the process, while also indicating they had been told the resident was leaving that day and did not know what would happen if the resident refused to leave.
Failure to Notify Long-Term Care Ombudsman of Involuntary Discharge
Penalty
Summary
Surveyors identified a deficiency when the facility failed to notify the Long-Term Care Ombudsman of a resident’s discharge. The resident was admitted with diagnoses including an ankle infection, mood disorder, and substance abuse, and a Minimum Data Set dated 01/04/2026 documented that the resident was cognitively intact. Following a verbal altercation with a nurse and concerns about aggression, verbal abuse toward staff, and the smell of alcohol on the resident, the facility issued a Transfer and Discharge Notice dated 02/18/2026, citing endangerment to the safety of others due to the resident’s clinical or behavioral status. The notice indicated it was given to the resident on 02/17/2026 with a discharge date of 02/19/2026, and the Recapitulation of Stay documented that the resident was being discharged to a shelter. During interview, the resident reported being told by the Social Service Director that they had to leave after the altercation and believed the discharge was not optional. The resident stated they did not know where to go, and the Social Service Director said they would work on a location, later providing a pamphlet that led the resident to believe they were going to another facility or senior housing, rather than a homeless shelter. The resident described being dropped off by the facility van at a homeless shelter, finding the doors locked, and learning there were no beds available for the night, after which they sought help from family. Record review on 02/25/2026 showed no documentation that the Long-Term Care Ombudsman had been notified of the discharge, and the Social Service Director acknowledged in interview that they had not sent the Transfer and Discharge Notice to the Ombudsman, stating they send such notices at the end of the month. This failure was cited under WAC 388-97-0120(5)(b).
Failure to Honor Existing POLST and Involve Representative in CPR Decision-Making
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident and the resident’s representative were fully informed and involved in decisions regarding cardiopulmonary resuscitation (CPR) and POLST orders. The facility’s policy required staff on admission to determine whether a resident had an advance directive, identify the primary decision-maker, and place a copy of any advance directive, including POLST and DPOA-HC, in the permanent medical record. For one resident with Alzheimer’s dementia, paraplegia/functional quadriplegia, cancer, severe cognitive impairment, and dependence in activities of daily living, hospital records and transfer orders documented an existing POLST indicating Do Not Resuscitate (DNR) and selective medical treatment, as well as a verified medical DPOA-HC designating a collateral contact as the decision-maker. Despite the existing POLST and DPOA-HC, facility staff completed a new POLST with the resident that changed the code status to attempt resuscitation/CPR and full treatment, and the form bore a legible resident signature even though the collateral contact reported the resident could not sign legibly due to quadriplegia. The Resident Care Manager/LPN who reviewed and signed this POLST stated they were likely given a note that the resident needed a POLST and that they typically spoke with residents and, if they seemed "withit," completed the POLST with them. This staff member acknowledged they were unaware that a prior POLST from the hospital had been uploaded into the electronic medical record. The resident’s care plan documented severe cognitive impairment (BIMS score of 7), and speech therapy notes indicated the resident lacked insight into their condition and risk factors and had reduced health literacy. Later, another Resident Care Manager completed yet another POLST with the collateral contact by phone, documenting DNR and selective medical intervention and indicating the discussion was with the POA, with no documentation that the resident was involved. This staff member reported they initiated the new POLST because a medical provider told them the resident did not have a POLST on file and stated they were unaware of the existing POLST. The collateral contact reported attending a care conference where the facility documented CPR full code and that the spouse stated he was POA, and also reported that the facility did not disclose that a new full-code POLST had been completed with the resident. The DNS stated staff were expected to review hospital records on admission, verify any existing POLST and DPOA-HC, assess cognitive status, and involve the resident representative in decision-making when there was an active DPOA-HC and/or cognitive issues, and acknowledged that staff likely did not see or were not aware of the hospital POLST.
Failure to Implement Nutrition Care Plan and Diet Modifications
Penalty
Summary
The deficiency involves the facility’s failure to implement care plan interventions for low meal intake and diet modifications for a resident with severe cognitive impairment, paraplegia/functional quadriplegia, dementia, and cancer. The resident’s MDS showed dependence on staff for eating, transfers, and bed mobility. A nutrition care plan dated 12/16/2025 identified the resident as at risk for nutritional problems related to a new environment, altered diet, poor appetite, and varied intake, with interventions to monitor and document circumstances around mealtimes and refusals, determine patterns or causes of low intake, alter or remove causes when possible, and monitor and report situations leading to decreased food consumption. Despite this, review of the medical record showed no documentation that staff attempted to determine circumstances, patterns, or causes of the resident’s limited meal intake. Meal intake records from mid- to late December showed the resident repeatedly consumed only 0–25% of multiple meals across many days, while a progress note on 12/23/2025 documented that the resident was on alert for low meal intake, triggering for skin conditions, low intake, and low fluid intake, with weight decreased from 201 to 195 pounds. The note indicated staff would encourage oral intake, assist with meals, and monitor weights, but there was no evidence that the specific care plan interventions to analyze mealtime circumstances and causes of poor intake were carried out. A speech therapy note on 12/23/2025 documented that the resident tolerated mildly thick (MT2) liquids better than thin liquids, that nursing staff were instructed on the diet change, and that no thin liquids should be accessible during meals. Corresponding physician orders and care plan updates specified a minced and moist diet with mildly thick liquids, no straws, upright positioning, and 1:1 assistance for oral intake. Despite these orders and care plan interventions, interviews and record review showed that staff did not consistently follow the diet modification and feeding instructions. The medical provider note on 12/24/2025 stated that all thin liquids had not been removed from the resident’s tray after the change to thickened liquids. The resident’s family brought Ensure from home, which staff poured directly into a sippy cup without thickening, and staff reported that the resident sometimes used a straw with this cup, contrary to the no-straw order. The RD acknowledged knowing about home snacks and Ensure but did not request staff to document or track what the resident consumed from these items and did not know what was in the resident’s sippy cup. CNAs and an LPN confirmed that they poured the family-provided supplement into the sippy cup, sometimes with a straw, and that the resident was dependent for eating and sometimes did not go to the dining room, with limited aides making it hard to provide the needed assistance. The DON stated that Ensure straight from the container is not mildly thick, that the resident required 1:1 assistance and no straws per the care plan, and that staff were expected to follow the care plan interventions.
