Lacey Post Acute & Rehabilitation
Inspection history, citations, penalties and survey trends for this long-term care facility in Lacey, Washington.
- Location
- 4524 Intelco Loop Se, Lacey, Washington 98503
- CMS Provider Number
- 505525
- Inspections on file
- 39
- Latest survey
- April 21, 2026
- Citations (last 12 mo.)
- 8
Citation history
Health deficiencies cited at Lacey Post Acute & Rehabilitation during CMS and state inspections, most recent first.
A resident with moderate cognitive impairment, admitted for rehab with multiple diagnoses, experienced repeated falls from bed while attempting to use the bathroom. After two such falls, staff implemented a 1:1 sitter for safety due to the resident being described as restless and confused. At shift change, the dayshift nurse discontinued the 1:1 sitter and left the resident unattended without documenting any reassessment showing the resident was no longer restless or confused. The resident then sustained a third fall from bed while trying to get up and go to the bathroom.
A resident receiving dialysis care had an AV fistula documented in the record, yet multiple nursing assessments incorrectly indicated no dialysis access site, and no post-dialysis AV fistula assessments were recorded over several days. The facility’s policy required monitoring and documentation of the access site after dialysis and ongoing communication with the dialysis center. The dialysis provider reported that the resident twice arrived without the required specialty transfer sling needed for safe transfer into the dialysis chair, causing one missed treatment and necessitating a four-person lift on another visit. The resident’s care plan did not include the sling intervention until after these incidents, and the Administrator/RN confirmed that required assessments were missing and that staff should have ensured the sling was in place.
Two residents admitted for rehab services, both alert and oriented per their 5-day MDS, were repeatedly addressed by an LPN using terms such as "honey" and "love" instead of their given names. Neither resident had been asked about name preferences; one stated she preferred not to be called "honey," and the other stated she usually goes by her birth name. The LPN reported a habit of using endearing names and was unaware of any policy or professional standard requiring use of residents' preferred names, while the administrator later stated staff should address residents by their preferred names.
A resident with anxiety and depression, documented as alert and oriented, had a physician order for Haldol 2 mg daily that was to be held pending clarification. Despite this hold instruction and without obtaining consent, staff administered Haldol as recorded on the EMAR. The resident’s family contact reported the resident was not supposed to receive Haldol due to concerns about hand tremors, and the Administrator/RN confirmed that the psychotropic medication had been given without the required consent.
An LPN administered stomach medication to a resident by opening two single-dose packages with bare hands, dropping the pills into his palm, and handing them directly from his hand to the resident, contrary to the facility’s infection prevention policy that recognizes glove use with routine hand hygiene as best practice. In a later interview, the LPN admitted he should have used gloves or a medication cup and attributed his actions to being in a hurry, while the Administrator/RN stated she expects nurses to wear gloves when handling medications.
A resident with moderately impaired cognition, poor judgment, and significant ADL dependence was discharged home against medical advice after insurance coverage ended, despite the provider not recommending discharge home alone and the resident’s son expressing concerns about unsafe home conditions, medication nonadherence, and lack of informal supports. Documentation showed the resident required maximum assist with dressing, was dependent with toileting, refused to participate in mobility and transfer training, and had poor safety awareness. Social services proceeded with planning discharge home and requested facility transportation when the resident’s ride did not arrive, and transportation staff took the resident home, while the administrator later reported being unaware that transportation had been provided.
Two residents experienced significant delays in receiving pain medication due to staff not following established procedures for accessing emergency medication and failing to promptly notify providers. One resident endured severe pain for several hours after admission, requiring family intervention and a 911 call, while another waited nearly 10 hours for pain relief due to a lapse in communication between nursing staff and the provider. Both residents suffered ongoing pain and psychological distress as a result.
A resident with an open wound and a catheter did not have Enhanced Barrier Precautions (EBP) implemented as required by facility policy. Staff failed to place EBP signage on the door, and direct care was provided without PPE. Interviews indicated confusion among staff regarding responsibility for EBP signage and understanding of EBP indications.
Three residents did not have comprehensive care plans addressing their specific needs, including safe smoking practices, mobility and ADL support for hemiplegia, and management of anticoagulant therapy for pulmonary embolism. Staff confirmed these omissions, noting that care plans lacked required focus areas and interventions for these conditions.
The facility did not provide wound care as ordered for a resident with multiple wounds, as dressing changes were not completed despite being documented as done. Additionally, three residents did not receive timely bowel assessments or PRN medications after several days without a bowel movement, and staff confirmed that bowel protocols were not initiated as required.
A resident with severe cognitive impairment and mental health diagnoses was administered quetiapine and duloxetine without documented consent from the resident or their representative. Staff confirmed that consent should have been obtained and documented, but no such records were found in the electronic health record.
A resident's trust funds were not conveyed to their representative or the state within the required 30-day period after discharge. The trust account remained open and continued to receive credits for over two months, and the funds were not issued to the Office of Financial Recovery until 78 days after discharge. The administrator confirmed that timely disbursement was not documented or completed as required.
A resident who was alert and oriented did not have documentation of an Advance Directive (AD) or evidence that information or assistance was provided to develop one. Despite indications that the resident had a Health Care DPOA, the paperwork was not present in the record, and the care plan did not address ADs. Staff confirmed that the facility's protocol for obtaining and documenting ADs was not followed during admission, re-admission, or quarterly care conferences.
Two residents were observed using bed rails without documented evaluation, consent, or physician order as required by facility policy. Staff confirmed that assessments and orders were missing for both residents, one of whom was severely cognitively impaired and the other alert and oriented.
