Life Care Center Of Port Orchard
Inspection history, citations, penalties and survey trends for this long-term care facility in Port Orchard, Washington.
- Location
- 2031 Pottery Avenue, Port Orchard, Washington 98366
- CMS Provider Number
- 505210
- Inspections on file
- 26
- Latest survey
- April 10, 2026
- Citations (last 12 mo.)
- 20
Citation history
Health deficiencies cited at Life Care Center Of Port Orchard during CMS and state inspections, most recent first.
The facility failed to provide enough nursing staff to meet resident needs, and multiple residents reported waiting 30 minutes to over an hour for call lights, showers, toileting, and other care. CNAs described weekly short staffing, difficulty completing routine care, transfers, and showers, and especially poor weekend coverage with only two aides or staff working alone on a hall. Grievances and staffing records also showed repeated complaints about delayed call light response and management staff covering nursing duties because of call outs.
Food was not consistently palatable, attractive, or served at an appetizing temperature on multiple halls. A test tray had room-temperature equipment, and the fish, corn, and coleslaw were served at temperatures or with quality issues that staff acknowledged did not meet expectations. Residents reported food that looked bad, tasted poor, was not hot, was repetitive, or was sometimes unidentifiable, and council minutes and grievance logs showed repeated food complaints over several months.
The facility failed to notify a resident’s court-appointed guardian of a new metformin order and an eye care appointment. The resident had dementia and moderate cognitive impairment, and the record showed the metformin was administered without prior notification to the representative. The EHR also lacked documentation that the guardian was informed of the eye referral or follow-up glasses appointment, and staff confirmed the notifications were not found in the record.
A resident who was able to make needs known reported missing clothing after a room move, including several pairs of pants and shirts. An RN searched the prior room but could not find the items, and no grievance was filed in the grievance logs. The RN confirmed no grievance was completed, and the Administrator stated staff were expected to submit a grievance form to social services when residents reported missing items.
Failure to document a resident-specific rationale for declining a psychotropic GDR. A resident with cognitive impairment, anxiety, depression, and insomnia had long-term citalopram use and lorazepam for anxiety-related behaviors. Pharmacy recommended a citalopram GDR, but the provider left the required rationale blank, and the IDT note cited maladaptive behaviors without identifying them or linking them to citalopram. The record also did not show a failed GDR of citalopram.
Inaccurate MDS Coding for Hospice Status and Dialysis Access: Two residents had MDS assessments that did not match the record. One resident receiving hospice had quarterly MDS entries marked no for a life expectancy question that should have been coded yes, and another resident with ESRD and a tunneled dialysis catheter was coded as having no IV access or central line despite the catheter and related care plan/orders in the chart.
Inaccurate PASRR Screening: A resident admitted with CKD, hyperlipidemia, and DM had a hospital PASRR that listed mood disorders, but the chart showed no MH diagnosis or behavioral health meds. The Social Services Director said the PASRR was incorrect, and the Administrator stated staff were expected to verify PASRR accuracy on admission.
Facility nurses did not follow PRN bowel care orders for two residents who went multiple days without a BM, failing to give MOM on the ordered day four. Nurses also initialed off on q-shift edema monitoring for a resident with renal insufficiency and diuretic use, but did not document whether edema was present, where it was located, or its extent.
Failure to monitor and document fluid restriction intake led to two residents receiving fluids outside ordered limits. One resident with CHF had a 2000 mL/day fluid restriction, but a water pitcher was kept at bedside, the diet slip did not reflect the restriction, and nursing and dietary communication was inconsistent. Another resident with hyponatremia had a 1500 mL/day free water restriction, yet bedside pitchers and visitor-provided water were observed, shift totals were not calculated into 24-hour intake, and the record showed no documentation of education or provider notification when the restriction was exceeded.