Failure to Timely Assess and Clarify Pressure Ulcer Versus MASD
Penalty
Summary
The deficiency involves the facility’s failure to accurately and timely assess, monitor, and treat a pressure ulcer for one resident with significant impairments. The resident was admitted with paraplegia/functional quadriplegia, dementia, cancer, severe cognitive impairment, and total dependence for ADLs, transfers, and bed mobility. On admission, documentation showed a Stage 2 pressure ulcer on the coccyx/sacrum area measuring approximately 2.5 inches by 0.1 inch, with a horizontal open area noted on the skin assessment. Provider notes from the SNF recommended repositioning every two hours and monitoring skin integrity, especially the sacral area. However, from admission through 12/27/2025, the medical record contained no wound care orders for the documented Stage 2 pressure ulcer. Further record review showed no weekly skin assessment documentation between 12/15/2025 and 12/28/2025, despite facility policy requiring weekly wound monitoring and documentation. On 12/27/2025, a nurse progress note indicated a sacral wound was present after CNA notification during ADL care. A weekly skin evaluation on 12/28/2025 documented a Stage 2 pressure ulcer on the sacrum, and a 12/29/2025 note described a new Stage 2 pressure area and referenced a healed Stage 4 pressure area in the same region. On 12/30/2025, the wound consultant assessed a wound on the left buttock, diagnosed as MASD and non-pressure related, located on the fleshy part of the buttock extending from left to right, and reported being unaware of any coccyx/sacral wound or prior healed Stage 4 ulcer. Staff interviews confirmed that weekly skin assessments were expected but not completed in the week after admission, that the record was unclear whether the sacral and buttock wounds were the same, and that the resident had an open wound on the bottom since admission, with frequent refusals to reposition.
Inaccurate Clinical Documentation for Continence, Tube Feeding, and Wounds
Penalty
Summary
The deficiency involves the facility’s failure to maintain accurate and consistent clinical documentation for a resident with paraplegia/functional quadriplegia, dementia, and cancer. The resident had a physician order for a suprapubic catheter, but nursing assistant documentation repeatedly recorded the resident as incontinent of urine on multiple dates in December. The MDS assessment also coded the resident as always incontinent of urine. The DON later stated this documentation was incorrect because the resident was not incontinent of urine, and the MDS coordinator confirmed the MDS was coded incorrectly. Additionally, the wound consultant’s note documented urinary incontinence based on an assumption related to bowel incontinence, and the wound consultant stated they were unaware the resident had a suprapubic catheter. Further documentation discrepancies involved PEG tube feeding and wound assessments. Medical provider notes on several dates listed SNF recommendations that included PEG tube feeds, but the physician assistant later stated the resident did not have PEG tube feeds and that these recommendations were erroneously pulled from hospital records using artificial intelligence and not corrected on proofreading. Wound documentation was also inconsistent: the admission evaluation identified a Stage 2 pressure ulcer on the coccyx, a later weekly skin evaluation documented a Stage 2 pressure ulcer on the sacrum, and the wound consultant’s initial assessment described a partial-thickness MASD wound on the left buttock extending across both buttocks. The resident care manager/LPN could not determine from the record whether these were the same wound, and the wound consultant reported being unaware of a coccyx/sacral wound or a healed Stage 4 pressure ulcer on the sacrum, indicating unclear and inaccurate wound documentation in the medical record.
Failure to Notify Resident Representative of Multiple Falls
Penalty
Summary
The facility failed to notify the resident representative of multiple falls experienced by a resident who had a history of stroke with hemiplegia and severe cognitive impairment. The resident required substantial assistance for bed mobility and transfers. According to interviews and record reviews, the resident's representative was only informed of one fall, despite the resident having experienced five falls during their stay. The representative stated they were present daily and were unaware of the additional incidents until a discharge meeting with staff. Review of incident reports revealed that notifications to the family and physician were inconsistently documented. In some cases, the reports indicated that notifications were made after a delay, while in others, there was no evidence of notification at all. Staff responsible for reviewing the incident reports acknowledged that they did not personally contact the family and relied on assumptions or secondhand information regarding whether notifications had occurred, particularly for falls that happened during night shifts.
Failure to Accurately Document and Reconcile Controlled Substances
Penalty
Summary
The facility failed to accurately document and reconcile controlled substances for two residents, resulting in incomplete and inconsistent records in the Controlled Substance Record Book. For one resident with a diagnosis of malnutrition and an order for dronabinol, a controlled substance, staff did not document medication administration for two consecutive days and failed to count the medication at shift changes because it was stored in a medication refrigerator rather than the medication cart. The Medication Administration Record indicated the medication was administered as ordered, but the inventory page showed missing and inconsistent entries, with staff later entering documentation for the missed days after being questioned. For another resident with an order for oxycodone as needed for pain, the facility's incident report revealed that documentation in the Controlled Substance Record Book was missing administration times and included entries for days when the resident was not present in the facility. The Director of Nursing confirmed that staff had not followed procedures for documenting and reconciling controlled substances, and multiple documentation errors were identified, including failure to review all pages of the record book and to ensure accurate medication counts during shift changes.
Failure to Perform Hand Hygiene During Medication Administration
Penalty
Summary
Facility staff failed to perform proper hand hygiene during medication administration, as observed with two staff members. One registered nurse was seen entering resident rooms and administering medications, including eye drops and a medication patch, without performing hand hygiene before or after resident contact, after glove removal, or after touching the resident's environment. The nurse also handled personal items and the medication cart without cleaning their hands between tasks. Another nurse, an LPN, was observed providing intravenous medication under enhanced barrier precautions, but removed their gown and gloves and exited the room without performing hand hygiene, then accessed the medication cart and continued down the hallway. A family member reported that nurses did not wash their hands when entering or leaving the resident's room and did not use gloves or perform hand hygiene when administering eye drops. The facility's policy required hand hygiene before and after resident contact, after touching the resident's environment, and immediately after glove removal. The Director of Nursing confirmed that staff were expected to follow these protocols, but observations and interviews demonstrated that these procedures were not consistently followed.
Failure to Inform and Document Advance Directive Options for Residents
Penalty
Summary
The facility failed to inform and provide written information to residents regarding their right to formulate an advance directive upon admission, as required. For three residents reviewed, there was no documentation that they were offered or declined the opportunity to establish an advance directive, such as a living will or durable power of attorney (POA) for health care. Specifically, one resident was cognitively moderately impaired at admission and was documented as their own responsible party, but neither the resident nor their family was provided information about establishing a POA until well after admission. Another resident, who was cognitively intact, had no documentation in their electronic health record of being offered or declining an advance directive, and only received POA paperwork after the issue was raised during the survey. A third resident, also cognitively intact, similarly had no documentation of being offered the opportunity to formulate an advance directive. Interviews with social services staff and administration confirmed that the process for offering and documenting advance directives was not consistently followed. Staff acknowledged that advance directives should be reviewed on admission and care planned, but admitted that documentation was lacking and that residents who were their own decision makers were not always offered the right to formulate an advance directive. Residents interviewed indicated they had not been approached about designating a decision maker in the event of incapacity, and expressed interest in doing so when the process was explained to them.