The facility did not ensure that PASRR assessments accurately documented mental health diagnoses for two residents with conditions such as depression, anxiety, and bipolar disorder. Required sections of the PASRR forms were left incomplete, and serious mental illness indicators were not recorded as per facility policy.
A resident who was alert and oriented did not have nutrition or hydration issues addressed in their care plan, and staff failed to document both the completion and refusal of weights in the EHR as required. Although the resident often refused to be weighed, there was no record of these refusals in the progress notes, despite staff stating this was the expected process.
Surveyors found expired and undated medications and medical equipment in both a medication storage room and a treatment cart. An LPN and a unit manager confirmed that items such as an opened vial of PPD, Bisacodyl suppositories, blood collection sets, and Hibiclens solution were not properly dated or discarded after expiration, and the administrator was aware of these storage issues.
A resident who required moderate assistance with transfers was discharged without documented transfer training or assessment of the spouse's ability to provide necessary care at home. Staff could not provide evidence that the family was prepared for the resident's care needs, and the spouse later reported not receiving training and feeling unprepared for the discharge.
A resident was admitted with conflicting code status information: transfer orders indicated full code, while the EHR showed no CPR per advance directives. The admission LPN did not validate the transfer order with the resident, and the required POLST form was not completed. The DON and nurse practitioner were unaware of the discrepancy, and there was no documentation clarifying the resident's wishes, resulting in the failure to honor the resident's advance directives.
A resident admitted with a Stage II pressure ulcer did not have a wound care plan documented in their comprehensive care plan. Although wound care orders were in place, the care plan was missing due to a recent update in the electronic medical record system that affected automatic care plan generation. Staff acknowledged the oversight and were addressing the issue.
The facility failed to obtain and document Advance Directives (AD) for a resident, compromising their right to have healthcare preferences honored. Despite being alert and oriented, the resident's AD paperwork was not requested or documented in the Electronic Health Record (EHR). Interviews with staff revealed inconsistencies in requesting and documenting ADs, with the Director of Nursing Services and the facility administrator emphasizing the importance of documentation.
A facility failed to provide the SNF ABN to a resident's representative, leaving them uninformed about potential financial liability for non-covered services. The Business Office Manager and Social Services Director confirmed the oversight and uncertainty about who was responsible for issuing the notice.
A facility failed to provide a written Bed-Hold notice to a resident or their representative during a hospital transfer. The resident, who was moderately cognitively impaired, had no documentation in their EHR regarding the Bed-Hold offer. The Admissions Liaison admitted to not having a form or documentation for this process, and the administrator confirmed the expectation for such documentation.
A facility failed to accurately complete the MDS assessment for a resident with a history of strokes, omitting their visual impairment. Despite staff awareness of the resident's vision loss and need for assistance with ADLs, the MDS did not reflect this condition, indicating a lapse in the assessment process.
A facility failed to implement PASARR Level II recommendations for a resident with Parkinson's Disease and Depression, who was experiencing hallucinations and delusions. The care plan did not include necessary behavioral health interventions, and staff were unable to locate specific interventions in the records. The Social Service Director and Administrator acknowledged the oversight, but the recommendations were not integrated into the care plan or the Kardex.
The facility failed to complete accurate PASARR assessments for two residents, risking inadequate mental health services. One resident's PASARR indicated a mood disorder with an exemption requiring a doctor's signature, which was misunderstood by the administrator. Another resident's PASARR lacked documentation of serious mental illness indicators, despite being on multiple psychiatric medications. The Social Services Director recognized the need for improved accuracy in PASARR reviews.
A resident with multiple health issues, including falls and cognitive impairment, did not have an updated care plan reflecting their needs for assistance with toileting, eating, and grooming. Despite multiple falls and an incident involving a urinary catheter, the care plan and Kardex lacked specific directives, leading to unmet care needs.
A resident with falls and aphasia experienced inconsistent toilet assistance, leading to a deficiency in care. The care plan and Kardex lacked specific directives for toileting, and staff were unaware of a toileting schedule. The resident, who was continent before admission, experienced multiple falls and often attempted to use the bathroom independently. Staff provided inconsistent accounts of the resident's needs, contributing to the deficiency.
The facility failed to provide necessary restorative care services to maintain or improve ROM and daily living activities for four residents, leading to an avoidable decline in their physical abilities. Residents with conditions such as hemiplegia, hemiparesis, and post-fall fractures did not receive appropriate therapy, and there was a lack of documentation and oversight of the restorative program.
A significant medication error occurred when a resident with a documented allergy to Tuberculin was administered the TB solution. Despite the allergy being noted in the resident's hospital records, the resident received both steps of the Tuberculin test. The error was confirmed by the Infection Preventionist and the Administrator, highlighting a failure in the facility's medication administration process.
A medication security lapse occurred when an LPN left a medication cup with lactulose unattended on a medication cart. The LPN was observed attending to a resident, leaving the medication accessible. The DON expected medications to be locked when not in use, highlighting a failure to secure medications properly.
The facility failed to ensure the suction machine on the 2nd Floor crash cart was in safe operating condition, as it had no suction when checked. Despite nightly checks by the night shift nurse, the staff did not verify the suction capability, only that the motor was running. The suction machine is crucial for clearing a resident's airway in emergencies, and a non-functional machine would necessitate obtaining another from the supply room.
The facility failed to obtain informed consents for wanderguards for two residents, one cognitively intact and one severely impaired, leading to the use of the device without proper authorization. Staff confirmed the absence of required consent documentation in both cases.