Missing Oxygen Order for Resident Using Oxygen. A resident with CKD, hyperlipidemia, and diabetes had an oxygen concentrator set at 2 L/min near the bed on multiple observations, but was not seen wearing a nasal cannula. The care plan included oxygen via nasal cannula at 2 L/min PRN for SOB, yet the EHR had no active provider order for oxygen. The resident stated oxygen was used only at night, and the DON confirmed the prior order had been discontinued even though the resident was still using oxygen.
Failure to complete CNA annual performance reviews was cited for 3 of 5 sampled CNAs. One CNA had no annual review on file, and two CNAs had reviews completed months after their hire anniversaries. The DON stated the reviews were completed within the year, but the regulation is based on the hire date and anniversary date, not the calendar year.
Opened meds on two med carts were found undated, including eye drops and inhalers with specific discard times after opening. In addition, two cups of creams were repeatedly observed left at a resident’s bedside; the resident had moderate cognitive impairment and orders for Calmoseptine to the coccyx, and both an LPN and the DON stated the creams should not have been left in the room.
Failure to follow up on a resident’s dental referral resulted in no documented completion of x-rays, evaluation for tooth extraction, or referral for new dentures. The resident had mouth/facial pain and difficulty chewing, reported broken and missing teeth, and the care plan directed staff to coordinate dental care and transportation as needed. The DON confirmed there was no documentation of follow-up on the dental consult.
Failure to Honor Resident Portion Size Preferences: Staff did not honor portion-size preferences for multiple residents during breakfast service. A cook used a #12 scoop instead of the #10 scoop listed on the diet spreadsheet and served regular portions or regular starch portions to residents who preferred small portions or smaller starch servings. The Dietary Mgr stated staff were expected to follow the diet spreadsheet and provide half portions when requested.
CNA Annual Training Deficiency: The facility failed to ensure CNAs completed the required 12 hours of annual continued competency training. Record review showed two CNAs had less than the minimum training hours required, and the DON stated the hours should have been completed when the deficiency was identified.
Two residents experienced hospitalization due to the facility's failure to monitor hydration and notify providers of abnormal lab results. One resident, with severe cognitive impairment, showed signs of dehydration and infection but was not promptly treated, leading to a critical condition. Another resident, with moderate cognitive impairment, suffered from poor oral intake and was hospitalized with electrolyte imbalances. Staff interviews revealed inadequate monitoring and communication regarding residents' conditions.
The facility failed to accurately assess MDS for two residents, leading to potential unmet care needs. One resident's MDS did not reflect a required Level II PASRR for depressive disorder, while another resident's MDS failed to code for continuous oxygen therapy despite documented orders. Staff acknowledged these oversights.
The facility failed to implement baseline care plans within 48 hours for two residents, one with a non-healing ulcer and on coumadin therapy, and another with Type 2 Diabetes requiring insulin. The DNS and Resident Care Manager acknowledged the omissions, which were due to a misunderstanding of the care plan timeline requirements.
The facility failed to develop comprehensive care plans for three residents, leading to potential unmet needs. A resident's activity preferences were not included in their care plan, another's oxygen usage was not documented, and a third's use of mobility bars was not care planned. Additionally, a resident with a pressure ulcer lacked specific interventions in their care plan. Staff acknowledged these omissions during interviews.
The facility failed to follow physician orders and maintain proper documentation for several residents, leading to medication errors and unmet care needs. A resident received Lisinopril despite low blood pressure, and another had insulin administered outside prescribed parameters. Daily weights were not recorded for a resident, and insulin was given after meals instead of before. Oxygen was administered at incorrect rates without notifying a physician.
The facility failed to implement or document the bowel protocol for two residents, leading to a deficiency in care. One resident with severe cognitive impairment did not have a bowel movement for seven days, and there was no documentation of interventions. Another resident, who was cognitively intact, did not receive prescribed medication after four days without a bowel movement. Staff confirmed the failure to follow the bowel protocol, placing residents at risk for discomfort.
Two residents in an LTC facility experienced deficiencies in pressure ulcer care due to inadequate monitoring and documentation. One resident with an unstageable heel ulcer lacked consistent assessments, while another developed an ear ulcer from nasal cannula straps, with inconsistent treatment documentation. Staff interviews revealed a lack of adherence to wound care policies.