Failure to Log and Resolve Resident Grievances Raised in Resident Council Meetings
Penalty
Summary
The facility failed to implement and maintain a system to ensure that grievances verbalized by residents during Resident Council (RC) meetings were properly initiated, logged, addressed, and resolved in a timely manner. Over a period of four out of six months, residents repeatedly raised concerns during RC meetings regarding issues such as the lack of beverages with meals, delayed response to call lights, loud televisions, and privacy curtains not being closed. Despite these recurring complaints, the facility did not document the specific residents involved, the number of residents affected, or the details necessary to investigate and resolve the issues. Additionally, these concerns were not entered into the facility's grievance log as required by policy. Review of facility policies revealed that staff were responsible for reporting RC meeting concerns to the Administrator or department heads, and for providing written responses to grievances in accordance with the grievance policy. The policy also required that all grievances be logged, investigated, and followed up with the resident or their representative within five days. However, interviews and record reviews confirmed that these procedures were not followed, as no grievances related to the RC meeting concerns were logged or investigated, and residents were not informed of findings or actions taken. During interviews, residents confirmed that staff did not act promptly on grievances brought forward in RC meetings and did not follow up with them individually or as a group regarding corrective actions or the effectiveness of any interventions. Some residents indicated that unresolved issues, such as the lack of beverages with meals and slow call light response times, persisted over several months, leading them to stop raising the issues. The Director of Nursing acknowledged that grievances should have been generated and logged for these concerns, but this did not occur.
Failure to Notify Ombudsman of Resident Hospitalizations
Penalty
Summary
The facility failed to notify the Office of the State Long-Term Care Ombudsman regarding the hospitalization of two residents. Specifically, documentation and notification were not provided for the hospital transfers of one resident on two separate occasions and another resident on one occasion. Interviews with facility staff confirmed that ombudsman notifications for these hospitalizations had not been sent at the time of the events, and the Social Services Director acknowledged that no such notifications had been made since February. The Administrator stated that the expectation was for monthly notifications to the ombudsman regarding resident hospitalizations, but this was not followed.
Failure to Complete and Update PASRR Screenings for Residents with Mental Health Diagnoses
Penalty
Summary
The facility failed to ensure that Pre-admission Screening and Resident Reviews (PASRR) were completed accurately and in a timely manner for seven out of eight residents reviewed. In several cases, residents were admitted with mental health diagnoses such as anxiety disorder, schizophrenia, depression, delusional disorder, and psychosis, but their PASRR Level I screenings either did not reflect these diagnoses or were not updated when new diagnoses were added. For example, one resident with an anxiety disorder and on antianxiety medication had a Level I PASRR that did not identify the diagnosis or trigger a Level II referral, which staff later acknowledged was inaccurate. Another resident with schizophrenia, depression, and anxiety had a Level I PASRR that triggered a Level II referral, but there was no documentation of follow-up or completion of the referral process. Additional deficiencies were observed where residents' PASRR Level I screenings failed to capture new or existing mental health diagnoses, such as delusional disorder or psychosis, even after these were added to the residents' medical records. In some cases, the PASRR forms were not updated for several months after a new diagnosis was made, and staff interviews confirmed that these omissions did not meet expectations. For one resident, the PASRR Level I did not indicate the need for a Level II evaluation despite the presence of a psychotic disorder, and the form was not corrected until months later. Staff interviews revealed a lack of oversight and follow-through in reviewing and updating PASRR evaluations. Social Services staff acknowledged that it was their responsibility to ensure the accuracy of Level I evaluations and to refer cases for Level II evaluation as needed, but admitted that several forms were inaccurate or not updated in a timely manner. In some instances, there was no documentation to confirm that required Level II referrals or invalidations had been completed, and mental health diagnoses such as PTSD and bipolar disorder were not consistently reflected on PASRR forms.
Failure to Follow Physician Orders and Document Care for Bowel Management, Hospice, and Skin Conditions
Penalty
Summary
The facility failed to provide appropriate treatment and care according to physician orders, resident preferences, and goals in several key areas. For bowel management, multiple residents experienced extended periods without bowel movements, yet staff did not administer as-needed (PRN) bowel medications as ordered. For example, one resident went up to 12 shifts without a bowel movement on several occasions, with no PRN medication given, despite clear orders to administer medications after three days without a BM. Similar failures were observed for other residents, including those with severe cognitive impairment and those on hospice, where the bowel protocol was not initiated or documented as required by facility policy and physician orders. In the area of hospice services, the facility did not maintain or document coordinated hospice plans of care for residents receiving hospice. For two residents on hospice, there was no evidence in the electronic health record (EHR) of a current hospice plan of care, hospice intake, terminal diagnosis, or documentation of hospice visits and services provided. Staff were unable to locate required hospice documentation, including the hospice plan of care, hospice election form, physician certification/recertification of terminal illness, and visit notes, either in the EHR or in hospice binders. This lack of documentation meant that staff could not determine what hospice disciplines were involved or the frequency of their visits. Regarding non-pressure skin monitoring, the facility did not routinely assess or monitor skin conditions or implement recommended interventions for a resident with self-inflicted abrasions and a generalized rash. Despite wound care consultant recommendations for specific treatments and monitoring, these were not implemented or documented in the MAR/TAR. There was no ongoing documentation or monitoring of the resident's skin abrasions, and staff confirmed that these issues were not tracked as required. The lack of assessment and follow-through on consultant recommendations contributed to the deficiency in skin care management.
Failure to Accurately Monitor Fluid Intake and Address Significant Weight Loss
Penalty
Summary
Facility staff failed to consistently and accurately monitor, document, and calculate fluid intake for a resident with end stage renal disease who was on a physician-ordered 1500 ml/day fluid restriction. The care plan required staff to record all food and fluid intake, with dietary and nursing staff responsible for providing and documenting specific fluid amounts per meal and shift. However, over a 14-day review period, staff did not consistently document fluid intake for all meals and did not accurately calculate the resident's 24-hour fluid intake on 14 of 15 days reviewed. In several instances, the documented totals did not match the actual intake, and some meal intakes were missing or not recorded at all. The administrator confirmed that the fluid intake records were incomplete and inaccurate, attributing the issue in part to confusing order entry. Additionally, the facility failed to identify significant weight loss and implement or evaluate nutritional interventions for another resident who was severely cognitively impaired and prescribed a controlled carbohydrate diet. Despite a documented weight loss of 14.5% over several months, staff were unaware of the weight loss and had not made a referral to the Registered Dietitian or implemented further interventions. The resident's care plan stated there should be no unplanned significant weight changes, and the nutritional evaluation had previously noted weight stability. However, upon review, both the RN Unit Manager and the Director of Nursing Services confirmed the weight loss and the lack of additional interventions. These deficiencies were identified through observation, interview, and record review, and were found to place residents at risk for continued weight loss, malnutrition, fluid volume overload, and other medical complications. The facility did not have an effective system in place to ensure accurate monitoring and documentation of fluid and nutritional intake, nor did it ensure timely identification and response to significant changes in residents' nutritional status.