The facility failed to conduct proper assessments before placing wanderguards on three residents, leading to potential risks related to improper use of the device. One resident was cognitively intact and did not exhibit wandering behavior, another was severely cognitively impaired and had a delayed assessment, and the third had an outdated safety evaluation.
Failure to Reassess Resident Before Discontinuing 1:1 Sitter After Multiple Falls
Penalty
Summary
The facility failed to provide necessary supervision and services to prevent neglect for one resident who was admitted for rehabilitation with multiple diagnoses and was documented as moderately cognitively impaired on a 5-day minimum data set dated 03/24/2026. The resident’s electronic health record (EHR) showed that on 03/24/2026 at 9:15 PM, the resident fell from bed, stating he needed to have a bowel movement. The EHR further documented that on 03/25/2026 at 1:06 AM, the resident experienced another fall from bed, again stating he needed to have a bowel movement. In response to these multiple falls, the facility implemented a 1:1 sitter for safety until another intervention could be provided. Despite this intervention, the EHR documented that on 03/25/2026 at 6:40 AM, the resident had a third fall from bed, stating he just wanted to get up and go to the bathroom. In an interview and record review on 04/21/2026, the Administrator and Registered Nurse (Staff A) reported she had been informed that the resident was restless and confused, which led to the initiation of the 1:1 sitter. Staff A stated that the dayshift nurse dismissed the 1:1 sitter during the morning shift change, leaving the resident unattended. Staff A was unable to locate any follow-up assessment indicating that the resident was no longer restless or confused before the sitter was removed and before the third fall occurred, and stated she would have expected the nurse to reassess the resident for safety prior to discontinuing the 1:1 sitter.
Failure to Coordinate Dialysis Care and Complete AV Fistula Assessments
Penalty
Summary
The deficiency involves the facility’s failure to provide safe, appropriate dialysis care and to complete required assessments and documentation for a resident receiving dialysis. The facility’s own policy on End Stage Renal Disease required immediate monitoring and documentation of the resident’s condition and dialysis access site upon return from treatment, as well as ongoing communication and coordination with the dialysis center. Record review showed that the resident had an AV fistula in the left upper extremity, yet multiple assessments in the electronic health record during March documented that the resident did not have an AV fistula or dialysis access site. Additionally, the medication administration record for several days in March showed no post-dialysis assessments of the AV fistula upon the resident’s return from dialysis. The Administrator/RN confirmed that nurses should have been completing these assessments and that she could not locate them in the EHR, and also stated she would expect the assessments in the record to be accurate. The facility also failed to coordinate care and services with the dialysis center regarding the resident’s transfer needs. The dialysis center reported that the resident arrived without the appropriate specialty transfer sling needed for a safe transfer into the dialysis chair, resulting in the resident being unable to receive dialysis on one occasion. The dialysis center requested rescheduling, but the facility was unable to arrange transportation for the next day, and the resident was to receive dialysis at the next scheduled session. On the following dialysis day, despite a reminder call from the dialysis center to place the resident on the appropriate sling, the resident again arrived without the sling in place, and dialysis staff had to perform a four-person lift to transfer the resident. The resident’s care plan did not include interventions for use of the specialty transfer sling for dialysis until mid-March, after these events had occurred. The Administrator/RN acknowledged that the facility should have ensured the sling was in place for safe transfer to the dialysis chair.
Failure to Address Residents by Preferred Names
Penalty
Summary
The deficiency involves staff failure to ensure residents were treated with dignity and respect by addressing them according to their stated name preferences. Resident 2 was admitted for rehabilitation services and was documented on the 5-day MDS as alert and oriented. During an observation and interview, Resident 2 reported she was waiting for stomach medication when an LPN (Staff B) entered the room, stood at the side of the bed, and said, "hey honey I got your pills." Staff B then opened a package containing two pills and instructed, "here honey put these under your tongue." Resident 2 later stated that no one had asked her about her name preference and that she would prefer not to be called "honey." Resident 3, also admitted for rehabilitation services and documented as alert and oriented on the 5-day MDS, was observed during the same time frame. Staff B walked by Resident 3 and said, "hey love do you need anything since I am here?" Resident 3 replied no, and Staff B responded, "ok love" and left the room. In a subsequent interview, Resident 3 stated she usually goes by her birth name and had not been asked about any other name preference. In an interview, Staff B acknowledged that both residents liked to be called by their given names but stated they tended to use more endearing names and were not aware of any facility policy or professional standards requiring use of residents' preferred names. The Administrator/RN later stated that staff should only call residents by their preferred name.
Psychotropic Medication Administered Without Required Consent
Penalty
Summary
The facility failed to ensure a resident’s drug regimen was free from unnecessary drugs when a psychotropic medication was administered without prior consent. Resident 1 was admitted with multiple diagnoses including anxiety and depression, and a 5-day MDS dated 03/04/2026 documented the resident as alert and oriented. A physician order dated 03/02/2026 for Haldol 2 mg orally once daily specified that the medication was to be held until the physician order was clarified for accuracy. Despite this, the March 2026 EMAR showed that the resident received Haldol on 03/07/2026 without consent for Haldol. In an interview, the resident’s collateral contact reported the resident was not supposed to receive Haldol due to concerns about hand tremors, and the Administrator/RN confirmed that Haldol had been given without obtaining the required consent for this psychotropic medication. This failure caused Resident 1 to be given psychotropic medication without prior consent and placed residents at risk for increased side effects and a diminished quality of life.