A resident with diabetes was subjected to significant medication errors when facility nurses administered insulin despite blood glucose levels being below the physician-ordered parameters. This occurred on 20 occasions, as confirmed by the Resident Care Manager, indicating a failure to follow prescribed insulin administration guidelines.
The facility failed to enforce Enhanced Barrier Precautions (EBP) and contact precautions for residents with urinary catheters and multidrug-resistant organisms (MDROs). Staff did not consistently wear gowns and gloves when required, and urinary catheter bags were observed touching the ground. Additionally, there was confusion among staff regarding the implementation of contact precautions outside of resident rooms, leading to residents with MDROs moving freely without appropriate restrictions.
A resident with COPD and chronic respiratory failure experienced a delay in receiving a physician-ordered chest x-ray due to ineffective communication and follow-up by the facility staff. The x-ray was not performed promptly, leading to the resident's hospital admission for pneumonia.
A facility failed to ensure safe transfers for a resident by not using the mechanical lift's manufacturer's recommended sling, resulting in the resident sliding from the sling and experiencing back pain. The staff were unaware of the manufacturer's recommendation to use only their brand of slings, leading to the incident.
Insufficient Nursing Staffing and Delayed Resident Care
Penalty
Summary
The facility failed to ensure sufficient qualified nursing staff were available to provide care and services, with residents and staff describing prolonged waits for assistance and difficulty completing routine care. Multiple residents reported waiting 30 minutes to over an hour for call lights, personal care, showers, toileting, and help getting out of bed. One resident said they pressed the call light and had already waited 45 minutes for staff to respond, while another said weekend and night shift waits were over an hour. A resident with a leaking colostomy bag reported waiting over 30 minutes for staff to clean and replace it, and another resident said delayed response times left them in pain by the time staff arrived. Staff interviews described ongoing staffing shortages and difficulty meeting resident needs with the number of aides available. A CNA said the facility had been short staffed weekly and that it was difficult to provide 4-5 showers plus routine care. Another CNA said staffing levels were not manageable with only two aides because of Hoyer transfers and the need to ensure all residents received showers, with weekends being harder because management was not available to help. A third CNA said they were sometimes working alone on a hall and that completing routine care, transfers, and showers was unmanageable without additional help. The record also showed repeated grievances about call lights not being answered in a timely manner and a grievance about a resident not receiving a shower as expected. Staffing records documented management staff covering medication carts and resident care duties due to call outs on multiple days. The staffing coordinator and DNS stated the facility used two aides per hall with float aides available when needed, but also acknowledged that weekends had been difficult due to call outs. The PBJ staffing data triggered excessively low weekend staffing for the first quarter of 2025, and the report cited WAC 388-97-1080(1) and 1090(1).
Food Not Served at Proper Temperature or in an Appealing Manner
Penalty
Summary
The facility failed to provide food that was palatable, attractive, and served at an appetizing temperature for residents on four sampled halls, including Halls A, B, North 1, and North 2. During observation of a test food tray, the tray had a white plate on a heated base system with an insulated cover, but both the heated base system and the plate were room temperature to the touch. The tray contained baked fish, coleslaw, corn, and an Oreo dessert. Taste testing found the corn was mushy and overcooked, and the fish lacked seasoning and was room temperature. The Dietary Manager took temperatures of the fish at 112 degrees Fahrenheit, the corn at 129.5 degrees Fahrenheit, and the coleslaw at 48.2 degrees Fahrenheit, and stated the Oreo dessert was out of temperature range because it had just been made. Resident interviews reflected ongoing concerns about food quality and temperature. One resident stated the food did not look good and they did not always get what they ordered from the menu. Other residents stated the food tasted bad, was not hot when received, was sometimes unidentifiable, was repetitive, or was never hot and only warm. Review of Resident Council Meeting Minutes showed food complaints from October 2025 through March 2026. Review of the grievance log showed repeated food grievances each month from October 2025 through March 2026. The Dietary Manager stated they were aware of issues with food temperature and had been waiting over 2 months for new plate warmers, and the Administrator stated the facility's lack of temperature and quality did not meet expectations.