Failure to Provide Restorative Nursing Services Due to Insufficient Staffing
Penalty
Summary
The facility failed to provide sufficient qualified nursing staff to deliver restorative nursing services to residents with limited range of motion. Specifically, two residents who were cognitively impaired and dependent on staff for activities of daily living were not provided with restorative nursing programs, despite being identified as at risk for further decline in function and mobility. Occupational and physical therapy evaluations and discharge summaries documented that these residents would have benefited from restorative services, and referrals were made for such programs. However, the restorative nursing programs were never implemented, and there was no documentation showing that the recommended interventions, such as passive range of motion exercises and splint and brace programs, were initiated. Interviews with facility staff, including the Director of Rehabilitation, Administrator, and Director of Nursing, confirmed that the lack of restorative nursing services was due to insufficient and unqualified staff. The therapy department acknowledged that residents who were at risk for declines in range of motion and contracture formation were not referred for restorative programs because there were not enough staff to provide these services. As a result, the residents did not receive the restorative care recommended by therapy, and the facility did not meet the regulatory requirement to provide adequate nursing staff to meet the needs of every resident.
Failure to Properly Explain Binding Arbitration Agreements
Penalty
Summary
The facility failed to ensure that binding arbitration agreements were properly reviewed and explained to residents or their legal representatives in a manner and language they could understand. For three sampled residents, including two who were cognitively intact and one with a legal Power of Attorney (POA) due to severe cognitive impairment, there was no evidence that the arbitration agreement was adequately explained. Residents reported not understanding the nature of the agreement, the rights they were waiving, or the voluntary nature of signing. One resident stated they did not know what an arbitration agreement was and were unaware they were giving up their right to a court proceeding. Another resident did not recall the agreement being explained and signed documents without understanding them. The POA for a severely cognitively impaired resident reported receiving the agreement via email with no explanation or discussion of the rights being waived. Staff interviews revealed inconsistent and incomplete explanations of the arbitration agreement process. The Business Office Manager (BOM) stated that the agreement was provided at admission or within 72 hours and described it as a voluntary legal document, but did not inform residents of the 30-day revocation period or that signing was not a condition of admission. The BOM also did not consistently assess residents' cognitive ability to understand the agreement, relying on basic questions or referring to Social Services if concerns arose. When agreements were sent to family or next of kin, there was no evidence of a thorough explanation or discussion, especially when using electronic signature systems. Further interviews with administrative staff confirmed that residents were told the agreement was voluntary, but staff did not consistently communicate that it was not a requirement for admission, the specific rights being waived, or the 30-day revocation period. When questioned, administrative staff acknowledged that the explanations provided by the BOM were lacking and did not meet expectations. There was no documentation or evidence that residents or their representatives were fully informed about the arbitration agreement in a manner they could understand, leading to the deficiency.
Failure to Arrange Transportation Results in Missed Medical Appointment
Penalty
Summary
A resident who was cognitively intact and able to communicate was admitted to the facility and had a neurology appointment scheduled for diagnostic testing to determine the cause of their inability to walk. The resident was expecting a nerve conduction test on their lower spine, which had been promised upon admission. However, transportation for the appointment was not arranged by the facility, resulting in the cancellation of the appointment. The resident was not informed by the facility about the cancellation and only discovered it by checking their own email. Staff responsible for transportation acknowledged that the failure to schedule transportation was an error on their part, which led to the missed appointment. The resident expressed significant distress and frustration over the delay, having already waited a month for the appointment and now facing an additional month’s wait due to the rescheduling. The DON confirmed that missing the appointment due to lack of transportation did not meet facility expectations.
Failure to Obtain Consent Prior to Administering Psychotropic Medications
Penalty
Summary
The facility failed to ensure that residents or their representatives were fully informed and provided consent prior to the administration of psychotropic medications. For one resident with a diagnosis of depression who was cognitively intact, Sertraline was ordered and administered before the consent form was signed, with staff acknowledging that consent should have been obtained at the time the order was placed. The Director of Nursing Service confirmed that the expectation was for consent to be obtained before medication administration. In another case, a resident who was severely cognitively impaired and had a court-appointed guardian received psychotropic medications, including Mirtazapine and Risperidone, before the guardian was notified and consent was obtained. The guardian reported not being alerted to the resident's arrival and did not receive the consent forms until after the medications had already been administered. Staff interviews confirmed that consents should have been obtained prior to the first dose, but this did not occur.
Failure to Monitor and Document Psychotropic Medication Use
Penalty
Summary
The facility failed to ensure that psychotropic medications were regularly monitored and properly documented for two residents. For one resident with diagnoses including depression, anxiety disorder, dementia with psychotic disturbance, and psychosis, the electronic health record showed missing documentation for behavior monitoring related to delusions, hallucinations, and paranoia on several dates. Additionally, side effect monitoring for both antipsychotic and antidepressant medications was either missing or not documented for multiple days, with no antidepressant side effect monitoring found for two consecutive months. Staff interviews confirmed that these omissions did not meet facility expectations for monitoring and documentation. For another resident with bipolar disorder and depression, there was no documentation of adverse side effect monitoring for a prescribed mood stabilizer. The resident was also taking an antipsychotic medication that required regular AIMS testing, but the required monitoring was not completed in a timely manner, despite a pharmacist's recommendation. Staff acknowledged that side effect monitoring and timely follow-through on pharmacist recommendations were expected but not performed in these cases.
Failure to Timely Report Alleged Abuse to State Agency
Penalty
Summary
The facility failed to report an allegation of abuse involving a resident with severe cognitive impairment within the required 24-hour timeframe. The resident, who was admitted on a specified date and assessed as severely cognitively impaired, made a statement indicating possible abuse, documented in a social services progress note. Despite this, the facility did not report the allegation to the State Agency until three days after it was made, as confirmed by a review of investigation logs and staff interview. The DON acknowledged that the delay did not meet expectations for timely reporting as required by regulation.
Failure to Complete and Update Comprehensive, Person-Centered Care Plans
Penalty
Summary
The facility failed to ensure that comprehensive, person-centered care plans were completed and updated to address all aspects of care for three residents. For one resident with Stage 3 and Stage 4 pressure injuries and an indwelling urinary catheter, the care plan did not document the indication or justification for catheter use, despite the need to prevent contamination of pressure ulcers. Staff acknowledged that the care plan should have specified the catheter's purpose but did not. Another resident with therapeutic nutritional risk had a care plan that was not updated to reflect their history of refusal, need for encouragement with food and fluid intake, and other relevant interventions, as confirmed by the dietician and resident care manager. A third resident with a diagnosis of anemia and recent hospitalization for blood transfusions did not have a specific care plan addressing anemia, monitoring considerations, or transfusion history. Additionally, the care plan for this resident's visual impairment did not mention their use of corrective lenses or related needs, despite the resident reporting difficulty reading and requiring staff assistance. Staff interviews confirmed that these omissions were not in line with facility expectations for care plan updates following changes in condition or hospitalizations.