Improper Medication Handling and Infection Control Practices
Penalty
Summary
The facility failed to implement appropriate infection prevention and control practices during medication administration for one resident. The facility’s policy, “Infection Prevention and Control General Guidelines” dated July 2023, stated that integration of glove use along with routine hand hygiene is recognized as best practice for preventing healthcare-associated infections. During an observation on 03/16/2026 at 12:16 PM, an LPN (Staff B) entered Resident 2’s room to administer stomach medication, opened two single-dose packages with bare hands, dropped each pill into his palm, and then handed both pills directly from his hand into the resident’s hand, instructing the resident to place the dissolvable pills under her tongue. In a subsequent interview, Staff B acknowledged he should have used gloves or a medication cup instead of handling the medication with his hands and stated he was in a hurry. In a separate interview, the Administrator/RN (Staff A) stated she would expect nurses to wear gloves when handling medications. The deficiency was cited under WAC 388-97-1320 (1)(a).
Failure to Ensure Safe Discharge Planning and Transportation for a Cognitively Impaired Resident
Penalty
Summary
The deficiency involves the facility’s failure to ensure a safe discharge plan for a resident whose needs and preferences required more support than was arranged. The resident was admitted after hospitalization and was initially documented as alert and oriented on the 5-day MDS. Subsequent EHR entries showed that the provider did not recommend discharge home alone due to safety concerns. Therapy and nursing documentation indicated the resident required maximum assistance with dressing, was dependent with toileting, refused to work on bed mobility, transfers, and ambulation, and demonstrated poor safety awareness. The resident’s cognition was documented as impaired: she was unable to sign the NOMNC due to decreased cognition, had a BIMS score of 9 indicating moderately impaired cognition, and scored 9/20 on a verbal test of practical judgment, suggesting severe impairment in judgment skills. Despite these findings, the facility planned to discharge the resident home and proceeded with discharge. The resident’s son expressed concerns to social services about the cleanliness of the home, the likelihood that the resident would not take medications as prescribed, and reported that informal supports would no longer assist due to safety concerns about her being home alone. The EHR documented that the resident was discharged against medical advice, with the discharge described as being facilitated to promote a safe environment at home. When the resident’s arranged ride did not arrive, transportation support staff provided transport to the home at the request of social services. The social services assistant later stated she did not feel the resident should have been discharged home but was unsure of what options were available, and the administrator reported being unaware that facility transportation had been provided for this discharge.
Failure to Provide Timely Pain Medication
Penalty
Summary
The facility failed to ensure that residents received timely pain medication, resulting in ongoing pain and diminished quality of life for two residents. One resident, admitted for rehabilitation and cognitively intact, reported not receiving pain medication for several hours after admission despite repeated requests. The nurse informed her that the pharmacy did not have her prescription and that there could be a two-hour wait, but the delay extended for several hours. The resident experienced severe pain, rated 10/10, and ultimately called her son for help, who then called 911 to intervene. The pharmacy narcotic log showed that pain medication was retrieved from the emergency medication stock supply several hours after admission. Another resident, admitted for rehabilitation and moderately cognitively impaired, was observed crying and requesting pain medication for leg pain. She reported asking for pain medication since early morning and was told she had run out of medication and that the nurse was waiting for a new prescription to be signed by the provider. The medication administration record indicated a significant gap between doses, with the resident waiting nearly 10 hours for pain relief. The nurse stated she was waiting for the provider to sign the order but did not attempt to contact the provider directly, assuming the provider was busy. The provider later confirmed she was available and had not been notified of the need for additional pain medication. Interviews with facility staff revealed that there was a system in place to access emergency medication stock, which should have allowed for timely administration of pain medication within 15 minutes. However, this process was not followed, resulting in prolonged pain for both residents. Both residents described experiencing severe physical and psychological distress due to the delays in receiving pain medication.
Failure to Implement Enhanced Barrier Precautions for Resident with Open Wound and Catheter
Penalty
Summary
The facility failed to implement Enhanced Barrier Precautions (EBP) for a resident who required them due to an open wound and the presence of a catheter. The resident, who was moderately cognitively impaired and admitted for rehabilitation after hospitalization, had a care plan indicating the need for EBP. However, during multiple observations, there was no EBP signage on the resident's door, and staff were seen entering the room and providing direct care without donning personal protective equipment (PPE) as required by the facility's EBP policy. Interviews with staff revealed a lack of clarity regarding responsibility for placing EBP signage and understanding of when EBP should be implemented. The admit nurse did not place the required signage during the admission process, and the infection control nurse did not identify the omission during routine checks. Additionally, a nursing assistant was unsure about the specific indications for EBP, and the administrator confirmed that the signage had not been placed as required.
Failure to Develop Comprehensive Care Plans for Smoking, Mobility, and Anticoagulant Use
Penalty
Summary
The facility failed to develop comprehensive care plans addressing all identified needs for three of four sampled residents. For one resident with COPD who was alert and oriented, the care plan did not include a focus, goal, or interventions related to safe smoking practices, despite the resident being observed smoking independently off facility property. Facility policy required evaluation and care planning for residents who smoke, but the care plan was not updated to reflect this until after the observation. Staff confirmed that the omission was due to a computer system change that resulted in the care plan entry being canceled and not reinstated until later. Another resident, who was alert, oriented, and dependent for personal hygiene and transfers due to hemiplegia, did not have a care plan addressing positioning, mobility, or ADL needs, despite requiring a hoyer lift for transfers and being unable to move one side of her body. Additionally, a third resident with a history of pulmonary embolism and prescribed apixaban, an anticoagulant, did not have a care plan addressing the diagnosis or the use of high-risk medication. Staff interviews confirmed that these care needs should have been included in the care plans but were not present at the time of review.