Failure to Notify Resident Representative of Medication Order and Eye Appointment
Penalty
Summary
The facility failed to notify Resident 6’s representative of a new metformin order and of an eye doctor appointment. Resident 6 was admitted to the facility with a diagnosis of non-Alzheimer’s dementia and was documented as moderately cognitively impaired on the Quarterly MDS dated 03/06/2026. The electronic health record showed Resident 6 had a court-appointed guardian as the resident representative, and on 04/06/2026 the representative stated they had not been notified about the new metformin order and had not been told about the eye appointment until they noticed Resident 6 wearing new glasses. Record review showed a metformin order dated 04/12/2025 to be given daily in the morning and discontinued on 04/14/2025, with the MAR documenting that metformin was given on 04/14/2025. The record did not show that the representative was notified of the new order before the medication was given. The EHR also contained documentation for an eye care consultation dated 04/24/2025 and later documentation about glasses being adjusted, but there was no record that the representative was notified of the appointment. Staff U stated the representative was not called about the metformin order and should have been notified before the medication was administered, and should also have been contacted about the eye appointment. Staff B stated they did not find documentation that the representative had been notified of either event.
Failure to Process Resident Grievance for Missing Clothing
Penalty
Summary
The facility failed to initiate, investigate, and resolve a grievance for Resident 3 regarding missing personal clothing after a room move. Resident 3, who was admitted with chronic kidney disease, hyperlipidemia, and diabetes and was able to make needs known, stated they did not receive all of their belongings after moving to a new room in February 2026 and reported missing approximately 3 pairs of pants and several shirts to Staff P, RN. Staff P looked in the previous room but could not locate the items. Review of the grievance logs for February, March, and April 2026 showed no grievance filed for the missing clothing. Staff P confirmed the report of missing clothing and stated no grievance was completed, and instead clothing was obtained from the donation bin for Resident 3. The Administrator stated that when residents reported missing items, staff were expected to complete a grievance form and submit it to social services for follow-up.
Failure to Document Rationale for Psychotropic GDR Decline
Penalty
Summary
The facility failed to ensure that pharmacy-recommended gradual dose reductions (GDRs) for psychotropic medications were carried out, or that a resident-specific clinical rationale was documented when a GDR was declined, for one resident reviewed for unnecessary medications. The resident had moderate cognitive impairment and diagnoses of anxiety disorder, depressive disorder, and insomnia, and was receiving antidepressant and antianxiety medications during the assessment period. Record review showed the resident had orders for lorazepam twice daily for target behaviors related to anxiety disorder and citalopram 20 mg daily for target behaviors of self-isolation and statements of sadness related to major depressive disorder. The resident had received citalopram 20 mg daily since 2022, and the record showed multiple instances where citalopram was discontinued on one day and restarted at the same dose the next day, with no missed doses. The pharmacist consultation later recommended a GDR of citalopram from 20 mg daily to 10 mg daily. The provider reviewed the consult and selected a response indicating that the resident's target symptoms had returned or worsened after the most recent GDR attempt and that a GDR at that time was likely to impair function or cause psychiatric instability, but the required patient-specific rationale section was left blank. An IDT note stated that the team reviewed the pharmacy recommendation and cited contraindication due to maladaptive behaviors and potential for increased target behaviors, with the PCP in agreement and no changes to citalopram, but the note did not identify the maladaptive behaviors or explain how they were associated with citalopram. The record contained no documentation of a failed GDR of citalopram and no resident-specific clinical rationale supporting why a GDR would impair function or cause psychiatric instability.