Failure to Follow Professional Standards in Medication Administration and Management
Penalty
Summary
The facility failed to meet professional standards of practice in several areas related to medication administration and management. One resident with hypothyroidism had a physician's order for levothyroxine to be administered at 6:00 AM, prior to breakfast and on an empty stomach. However, medication administration records showed that the medication was frequently given more than one hour after the scheduled time, often after breakfast, on 27 out of 36 reviewed days. Both the resident and nursing staff confirmed that the medication was not being administered as ordered, and staff acknowledged that this did not meet expectations for proper medication timing. Another resident with hypertension had an order for lisinopril 20 mg twice daily, with instructions to hold the dose if systolic blood pressure was below 100. The resident reported that at home, they only took the medication once daily and expressed concern about receiving too much medication at the facility. Documentation showed that the medication was held on several occasions due to low blood pressure, and a progress note indicated the resident's concern about the dosing. However, there was no evidence that staff communicated this concern to the provider or followed up to clarify the appropriate dosing regimen. Additional deficiencies were observed in medication administration practices, including a resident receiving a chewable aspirin tablet in a manner inconsistent with the order, as the resident preferred to swallow all medications together rather than chew the tablet. Staff did not seek a provider order to change the medication form. Furthermore, a controlled substance (Oxycodone) was found improperly stored in a plastic bag attached to the controlled substance book, rather than being wasted immediately as required. Staff acknowledged that the leftover medication should have been destroyed promptly, but this was not done.
Failure to Consistently Assess Pressure Injuries and Maintain Pressure Redistribution Equipment
Penalty
Summary
The facility failed to ensure that pressure injuries (PIs) were consistently assessed and that ordered pressure redistribution equipment was in place and functional for a resident with multiple PIs. Upon admission, the resident was cognitively intact, required substantial to maximal assistance with bed mobility, was at risk for PI formation, and had two Stage 3 and one Stage 4 PIs. The resident had an order for a low air loss (LAL) mattress for pressure redistribution, but observations revealed that the mattress was not functioning properly, as indicated by red flashing lights for low pressure and power failure. The resident reported feeling the bed frame through the mattress since admission, requiring pillows for comfort, and staff did not notice or address the malfunction until several days later. In addition to equipment issues, the facility did not consistently assess or document the resident's pressure injuries. While the initial evaluation and hospital records documented unstageable PIs to both heels and other areas, subsequent wound care consults failed to mention or assess the right heel PI. Facility progress notes indicated ongoing wound care and dressing changes for both heels, but there was no documentation of measurements or assessments for the right heel PI after admission. The wound care company responsible for weekly assessments also did not document the right heel PI in their consults. Interviews with facility leadership confirmed that the resident was admitted with PIs to both heels, consistent with hospital records, and that facility staff documented heel wounds through several weeks. However, there was no evidence that the right heel PI was measured, assessed, or monitored after admission, despite ongoing wound care. This lack of consistent assessment and failure to ensure functional pressure redistribution equipment constituted the deficiency identified in the report.
Failure to Assess and Discontinue Indwelling Catheter After Resolution of Pressure Injuries
Penalty
Summary
The facility failed to ensure that a resident admitted with an indwelling urinary catheter was properly assessed for catheter removal as soon as possible, and did not ensure that a clinical justification existed for the continued use of the catheter. The facility's policy required a medical justification for both the initiation and ongoing use of indwelling catheters, including a Bladder Data Collection/Evaluation and a plan of care documenting justification for continued catheterization beyond 14 days. For the resident in question, who was cognitively intact and dependent on staff for toileting, the initial justification for the catheter was the presence of Stage 3 pressure injuries to the sacrum and right buttock. Subsequent wound care consults documented that both pressure injuries had resolved, and a recent Bladder Data Collection and Evaluation did not identify any ongoing conditions that would justify continued catheter use. Despite this, the catheter remained in place, and staff confirmed that no action was taken to contact the provider for a trial discontinuation order after the wounds had healed. The resident's medical record did not contain diagnoses such as obstructive uropathy, neurogenic bladder, benign prostate hyperplasia, or urinary retention that would otherwise justify the catheter's continued use.
Failure to Provide and Document Non-Pharmacological Pain Interventions and Medication Review
Penalty
Summary
The facility failed to ensure that residents' drug regimens were free from unnecessary medications by not providing or documenting non-pharmacological interventions (NPIs) for pain management, not monitoring for side effects, and not reassessing the necessity of certain medications upon admission. For one resident on hospice care with severe cognitive impairment, morphine was administered multiple times for pain and dyspnea, but there was no documentation that NPIs were attempted prior to medication administration, despite facility policy and staff expectations that NPIs should be tried and documented before giving medication. Another resident with a pelvic fracture and constant pain received both acetaminophen and morphine as needed for pain, but there was no documentation of NPIs being offered or attempted, nor was there documentation of side effect monitoring, even though these were ordered. Additionally, this resident was given omeprazole for GERD without an active diagnosis for the condition, and staff confirmed that the necessity of this medication was not reassessed upon admission. A third resident with a history of hip fracture and pain received as needed acetaminophen on multiple occasions, but again, there was no documentation that NPIs were attempted or provided. Staff interviews confirmed that NPIs should have been offered and documented, and that the lack of documentation did not meet facility expectations. The facility's own pain management policy required staff to determine and document both pharmacological and non-pharmacological interventions and to evaluate their effectiveness, which was not followed in these cases.
Improper Storage, Labeling, and Expired Medications Found on Medication Carts
Penalty
Summary
Surveyors observed that medications and biologicals were not properly stored or labeled in two of five medication carts reviewed. On one cart, an unattended bottle of Tylenol was found on top, and a bottle of Day Time Cold and Flu Relief with an expired date was inside the cart. Additionally, two antifungal creams were found in the cart drawers without resident names or labels. Staff confirmed the Tylenol was left by a new employee from central supply and acknowledged the expired medication. On another medication cart, four opened bottles of nystatin powder were found without any resident identifiers or labels. Staff confirmed the lack of labeling and disposed of the bottles. The Resident Care Manager/Registered Nurse stated that expired medications should be removed and destroyed, and all medications should be labeled with resident names, confirming that the observed practices did not meet expectations.
Failure to Maintain Food Storage Temperature Logs
Penalty
Summary
The facility failed to store food in accordance with professional standards by not maintaining documented refrigerator and freezer temperature logs for all five refrigeration/freezer units reviewed. Temperature logs for the snack refrigerators on multiple halls, as well as the walk-in cooler and walk-in freezer in the kitchen, showed numerous missing entries over several months. Specific dates were identified where no temperatures were recorded, indicating a lack of consistent monitoring of food storage conditions. During an interview, the Dietary Manager confirmed that kitchen staff were responsible for checking all refrigerators daily and acknowledged the presence of many missing temperature records. The issue was identified upon the Dietary Manager's hiring, and it was noted that the missing dates should have been filled in. This failure to document and monitor refrigerator and freezer temperatures was observed and verified through record review and staff interview.