Failure to Provide Ordered Wound Care and Bowel Management
Penalty
Summary
The facility failed to provide appropriate treatment and care according to physician orders and residents' needs in several instances. For one resident with multiple wounds, including a left hip abrasion and diabetic foot ulcers, the treatment administration record indicated that wound care was to be performed every other day. However, documentation and staff interviews revealed that the dressing change for the left hip/buttock was not completed as ordered, despite being signed off in the treatment record. A nurse was unaware of the wound and only discovered it upon direct observation, confirming that the treatment had not been performed as documented. Additionally, the facility did not initiate bowel interventions for three residents who had not had a bowel movement for several days. Review of medication administration records and bowel movement task sheets showed that PRN bowel medications and assessments were not administered or documented as required after 72 hours without a bowel movement. Staff interviews confirmed that bowel protocols and assessments were not initiated in a timely manner, contrary to facility expectations and residents' care needs.
Failure to Obtain Consent for Psychotropic Medication Administration
Penalty
Summary
The facility failed to ensure that residents and/or their representatives were informed and provided consent prior to the administration of psychotropic medications. Specifically, a resident with severe cognitive impairment and multiple mental health diagnoses, including bipolar disorder and depression, was prescribed and administered quetiapine and duloxetine. Documentation in the Electronic Health Record did not show any evidence of consent from the resident or their representative for either medication. Staff interviews confirmed that a consent form should have been completed when the psychotropic medications were prescribed or if the dosage was changed. Both the Administrator and the DON acknowledged that they could not locate the required consent documentation for the medications in question, indicating that the necessary process for obtaining and recording consent was not followed.
Delayed Disbursement of Resident Trust Funds After Discharge
Penalty
Summary
The facility failed to ensure that a discharged resident's trust funds were conveyed to the resident's representative or to the state Office of Financial Recovery (OFR) within 30 days of discharge, as required. Record review showed that the resident was discharged with return anticipated, but the trust account continued to show credits and a balance for over two months after discharge. The account was not closed and the funds were not issued to the OFR until 78 days after discharge, with the issue date for the payment to OFR occurring even later. The administrator confirmed that dispersing funds within 30 days of discharge was not documented in the resident's electronic health record and acknowledged that this step should have been addressed.
Failure to Obtain and Maintain Advance Directives Documentation
Penalty
Summary
The facility failed to obtain and/or maintain Advance Directives (AD) documentation for one resident who was alert and oriented. Upon admission and re-admission, there was no documentation in the resident's electronic health record (EHR) regarding the presence of an AD or that information or assistance was provided to develop one. The Social Service Initial Evaluation indicated the resident had a Health Care Durable Power of Attorney (DPOA), and a progress note stated that DPOA paperwork was supposed to be brought to the facility, but it was not present in the record. The care plan did not address ADs, and quarterly notes did not reflect any change or follow-up regarding the AD status. Staff interviews confirmed that the facility's protocol was not followed, as the AD was not readdressed upon the resident's re-admission, nor was a copy requested or obtained during the quarterly care conference. The Social Services Director acknowledged the lack of documentation and stated that reminders to provide the AD were given periodically, but no documentation or follow-up was completed. The Administrator also confirmed that the protocol for obtaining and documenting ADs was not followed for this resident.
Failure to Obtain Assessment, Consent, and Physician Order for Bed Rail Use
Penalty
Summary
The facility failed to obtain required evaluation assessments, consents, and physician's orders for the use of bed rails for two residents. According to the facility's policy, any resident considered for bed rail use must be evaluated by the interdisciplinary team to determine appropriateness, and if deemed suitable, the facility must educate the resident or representative on risks, obtain documented consent, notify the representative as appropriate, and secure a specific physician's order detailing the type and use of bed rails. For both residents sampled, there was no evidence in the electronic health records of an evaluation assessment, consent, or physician's order related to the use of bed rails. One resident, who was severely cognitively impaired, was repeatedly observed with quarter length bed rails in use on various days, with no documentation of the required assessment, consent, or order. Another resident, who was alert and oriented, was also observed with a one-third length bed rail in use on multiple occasions, again without the necessary documentation. Staff interviews confirmed that the expected procedures were not followed for these residents, and the required documentation was missing.
Inaccurate PASRR Assessments for Mental Health Diagnoses
Penalty
Summary
The facility failed to ensure that the Pre-admission Screening and Resident Review (PASRR) assessments accurately reflected the mental health diagnoses for two residents. For one resident admitted with depression and anxiety, the Level 1 PASRR did not document a serious mental illness indicator, nor was Section IV Service Needs and Assessor Data completed to indicate if a Level II evaluation was necessary. Similarly, another resident admitted with depression, bipolar disorder, and anxiety had a Level 1 PASRR that did not document these serious mental illness indicators, and Section IV was also left incomplete. According to facility policy, the Social Worker, Admissions Coordinator, or designee is responsible for reviewing completed screening forms prior to admission and ensuring they are placed in the electronic medical record. However, interviews and record reviews revealed that these steps were not properly followed, resulting in inaccurate PASRR documentation for both residents. Staff acknowledged the inaccuracies upon review.