Inaccurate MDS Coding for Hospice Status and Dialysis Access
Penalty
Summary
The facility failed to ensure the MDS accurately reflected resident status for 2 of 18 sampled residents. For Resident 28, the quarterly MDS documented moderate cognitive impairment, substantial to dependent assistance with ADLs, and hospice care, but the MDS questions asking whether the resident had a condition or chronic disease that may result in a life expectancy of less than 6 months were marked no on two quarterly assessments. The EHR also contained a Hospice Certification and Plan of Care with a start of care date of 05/16/2025. During interview, the RN/MDS Coordinator reviewed the assessments and stated they should have been marked yes because the resident was receiving hospice services. For Resident 5, the admission MDS and a later quarterly MDS documented the resident as cognitively intact, with end stage renal disease and dialysis services, but without intravenous access and without a central line. Record review showed the resident’s dialysis access was via a tunneled dialysis catheter, and there were no orders in place from 03/03/2025 through 03/06/2025 directing staff to assess or monitor the catheter. Later orders directed nurses to monitor the dialysis catheter site for signs and symptoms of infection or bleeding every shift and to assess the resident’s right subclavian port upon return from dialysis. The dialysis care plan also directed staff to assess the resident’s subclavian access site. When asked about the MDS coding, the MDS Coordinator stated the resident had a TDC and the MDS was inaccurate.
Inaccurate PASRR Screening
Penalty
Summary
PASRR screening for mental disorders or intellectual disabilities was not accurately completed for one resident. The resident was admitted with diagnoses including chronic kidney disease, hyperlipidemia, and diabetes, and was able to make needs known. Review of the hospital PASRR dated 12/15/2025, completed before admission, showed mood disorders indicated as a diagnosis on the form. However, review of the resident’s medical diagnosis list and provider orders showed no mental health diagnosis and no behavioral health medication prescribed. During interview, the Social Services Director stated the PASRR was incorrect and a new one should have been completed, and the Administrator stated staff were expected to ensure PASRRs were correct upon admission and, if not, a new one should have been completed to reflect accurate resident information.
Failure to Follow Bowel Care Orders and Document Edema Monitoring
Penalty
Summary
Facility nurses failed to provide bowel care according to provider orders for two residents. One resident, who had moderate cognitive impairment and reported constipation as an ongoing problem, had PRN bowel orders directing Milk of Magnesia on day four without a bowel movement, followed by a bisacodyl suppository on day five and a Fleet enema on day six if needed. The bowel record showed multiple 4-day periods without a bowel movement in February and March 2026, and the MAR showed the ordered Milk of Magnesia was not administered on the fourth day without a bowel movement on those occasions. Another resident had no bowel movement for five days in March 2026 and also had PRN bowel orders for Milk of Magnesia on day four, bisacodyl suppository on day five, and Fleet enema on day six, but the MAR showed the Milk of Magnesia was not given on the fourth day without a bowel movement. Facility nurses also failed to properly monitor edema for one resident with renal insufficiency who required diuretic medication during the assessment period. The resident had care plan directions to observe and report dependent edema, weight gain greater than two pounds in 24 hours, neck vein distension, and/or shortness of breath, and had an order to monitor edema every shift. Although nurses initialed the MAR each shift indicating edema was monitored, there was no documentation of whether edema was present or absent, where it was located, or the extent of the edema. Staff later acknowledged the order had been entered without a place or direction to document the presence or absence of edema and its location and extent.