Infection Control Deficiencies in Wound Care, Meal Delivery, and Laundry Practices
Penalty
Summary
Staff failed to maintain infection control practices in several areas. During wound care for a resident, a nurse did not perform hand hygiene before donning gloves and, after holding the resident's leg, continued wound care without changing gloves or performing hand hygiene. Additionally, during meal tray delivery, a CNA repeatedly entered multiple resident rooms, touched various surfaces and residents, and did not perform hand hygiene between room entries or after assisting residents, contrary to facility expectations. The CNA stated that hand hygiene was only performed once during the entire meal pass, and there was confusion about the correct protocol among staff. A review of the laundry room's washer temperature logs revealed multiple days with missing documentation, indicating that regular temperature checks were not consistently completed. The Housekeeping and Laundry Manager confirmed that these checks were necessary to ensure proper sanitation of laundry. The facility administrator also acknowledged that the temperature logs should have been completed as required.
Failure to Implement Care Plan for Dependent Resident
Penalty
Summary
The facility failed to implement the care plan for a resident with multiple complex needs, including diabetes, multiple sclerosis, severe cognitive impairment, and a stage III pressure ulcer. The resident required substantial to maximal assistance with bed mobility, transfers, and activities of daily living, and was dependent on staff for repositioning, dressing, personal hygiene, and eating. Despite care plan interventions specifying frequent repositioning, scheduled check/change for incontinence, and 1:1 assistance with meals, the resident was repeatedly observed lying in bed for extended periods in uncomfortable and improper positions, with the head of the bed at 90 degrees and the resident slumped or with their head bent at an angle. The resident was also observed with exposed skin, uncombed hair, and without staff present to assist with meals, leaving the meal tray untouched and the resident unable to eat due to their position. Staff interviews revealed inconsistent implementation of the care plan, with CNAs indicating confusion or lack of follow-through regarding getting the resident out of bed and providing meal assistance. Documentation showed that after a recent incident where the resident slid out of their wheelchair, staff hesitated to transfer the resident, and therapy had recommended repositioning and returning the resident to bed after meals or when fatigued. However, these recommendations were not consistently followed, as evidenced by multiple observations of the resident remaining in bed, improperly positioned, and without necessary assistance for eating and personal care.
Failure to Administer Seizure Medications as Ordered
Penalty
Summary
The facility failed to ensure that medications to prevent seizures were administered according to physician orders for a resident with dementia and a seizure disorder. The resident was admitted with severe cognitive impairment and had physician orders for Valproic Acid, Dilantin, and Levetiracetam to manage epilepsy. However, the resident did not receive these medications as prescribed due to unavailability and refusals, and there was a failure to notify the physician or the resident's representative about these omissions. The resident's Medication Administration Record (MAR) indicated multiple instances where the resident refused or did not receive their prescribed medications. Specifically, the resident refused Valproic Acid, Dilantin, and Levetiracetam on several occasions, and the Valproic Acid was noted as unavailable on one day. Despite these issues, there was no documentation in the electronic medical record (EMR) that the physician or the resident's representative was informed of the medication refusals or the unavailability of the medication. As a result of these failures, the resident experienced harm when they were found unresponsive and required emergency medical intervention, including CPR and hospitalization. The hospital records indicated that the resident had subtherapeutic levels of anticonvulsant medications, which likely led to a seizure. The Acting Director of Nursing confirmed that the staff should have notified the physician about the medication refusals and unavailability, especially for seizure medications.
Non-compliance with PPE Protocols for COVID-19
Penalty
Summary
The facility failed to ensure that three staff members adhered to CDC guidelines for using personal protective equipment (PPE) when caring for residents with known COVID-19 infections. Staff B, a Licensed Practical Nurse, entered a resident's room with the appropriate PPE but failed to remove the N95 respirator upon exiting, continuing to wear it while interacting with others in the hallway. Staff C, a Certified Nursing Assistant (CNA), also did not change the N95 respirator or eye protection after exiting a resident's room and proceeded to engage with other residents. Similarly, Staff D, another CNA, did not remove the N95 respirator or eye protection after leaving a COVID-19 positive resident's room, citing a lack of available PPE as a reason. The Acting Director of Nursing, Staff A, confirmed that residents with COVID-19 were placed on aerosol precautions and expected staff to remove all PPE upon exiting such rooms. However, the staff did not follow these infection control procedures, as evidenced by their actions. This non-compliance with PPE protocols placed both residents and staff at risk of contracting and spreading COVID-19, as the staff continued to interact with others without changing their PPE.
Failure to Assist Residents with Daily Living Activities
Penalty
Summary
The facility failed to provide necessary assistance with activities of daily living, such as bathing, dressing, and personal hygiene, for two residents. Resident 1, who was cognitively intact and required substantial assistance, reported receiving only one shower 11 days after admission despite repeated requests. The resident's care plan indicated a need for assistance with bathing twice a week and total assistance with personal hygiene, yet documentation showed only one shower was provided since admission. Similarly, Resident 2, also cognitively intact, reported inadequate assistance with daily hygiene and dressing. The resident stated they were left in bed for extended periods without regular hygiene care, and documentation confirmed only one shower was provided since admission, with one additional shower offered and refused. Staff interviews revealed that the assigned Certified Nursing Assistant was too busy to provide the necessary care, and the Acting Director of Nursing acknowledged the expectation for staff to follow the care plans, which was not met in these cases.
Improper Use of Restraints in Wheelchairs
Penalty
Summary
The facility failed to ensure that three residents were free from the use of physical restraints, which placed them at risk for injury, frustration, and decreased quality of life. Resident 1, who had severe cognitive impairment and a history of falls, was observed with a Velcro strap securing their contracted right arm to the wheelchair armrest. This restraint was used without any documented assessment, care plan, consent, or physician order. Staff members were unaware of the requirement for such documentation and continued to use the Velcro strap to prevent further contraction of the resident's arm. Resident 2, also with severe cognitive impairment, was placed in a tilt-in-space wheelchair that was tilted back as far as possible to prevent the resident from getting up and walking, as they were considered a fall risk. The care plan and physician orders did not specify the degree of tilt or provide guidance on managing the resident's attempts to get out of the wheelchair. Staff members admitted to tilting the wheelchair back to restrict the resident's movement, which was not in line with the intended use of the wheelchair for positioning. Similarly, Resident 3, who had severe cognitive impairment, was placed in a tilt-in-space wheelchair tilted at approximately 45 degrees, which restricted their ability to engage in activities and maintain proper body alignment. The care plan and safety device evaluation did not provide adequate instructions on the use of the wheelchair, and staff members used the tilt to prevent the resident from climbing out of the chair. The Director of Nursing acknowledged that the wheelchairs were being used improperly, as they should not have been tilted beyond 20 degrees for positioning purposes.