Failure to Document Resident Weight Refusals and Monitoring
Penalty
Summary
The facility failed to document the completion and/or refusal of weights for one resident reviewed for nutrition. The resident was admitted alert and oriented, but their care plan did not include any identified problems or goals related to nutrition or hydration. The electronic health record (EHR) showed several recorded weights over a two-month period, but staff interviews revealed that the resident often refused to be weighed. Despite this, there was no documentation in the EHR progress notes regarding the resident's refusals. Certified Nursing Assistants (CNAs) were responsible for obtaining weights and reporting them to nursing staff, who then entered the data into the EHR. Both nursing and dietary staff confirmed that refusals should be documented in the EHR progress notes, and that the process included educating the resident on the risks and benefits of refusing weights. However, a review of the EHR found no documentation of weight refusals for this resident, indicating a failure to follow established procedures for documenting refusals and monitoring nutritional status.
Expired and Undated Medications and Equipment Found in Storage Areas
Penalty
Summary
Surveyors observed that drugs, biologicals, and medical equipment in the facility were not consistently dated upon opening or discarded once expired. In the medication storage room refrigerator on the 2nd floor, a vial of Tuberculin Purified Protein Derivative (PPD) was found opened without a date indicating when it was opened or when it should be disposed of. Additionally, two boxes of Bisacodyl Suppositories and a box containing 35 BD Vacutainer Safety Lock Blood Collection Sets were found with expiration dates that had passed. On the 1st floor treatment cart, a bottle of Hibiclens Solution was observed with an expiration date of 04/2024, and staff confirmed it should have been discarded after expiration. Staff interviews confirmed that medications and equipment in the medication storage room and refrigerator are expected to be destroyed at the time of expiration, and the administrator was aware of the medication storage issues.
Failure to Provide Transfer Training to Family Prior to Discharge
Penalty
Summary
The facility failed to ensure that transfer training was provided to the family of a resident who was being discharged, resulting in an unsafe discharge. The resident, who was cognitively intact but required moderate assistance with transfers, was admitted for rehabilitative services after previously being independent with mobility prior to hospitalization. Documentation showed that the resident's spouse was not trained or assessed for the ability to provide necessary transfer assistance at home. Staff interviews confirmed that there was no record of transfer training being provided to the spouse, and discharge planning did not include a formal conference close to the discharge date. Further, the resident's progress towards discharge was not documented after weekly skilled rounds, and there was no evidence that the spouse was prepared to safely care for the resident post-discharge. The spouse later reported not receiving any training and expressed concerns about the resident's safety at home following discharge. The lack of documented training and preparation for the family member responsible for care led to an unsafe discharge process for the resident.
Failure to Implement and Document Advance Directives on Admission
Penalty
Summary
The facility failed to ensure that advance directives were properly implemented upon admission for one resident. Upon admission, the resident was provided with conflicting information regarding their code status: acute care transfer orders indicated full code status (to perform CPR), while the advance directives in the electronic health record (EHR) indicated no CPR. The admission nurse did not validate the transfer order with the resident for accuracy, and the process for confirming and documenting the resident's wishes was not followed. The required Physician Order for Life Sustaining Treatment (POLST) form was not completed, and there was no documentation in the EHR clarifying the resident's CPR status. Interviews with staff revealed that the process for discussing and documenting advance directives was not streamlined. The nurse practitioner responsible for discussing advance directives with new admissions was unaware of the resident's existing directives and could not recall why the POLST form was not completed. The director of nursing confirmed that the order for CPR should have been entered into the EHR and that conflicting information should have been clarified with the physician, but there was no evidence this occurred. This failure resulted in the resident's advance directives not being honored as required by policy and state regulations.
Failure to Establish Wound Care Plan for Resident with Pressure Ulcer
Penalty
Summary
The facility failed to establish a wound care plan for a resident who was admitted with a Stage II pressure ulcer. Upon admission, the resident was documented as having a pressure injury to the sacrum, but the comprehensive care plan did not include a wound care plan for this condition. Interviews with staff revealed that although wound care orders were in place, the expected care plan was missing from the resident's documentation. The Director of Nursing Services acknowledged the absence of a wound care plan and noted that a recent update to the electronic medical record system had altered the automatic generation of care plans for residents admitted with skin issues. This change occurred shortly before the resident's admission, leading to the oversight. The facility recognized the deficiency and was in the process of correcting the issue to ensure care plans would be automatically generated in the future.
Failure to Obtain and Document Advance Directives
Penalty
Summary
The facility failed to obtain and maintain Advance Directives (AD) for one of the sampled residents, which compromised the resident's right to have their healthcare preferences honored. Resident 157, who was alert and oriented, was admitted to the facility, and the initial evaluations documented that the resident's son was the Power of Attorney (POA). However, there was no documentation in the Electronic Health Record (EHR) indicating that AD paperwork was requested or obtained. Interviews with facility staff revealed a lack of consistent procedures in requesting and documenting ADs. The Director of Social Services and a Social Worker both indicated that they would ask for AD copies during the care conference, but there was no documentation of such a request for Resident 157. The Director of Nursing Services confirmed that it was the social worker's responsibility to request and document ADs in the EHR. The facility administrator also stated that it was expected for staff to request and document ADs, emphasizing that if it wasn't documented, it wasn't done.
Failure to Provide SNF ABN to Resident's Representative
Penalty
Summary
The facility failed to provide the Skilled Nursing Facility Advanced Beneficiary Notice of Non-Coverage (SNF ABN) to a resident's representative, which is required to inform them of potential financial liability for services not covered by Medicare. Specifically, for one of the three sampled residents, the Notice of Medicare Non-Coverage indicated that the resident's representative was informed of the termination of services, but the SNF ABN was not provided. This oversight was confirmed during interviews with the Business Office Manager and the Social Services Director, who acknowledged the lack of clarity regarding responsibility for issuing the SNF ABN. The resident remained in the facility without being informed of potential financial obligations.