Failure to Monitor and Document Fluid Restriction Intake
Penalty
Summary
The facility failed to monitor and accurately document fluid intake for two residents with fluid restriction orders. Resident 48 was admitted with diagnoses including heart failure, diabetes, and muscle weakness, and was able to make needs known. The record showed a 03/20/2026 order to monitor and document fluid intake and a fluid restriction total of 2000 mL per day related to CHF, with specific amounts assigned for each shift and meal. However, on 04/06/2026 a water pitcher with a straw was observed on the resident’s overbed table for easy access, and the resident stated on 04/07/2026 that they were upset the pitcher had been taken by a CNA and did not understand why. Staff Q, CNA stated they had been instructed to remove the pitcher because of the fluid restriction, and Staff R, RN/MDS, stated they noticed the pitcher during medication administration and told Staff Q to take it and provide a cup of water. Resident 48’s meal tray card did not show a fluid restriction, and the Dietary Manager reviewed a Diet Order and Communication form dated 04/04/2026 that did not reflect the restriction. The Dietary Manager stated communication between nursing and dietary had been an ongoing concern. The DON later stated residents on fluid restrictions should not have a water pitcher at the bedside, and after reviewing the April 2026 MAR, stated the totals were inaccurate and did not meet expectations. The DON also stated Resident 48’s diet slip should have accurately reflected the fluid restriction and that the lack of communication between nursing and dietary did not meet expectations. Resident 96 had an order for a 1500 mL per day free water restriction for hyponatremia. Observations showed a pitcher containing clear fluid at the bedside on multiple occasions, and a visitor was seen bringing bottled water to the resident while another pitcher of clear fluid was present. The March 2026 MAR directed nurses to document the amount of free fluid provided each shift, but there was no direction to calculate or record the resident’s total 24-hour free water intake. When the seven-day intake totals were reviewed, Resident 96 exceeded the restriction on three days, and the EHR showed no documentation that staff calculated the 24-hour totals, identified the repeated excess intake, provided patient education, or notified the provider. The DON stated that for residents with fluid restriction orders, staff would record intake each shift and calculate the total 24-hour intake, and confirmed there was no documentation of calculation, education, or provider notification for the days the restriction was exceeded.
Missing Oxygen Order for Resident Using Oxygen
Penalty
Summary
Provide safe and appropriate respiratory care for a resident when needed was not met for one resident who was admitted with chronic kidney disease, hyperlipidemia, and diabetes and was able to make needs known. Observations on 04/06/2026, 04/07/2026, and 04/08/2026 showed an oxygen concentrator set to 2 liters per minute near the resident's bed, but the resident was not observed wearing a nasal cannula during those observations. The resident's care plan, initiated on 03/19/2026, included an intervention for oxygen via nasal cannula at 2 liters per minute as needed for shortness of breath, yet the EHR showed no active provider order for oxygen. During an observation and interview on 04/08/2026, the resident stated they only used oxygen at night, and staff checked the EHR and stated there was no active oxygen order on file but there should have been. The DON later stated the oxygen order had been discontinued, but since the resident was still using oxygen, a new order should have been obtained.
Failure to Complete CNA Annual Performance Reviews
Penalty
Summary
The facility failed to complete annual CNA performance reviews for 3 of 5 sampled nursing assistants reviewed. Staff H, a CNA hired on 04/09/2025, had no annual performance review completed when the record was reviewed on 04/09/2026. Staff I, a CNA hired on 04/25/2024, had an annual performance review completed on 09/17/2025, which was 5 months past the annual review date. Staff J, a CNA hired on 06/20/2024, had an annual performance review completed on 09/17/2025, which was 3 months past the annual review date. On 04/09/2026 at 12:38 PM, the DON said annual performance reviews needed to be completed and pointed to a binder showing CNA annual performance reviews that needed to be completed. When shown the listed staff without or past due annual performance reviews, the DON said the annual performances were completed within the year, and it was explained that the regulation is based on hire date and hire anniversary rather than calendar year.
Undated Opened Medications and Creams Left at Bedside
Penalty
Summary
Medications in two medication carts were found to be opened without dates recorded. On the North Hall medication cart, Resident 104’s latanoprost eye drops and fluticasone propionate were opened and undated, Resident 103’s latanoprost eye drops were opened and undated, and Resident 14’s Spiriva Respimat was opened and undated. On the A Hall medication cart, Resident 47’s Wixela inhaler was opened and undated. Review of the package inserts showed the eye drops and inhalers had specific discard times after opening, and the Resident Care Manager stated the nurse who opened the medications should have recorded the date opened but did not do so. Medications were also observed left at the bedside of Resident 28. Resident 28 had a quarterly MDS dated 02/20/2026 documenting moderate cognitive impairment and substantial to dependent assistance with ADLs. The electronic record showed orders for Calmoseptine to the coccyx for blanchable redness every 24 hours as needed after each incontinent episode and every shift. On multiple observations, two medicine cups containing a pink cream and a white cream were seen on the resident’s bedside table, labeled with the resident’s name or initials. An LPN later observed the cups and discarded them, stating the creams should not have been left at the bedside. The DON also stated the medicine cups with creams should not have been left in the resident’s room.