Failure to Prevent and Manage Pressure Ulcers
Penalty
Summary
The facility failed to accurately assess and take timely action to prevent the development of pressure ulcers in a resident, leading to significant harm. The resident, who had a history of pressure ulcers and was at risk due to conditions such as developmental delay, diabetes, and morbid obesity, developed pressure ulcers on both heels. These ulcers required hospitalization, surgical intervention, and ultimately resulted in a below-the-knee amputation of the right lower extremity. The facility's policy required weekly monitoring and documentation of wounds, but there were significant lapses in the assessment and documentation of the resident's condition. Despite having orders for weekly diabetic foot checks and a history of pressure ulcers, the resident's skin evaluations were not consistently documented, and there were gaps in the monitoring of the resident's feet. Staff failed to document changes in the resident's condition, and there was a lack of communication among the nursing staff and the interdisciplinary team regarding the resident's deteriorating condition. Interviews with staff revealed a lack of awareness and communication about the severity of the resident's wounds. Staff members were not fully informed about the resident's condition, and there was confusion about whether the resident was on the wound consultant's caseload. The Director of Nursing Services acknowledged inaccuracies in the documentation and a failure to communicate the resident's condition effectively, which contributed to the delay in addressing the resident's needs and ultimately led to the resident's hospitalization and amputation.
Failure to Implement Care Plans for Two Residents
Penalty
Summary
The facility failed to implement care plan interventions for two residents, leading to deficiencies in their care. Resident 2, who was admitted with dementia and depression, was dependent on staff for various activities of daily living, including transfers, dressing, and hygiene. Despite having a care plan that required the use of hearing aids and TED hose, Resident 2 was repeatedly observed without these aids and remained in bed wearing a hospital gown. Staff, including a CNA and the Unit Manager, were either unaware of or did not follow the care plan, resulting in Resident 2 not receiving the necessary assistance to get out of bed or maintain hygiene. Resident 3, who was cognitively intact and required assistance with bathing, did not receive a shower or bed bath during the first week of admission, contrary to their care plan. The task report for bathing showed no documentation of showers, and the Unit Manager could not provide a reason for this oversight. The Director of Nursing acknowledged that the care plans for both residents were not consistently implemented by the facility staff.
Resident Burned Due to Unsafe Heater Conditions
Penalty
Summary
The facility failed to ensure a safe environment free from hazards for residents in the locked dementia unit, resulting in a significant incident involving Resident 1. This resident, who had Alzheimer's Disease, dementia, and hypertension, was found unsupervised and seated on a baseboard heater, leading to a second-degree burn on the left hip. The resident's care plan indicated cognitive impairment, wandering behaviors, and impaired safety awareness, yet the resident was able to access the heater unsupervised, resulting in harm. The incident occurred when Staff F, a Nursing Assistant, found Resident 1 sitting on the heater with skin between the heater panels, causing burns. Despite moving the resident away and seeking assistance, the resident returned to the heater before being sent to the hospital for evaluation and treatment. The facility's investigation could not determine why the resident was near the heater, highlighting a lack of adequate supervision and environmental safety measures. Observations revealed that the baseboard heaters in the dementia unit were difficult to regulate, with several being too hot to touch, posing a burn risk. Staff reported issues with the heaters, and the facility's infrared thermometer was malfunctioning, preventing accurate temperature assessments. This lack of proper equipment and supervision contributed to the unsafe conditions that led to Resident 1's injury.
Removal Plan
- Review of the temperature logs
- Staff education related to temperature checks
- Verification of repairs to the baseboard heaters
Failure to Prevent Resident Elopement
Penalty
Summary
The facility failed to adhere to its elopement prevention policy for a resident with cognitive impairment and a history of elopement. The policy required completing an admission assessment, elopement evaluations, and developing individualized interventions, including the use of an electronic monitoring/alarm system. However, the resident's care plan did not indicate a risk for elopement, and there was no physician's order for the application of a wander guard, which was applied after the resident's initial elopement. The facility's accident and incident logs also lacked documentation of the resident's elopement. The resident, diagnosed with hepatic encephalopathy and cirrhosis of the liver, left the facility unattended and was returned by police. Despite this incident, the care plan was not updated to reflect the risk of elopement. The wander guard alarm was reportedly not functioning properly, and staff acknowledged the failure to follow the facility's policy. The resident later left the facility against medical advice, highlighting the ongoing issue with elopement prevention measures.
Failure to Administer Pain Medication to Newly Admitted Resident
Penalty
Summary
The facility failed to assess and treat pain for a resident who was admitted with a fractured left femur, neuropathy, and hypertension. Upon admission, the resident was on a scheduled pain medication regimen, including oxycodone and pregabalin. However, the resident did not receive any medications on the day of admission and only received oxycodone the following day. The resident reported experiencing significant pain throughout the night without any relief, as the facility staff did not administer the prescribed pain medications. The deficiency occurred because the nurse responsible for the resident's care during the night shift was new and did not have access to the Omnicell, a secure electronic medication dispensary, to retrieve the necessary medications. Additionally, the nurse was not trained on admissions and was unaware of the procedure to obtain medication or whom to contact for assistance. The Director of Nursing Services later acknowledged that all nurses should have access to the Omnicell and that the nurse should have reached out to her or another staff member for help.
Failure to Notify Resident and Ombudsman of Emergency Transfer
Penalty
Summary
The facility failed to provide a written notice of an emergency transfer to a resident, their representative, and the Office of the State Long-Term Care Ombudsman. This deficiency was identified during a review of hospitalization cases, specifically for one resident who was transferred to the hospital from a scheduled appointment. The resident, who had no cognitive impairment and required moderate to total dependence on staff for assistance with activities of daily living, was admitted to the intensive care unit without receiving the required notification of transfer. The resident had an active plan to return to the community, but no referrals had been made for discharge planning. The facility's Director of Nursing Services acknowledged that the notification was not completed because the transfer did not occur directly from the facility. This oversight placed the resident and their representatives at risk of not being informed about the transfer and their rights, as there was no documentation of the required written notification in the resident's electronic record.
Failure to Re-admit Resident After Hospitalization
Penalty
Summary
The facility failed to consider the re-admission of a resident after an unplanned hospitalization, which placed the resident at risk for increased anxiety and diminished quality of life. The resident, who was admitted with chronic inflammatory demyelinating polyneuritis, required infusions to manage her condition and needed assistance with mobility. After being transferred to the hospital from an infusion appointment, the resident did not receive any communication from the facility regarding her return. The facility did not document any inability to provide care, nor did they issue a formal notice to the resident about the discharge or discuss plans for her return. Staff at the facility, including the Business Office Manager and the Director of Nursing Services, acknowledged that they informed the resident they could not provide the necessary care due to staffing constraints for the infusion appointments. However, there were no documented efforts or discharge planning notes to find a suitable placement for the resident. The facility's administrator admitted to not documenting conversations with the resident about the facility's inability to meet her needs, resulting in a lack of formal communication and planning for the resident's discharge.