Failure to Provide Bed-Hold Notice
Penalty
Summary
The facility failed to provide a written Bed-Hold notice to a resident or the resident's representative at the time of transfer to the hospital. This deficiency was identified for a resident who was moderately cognitively impaired and had been admitted to the facility prior to hospitalization. The Electronic Health Record (EHR) lacked documentation of a written Bed-Hold notice or any contact made to the resident or their representative regarding the Bed-Hold. During an interview, the Admissions Liaison stated that while they typically contacted the resident or representative to offer a Bed-Hold, there was no form filled out or documentation available for this particular resident. The facility administrator confirmed the expectation that a Bed-Hold should be offered and documented when a resident is transferred to the hospital.
Inaccurate MDS Assessment for Visually Impaired Resident
Penalty
Summary
The facility failed to ensure the Minimum Data Set (MDS) assessment accurately reflected a resident's condition, specifically regarding visual impairment, for one of the sampled residents. The resident, who had a history of strokes, was documented in the MDS as alert and oriented, able to make care needs known, but the assessment did not account for the resident's visual deficit. This oversight was identified through observations, interviews, and record reviews, revealing that the resident had significant vision loss due to strokes, impacting their ability to perform Activities of Daily Living (ADLs) independently. Interviews with staff, including the Activity Director and Certified Nursing Assistant, confirmed the resident's visual impairment and the need for assistance with daily activities such as reading the activity calendar and identifying food items during meals. Despite the staff's awareness of the resident's condition, the MDS assessment did not reflect this critical aspect of the resident's health status, indicating a lapse in the facility's assessment process. Staff involved in the MDS assessments stated they followed CMS guidance, yet the deficiency suggests a failure in accurately gathering and documenting comprehensive information about the resident's needs.
Failure to Implement PASARR Level II Recommendations for Resident
Penalty
Summary
The facility failed to follow the recommendations of the Preadmission Screen and Resident Review (PASARR) Level II for a resident diagnosed with Parkinson's Disease and Depression, who was also experiencing hallucinations and delusions. The PASARR, dated 06/25/2024, indicated that Level II services were appropriate for new behaviors of a psychotic disorder. The Notice of Determination and the Initial Psychiatric Evaluation Summary recommended specialized behavioral health services, which could be provided in a skilled nursing facility by a licensed mental health professional. These recommendations included providing a low-stimulation environment, routine, and predictability, as well as specific behavioral interventions such as reorientation, redirection, empathic listening, and simple communication. Despite these recommendations, the resident's care plan, dated 07/28/2024, did not include the PASARR Level II recommendations for behavioral health interventions. Observations revealed that the resident was calling out, tearful, and making disorganized statements, indicating distress and confusion. Staff members, including a Certified Nursing Assistant and a Licensed Practical Nurse, were unable to locate specific interventions for behavior management in the electronic medical records or the Medication Administration Record. The Social Service Director and the Administrator acknowledged that PASARR Level II recommendations should be integrated into the care plan, but they were not found in the resident's care plan or the Kardex, which directs care for nursing assistants.
Inaccurate PASARR Assessments for Two Residents
Penalty
Summary
The facility failed to ensure the Pre-Admission and Resident Review (PASARR) assessments were completed correctly for two residents, which placed them at risk of not receiving necessary mental health services. Resident 38 was admitted with a diagnosis of depression, and the PASARR indicated a mood disorder with an exemption for a Level II evaluation due to an exempted hospital discharge. However, the exemption required a doctor's signature and was valid for only 30 days, which was not initially understood by the facility's administrator. Resident 100, admitted with depression and anxiety disorders, was noted to be severely cognitively impaired. The PASARR from the local hospital did not document any serious mental illness indicators, despite the discharge summary listing medications for anxiety and antipsychotic treatment. The Social Services Director acknowledged the need for a better system to review PASARRs for accuracy, indicating a lapse in the current review process.
Failure to Update Care Plan for Resident's Changing Needs
Penalty
Summary
The facility failed to update the care plan for a resident, identified as Resident 67, to reflect their changing needs, which placed the resident at risk for unmet care needs and diminished quality of care. Resident 67 was admitted with multiple diagnoses, including falls with fractures, dysphagia, aphasia, and dementia. The Minimum Data Set (MDS) assessment indicated that the resident was moderately cognitively impaired and required moderate assistance with toileting. Despite these needs, the care plan initiated on 07/31/2024 did not document the specific assistance required for toileting, eating, and grooming. The resident experienced multiple falls and had an incident where they pulled out their urinary catheter, which was not replaced. Observations showed that the resident had difficulty eating independently and was not offered assistance with toileting before meals. The Kardex, which is used to communicate care instructions to caregivers, also lacked specific directives for the resident's assistance needs. Staff J, the Unit Manager, acknowledged that the care plan was not updated to include these directives, indicating a lapse in communication and documentation of the resident's care needs.
Inconsistent Toilet Assistance for Resident with Falls and Aphasia
Penalty
Summary
The facility failed to provide consistent toilet assistance in accordance with Resident 67's preferences and abilities, leading to a deficiency in care. Resident 67, who was admitted with diagnoses including falls and aphasia, had moderate cognitive impairment and required moderate assistance with toileting. Despite this, the care plan did not specify the assistance needed for toileting, and the Kardex lacked directives for such care. Observations revealed that Resident 67 was not offered assistance to use the bathroom before meals, and staff interviews indicated a lack of awareness of a toileting schedule or specific assistance requirements. Resident 67 experienced multiple falls shortly after admission, and staff reported that the resident often attempted to use the bathroom independently, which led to falls. The resident's representative noted that Resident 67 was continent before hospitalization and questioned the use of incontinence briefs at the facility. Staff members provided inconsistent accounts of the resident's toileting needs, with some stating the resident required total care for incontinence, while others acknowledged the resident's requests for bathroom assistance. The lack of a clear toileting program and communication among staff contributed to the deficiency in care.