Failure to Follow Up on Dental Referral and Denture Needs
Penalty
Summary
The facility failed to provide dental services for one Medicaid resident who was cognitively intact and had mouth or facial pain, discomfort, and difficulty chewing. The resident reported chipped and cracked lower teeth, stated they had pulled one tooth out the prior week, and said they had no upper teeth and difficulty eating spaghetti. The resident’s care plan, initiated for natural carious and broken teeth with pain and difficulty chewing, directed staff to coordinate dental care and transportation as needed or as ordered. A provider order dated 11/22/2025 directed the resident to receive dental services as needed. A dental consult dated 11/10/2025 documented a referral for x-rays and evaluation for extraction of tooth 18, with a plan to refer the resident for new dentures. The dentist wrote that the resident wanted tooth extraction and new dentures made. Review of the electronic health record showed no documentation that staff followed up on the dental referral for extraction or new dentures, and the DON stated there was no documentation that the referral for x-rays, evaluation, tooth extraction, or dentures had been followed up on.
Failure to Honor Resident Portion Size Preferences
Penalty
Summary
The facility failed to ensure food preferences related to portion sizes were honored for 7 of 19 sampled residents reviewed for resident rights. On 04/10/2026, the breakfast menu called for cheese scrambled eggs, bacon, buttered toast, and a choice of cereal, with the entree to be served using a #10 scoop for residents on a regular diet. During observation, Resident 61 preferred small portions and a small serving of starch, but Staff T, Cook, used a size #12 scoop to plate a regular portion size and a regular portion size of starch. Similar observations were made for Resident 77, Resident 57, Resident 87, and Resident 4, each of whom preferred small portions or a small serving of starch, yet Staff T used a size #12 scoop to plate regular portion sizes or regular starch portions. Additional observations showed Resident 37 preferred a small serving of starch, Resident 63 preferred a small serving of starch, and Staff T again used the size #12 scoop to plate a regular portion size of starch. During interview, Staff T stated they were unable to locate the #10 scoop for the breakfast entree and used the #12 instead, and stated that residents who preferred small portions or small starch should have been served using a smaller scoop. The Dietary Manager stated staff were expected to follow the diet spreadsheet and use the correct scoop sizes when serving meals, and that when residents requested smaller portion sizes or a smaller amount of starch, the expectation was to provide half the regular serving size as requested.
CNA Annual Training Deficiency
Penalty
Summary
The facility failed to implement a system to ensure Certified Nursing Assistants received the required annual continued competency training of no less than 12 hours per year. Record review showed Staff I, a CNA hired on 04/25/2024, had only 3.75 hours of annual training for the period from 04/25/2024 to 04/25/2025. Staff K, a CNA hired on 07/15/2024, had 11.25 hours of annual training for the period from 07/15/2024 to 07/15/2025. On 04/09/2026 at 12:38 PM, when the staff members who did not meet the required annual 12-hour minimum were identified, the Director of Nursing Services stated the training hours should have been completed.