Failure to Provide Quarterly Personal Fund Statements
Penalty
Summary
The facility failed to provide quarterly personal fund statements to residents with personal fund accounts, affecting four sampled residents. Resident 24, who has a neurological condition and is capable of expressing needs, reported not receiving statements of their account balance. A review of the Trial Balance document confirmed that Resident 24, along with Residents 4, 5, and 19, had balances held in trust by the facility. During interviews, the Business Office Manager admitted to not consistently providing these statements and could not specify when the last statements were issued. The Administrator was unaware of this lapse, although the expectation was for the business office staff to provide these statements quarterly.
Deficiencies in Medication and Treatment Administration
Penalty
Summary
The facility failed to ensure that services provided met professional standards of practice for two residents. For Resident 129, the facility nurses did not obtain, accurately transcribe, or clarify physician's orders for pain medication and oxygen therapy. The orders for oxycodone did not include parameters for use, such as a pain scale, to determine the appropriate dosage. Additionally, the hospital transfer order for oxygen therapy was not transcribed into the resident's electronic health record, resulting in the resident receiving oxygen without a proper order. The Director of Nursing acknowledged that the nurses should have identified and corrected these issues. For Resident 69, the facility failed to administer a prescribed antibiotic, Levaquin, on two occasions due to the nurse's inability to locate the medication. The nurse did not utilize available options such as checking the Pyxis system or contacting the pharmacy. Furthermore, there was no alert charting completed for the resident's antibiotic therapy, which was necessary to monitor side effects and effectiveness. The Director of Nursing indicated that the nurse had entered the wrong type of note, preventing the alert charting from being triggered.
Failure to Provide Timely Vision Services
Penalty
Summary
The facility failed to provide timely vision services for two residents, leading to a deficiency in maintaining their vision. Resident 50, who was admitted with diagnoses including diabetes and kidney failure, was assessed to have moderately impaired vision. Despite expressing issues with their vision and waiting for several months, an appointment with the eye doctor was not scheduled as expected. The Social Service Assistant acknowledged that multiple appointments, including Resident 50's, were not made, and the resident should have been seen in March 2024. Similarly, Resident 69, admitted with multiple diagnoses including depression and a recent myocardial infarction, reported difficulty with vision, specifically gray splatters in her right eye. Despite requesting an eye appointment upon admission, no follow-up was conducted. The Social Services Assistant revealed that the resident was not seen during the eye exam company's visit due to a COVID infection and was unable to explain why a community appointment was not arranged. The assistant also noted limited working hours and poor communication within the facility.
Staffing Shortages Lead to Unmet Resident Needs
Penalty
Summary
The facility failed to provide sufficient qualified nursing staff to meet the needs of residents, as evidenced by interviews and observations involving four residents and two staff members. Residents reported delays in receiving assistance with activities of daily living (ADLs) such as showers, nail care, and shaving. One resident mentioned waiting four hours for pain medication, while another reported wait times of 45 minutes or longer for assistance. Staff interviews confirmed that due to insufficient staffing, certain tasks like showers, nail care, and range of motion exercises were not completed regularly. The Resident Council Meeting Minutes further highlighted ongoing issues with nursing care, including grievances about call lights not being answered and residents not being checked as scheduled. The Director of Nursing Services and the Administrator acknowledged the staffing issues and the lack of Registered Nurse (RN) coverage on multiple occasions. These deficiencies were previously cited, indicating a persistent problem with staffing levels and RN availability at the facility.
Failure to Record Refrigerator Temperatures in Medication Room
Penalty
Summary
The facility failed to ensure that refrigerator temperatures were recorded for one of the two refrigerators in the locked medication rooms. This deficiency was identified during an observation on May 8, 2024, when a Registered Nurse (RN), Staff E, was unable to find a temperature log for the locked refrigerator in the medication room near the front entrance of the facility. Staff E confirmed that there should have been a temperature log, which is typically recorded by the night shift staff. Later, the Director of Nursing Services (DNS), Staff B, also could not locate the temperature log and acknowledged that it is usually placed on top of the refrigerator. On May 10, 2024, Staff B reiterated that refrigerator temperatures should be monitored and documented, and if the log is missing, a new one should be started.
Deficiency in Food Storage and Sanitation
Penalty
Summary
The facility failed to ensure food was stored and served under safe and sanitary conditions, as observed in the kitchen. During an initial tour, several uncovered cups of juice were found on a rolling cart in the industrial refrigerator, and uncovered bowls of pudding were observed on a separate cart in the path of a fan blowing visible dust and debris. In the industrial freezer, packages of hot dogs, chicken patties, and manicotti were found unsealed and undated, with the chicken patties and manicotti having a thick layer of frost. Additionally, three plastic containers of used spices were found without a date. During a follow-up kitchen observation, uncovered desserts were again found in the path of a fan with visible dust and debris. Staff J, the Dietary Manager, acknowledged that the desserts should not have been in the path of the fan and disposed of them. Staff J also noted that the evening staff was responsible for pouring juices the night before and that they should have been covered and labeled. Staff A, the Administrator, confirmed that the expectation was for food to be stored, prepared, and served according to required guidelines.
Failure to Honor Resident Preferences for Bathing and Room Assignment
Penalty
Summary
The facility failed to honor the bathing preferences of Resident 24, who was admitted with a neurological condition. Despite the resident's care plan specifying a bath or shower twice a week, documentation revealed missed showers on specific dates. Interviews with Resident 24 and staff confirmed the inconsistency in providing the scheduled showers, with staff acknowledging the lack of documentation for refusals or missed showers. Additionally, the facility did not respect the room preference of Resident 74, who was admitted with anxiety, depression, and PTSD. After being moved due to quarantine, Resident 74 expressed a desire to return to their original room. Despite daily complaints and acknowledgment from staff and the administrator, the resident was not moved back because the room was occupied by a new admission. The administrator admitted awareness of the resident's dissatisfaction but had not yet acted to resolve the issue.
Failure to Notify Resident of Excess Personal Fund Balance
Penalty
Summary
The facility failed to notify a Medicaid recipient, Resident 19, when their personal fund account balance reached $1,800, which is within $200 of the $2,000 resource limit that could impact their Medicaid coverage. Resident 19, who was admitted with diagnoses including diabetes and depression, had a balance of $2,888.64 as of May 8, 2024, and the balance had been over $2,000 since August 2023. This oversight placed the resident at risk for personal financial liability for their care. Interviews with facility staff revealed that the Business Office Manager, Staff H, did not consistently provide residents with quarterly personal fund statements. Although Staff H had recently discussed the balance with Resident 19, they found it challenging to assist with spending the money due to the resident's limited mobility and existing burial trust. The Administrator, Staff A, acknowledged that there should have been ongoing conversations and documentation regarding the resident's trust fund balance, especially when it was within or over the resource limit, and that these discussions should occur at quarterly conferences.
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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