Failure to Provide Restorative Care Services
Penalty
Summary
The facility failed to provide necessary care and services to maintain or improve the range of motion (ROM) and activities of daily living for four residents, leading to an avoidable decline in their physical abilities. Resident 64, who was admitted with hemiplegia affecting the left side, was observed with limited mobility in her left arm and hand, yet no restorative therapy services were included in her care plan. Similarly, Resident 82, who suffered from hemiparesis following a stroke, reported that staff did not address his left-hand function, and he resorted to using online videos for exercises. Resident 15, who had a history of falls resulting in fractures, was observed using her non-dominant hand for eating due to weakness in her dominant arm. Despite her need for therapy to prevent stiffness in her right shoulder, no restorative services were documented in her care plan or electronic health record. Additionally, Resident 67, who was at risk of falls due to cognitive impairment and deconditioning, had multiple falls and was supposed to participate in a restorative program. However, there was no documentation of a plan, interventions, or goals for his participation. The facility's staff, including the Unit Manager, Activities Assistant, and Director of Rehab, indicated a lack of awareness and oversight regarding the restorative program. The program was reportedly overseen by the activities department, but there was no schedule or task assignment for restorative services, and participation was not adequately documented. The facility administrator acknowledged the absence of restorative documentation in resident records and the need to re-establish a restorative program.
Significant Medication Error: Tuberculin Administered to Allergic Resident
Penalty
Summary
The facility administered Tuberculin (TB) Solution to a resident who was allergic to it, resulting in a significant medication error. The resident, who was severely cognitively impaired, had a documented allergy to Tuberculin in their hospital history and physical note. Despite this, the resident was given the first step of the Tuberculin test on August 8, 2024, and the second step on August 16, 2024, as recorded in the Medication Administration Record. The error was confirmed by the Infection Preventionist and the Administrator after reviewing the resident's electronic health record, which indicated the resident should not have received the Tuberculin due to the allergy. This oversight placed the resident at risk for medical complications and diminished quality of life.
Medication Security Lapse in Medication Cart
Penalty
Summary
The facility failed to ensure the security of medications in one of the four medication carts reviewed, specifically the 100 hall medication cart. During an observation, a Licensed Practical Nurse (LPN), identified as Staff K, was seen leaving a medication cup with a clear yellow liquid on the cart unattended while attending to a resident in a room. The LPN later identified the liquid as lactulose, a medication used to prevent constipation, which the resident had refused. This incident occurred despite the expectation set by the Director of Nursing Services that all medications should be locked in the medication cart when not being administered, thereby placing residents at risk of unauthorized access to medications.
Failure to Maintain Suction Machine on Crash Cart
Penalty
Summary
The facility failed to maintain patient care equipment in safe operating condition, specifically the suction machine on the 2nd Floor crash cart. During an inspection, it was discovered that the suction machine had no suction when turned on. Staff L, an LPN, was unaware of what the sign-off forms on the cart were for, despite the crash cart being checked every night shift. Staff B, the Director of Nursing Services, confirmed that the night shift staff were responsible for checking the crash cart, including ensuring the suction machine was functional. However, it was acknowledged that the staff did not verify the suction capability of the machine, only that the motor was running. Staff M, an RN, explained the importance of the suction machine for clearing a resident's airway in emergencies, indicating that a non-functional machine would require obtaining another from the supply room.
Failure to Obtain Informed Consent for Wanderguards
Penalty
Summary
The facility failed to ensure consents for wanderguards were in place for two residents reviewed for informed consents regarding wanderguards. Resident 1, who was cognitively intact and did not exhibit wandering behavior, was asked to wear a wanderguard after a hospital stay without signing a consent. The resident expressed discomfort with the device and did not recall giving consent. Staff confirmed that an informed consent should have been obtained but could not locate the consent in the resident's electronic medical record (EMR). Resident 2, who was severely cognitively impaired and exhibited wandering behavior, also had a wanderguard placed without documented informed consent. The resident's care plan included monitoring for skin breakdown under the wanderguard, but there was no consent found in the EMR. Staff acknowledged the absence of the required consent documentation for both residents.
Failure to Conduct Proper Wanderguard Assessments
Penalty
Summary
The facility failed to ensure proper assessments and placement of wanderguards for three residents, leading to potential risks related to improper use of the device. Resident 1, who was cognitively intact and did not exhibit wandering behavior, was asked to wear a wanderguard without a prior safety evaluation. The Director of Nursing Services confirmed that no safety evaluation was completed before the wanderguard was placed on Resident 1. Resident 2, who was severely cognitively impaired and exhibited wandering behavior, had a wanderguard applied 47 days after an elopement care plan intervention was documented, but no prior elopement risk evaluations were found in the resident's electronic medical record (EMR). The Director of Nursing Services could not find a prior safety evaluation for Resident 2 either. Resident 3, who exhibited wandering behavior, had a safety evaluation indicating no elopement risk, but a wanderguard was ordered and placed without a subsequent safety assessment. The Director of Nursing Services acknowledged that the safety evaluation for Resident 3 was not updated before the wanderguard placement. These lapses in conducting timely and appropriate safety evaluations before placing wanderguards on residents led to deficiencies in the facility's accident hazard prevention measures.
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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