Inadequate Hydration and Monitoring Lead to Hospitalization
Penalty
Summary
The facility failed to provide adequate care and services to prevent hospitalization for two residents, primarily due to insufficient monitoring and intervention regarding hydration and abnormal laboratory results. Resident 1, who had severe cognitive impairment and was dependent on staff for activities of daily living, was admitted for aftercare following fractures. Despite being clinically stable initially, the resident's condition declined, with elevated white blood cells and sodium levels indicating potential infection and dehydration. The facility staff did not promptly notify the provider or family of these lab results, and the resident eventually required emergency medical attention for critically low oxygen levels and was diagnosed with multiple conditions, including dehydration and infections, upon hospital admission. Resident 2, with moderate cognitive impairment and requiring substantial assistance, also experienced a decline in condition due to poor oral intake and hydration monitoring. The resident's family expressed concerns about increased lethargy and inadequate fluid intake, which were not adequately addressed by the facility. The resident was eventually hospitalized with hypernatremia and hypomagnesemia, conditions related to poor oral intake, and required intravenous fluids for stabilization. Interviews with facility staff revealed a lack of consistent monitoring and documentation of fluid intake and output, particularly for residents not on fluid restrictions. Staff members were unclear about the process for notifying providers of lab results and changes in resident conditions. The facility's infection preventionist and director of nursing services were not fully aware of the residents' declines or the need for testing during an outbreak, indicating systemic issues in communication and care coordination.
Inaccurate MDS Assessments for Two Residents
Penalty
Summary
The facility failed to accurately assess the Minimum Data Set (MDS) for two residents, leading to potential risks for unmet care needs. Resident 12, who was admitted to the facility, had an Annual MDS that did not reflect the requirement for a Level II Preadmission Screening and Resident Review (PASRR) for a depressive disorder, despite documentation indicating the need for specialized services. Staff H, the Registered Nurse and MDS Coordinator, acknowledged that Resident 12 should have been coded for a Level II PASRR on both annual MDSs. The Director of Nursing, Staff B, confirmed the expectation for accurate MDS coding. Resident 39, admitted with acute and chronic respiratory failure and dependence on supplemental oxygen, had an Admission MDS that failed to code for oxygen usage, despite orders and documentation indicating continuous oxygen therapy. Staff G, a Licensed Practical Nurse, confirmed that Resident 39 had been on oxygen since admission, and Staff H provided documentation showing that oxygen therapy should have been coded during the MDS capture period. This oversight in MDS coding for oxygen therapy was acknowledged by the MDS Coordinator.
Failure to Implement Timely Baseline Care Plans
Penalty
Summary
The facility failed to develop and implement baseline care plans within 48 hours of admission for two residents, leading to potential risks for unmet care needs. Resident 131 was admitted with a non-healing ulcer on the right foot, requiring daily dressing changes, and was on coumadin therapy, necessitating regular INR testing. However, the baseline care plan did not address these critical health issues, as confirmed by the Director of Nursing Services (DNS), who acknowledged that these elements should have been included. Similarly, Resident 331, who was admitted with Type 2 Diabetes and required insulin, did not have a baseline care plan developed within the required timeframe. The Resident Care Manager confirmed that the high-risk insulin medication should have been included in the care plan. The DNS mistakenly believed that there was a 21-day period to complete a comprehensive care plan, which contributed to the oversight.
Failure to Implement Comprehensive Care Plans
Penalty
Summary
The facility failed to develop and implement individualized comprehensive care plans for three residents, leading to potential unmet care needs. Resident 1, who was cognitively intact, expressed specific activity preferences that were not included in their care plan, despite being identified as very important. The Activities Director acknowledged that these preferences should have been care planned. Resident 39, also cognitively intact, was observed using supplemental oxygen, but their care plan did not include details about their oxygen usage, which the Director of Nursing Services confirmed should have been included. Resident 44, who was moderately cognitively impaired, used mobility bars for assistance, but their care plan lacked documentation for this equipment. The Resident Care Manager confirmed the absence of a care plan for the mobility bars. Resident 59, with severe cognitive impairment, had a diagnosis of an unstageable pressure ulcer on their left heel, but their care plan did not include specific interventions for this condition. The Resident Care Manager and Director of Nursing Services both acknowledged that the pressure ulcer should have been care planned. These deficiencies were identified during interviews and record reviews, highlighting the facility's failure to address the residents' specific needs in their care plans.
Non-Compliance with Physician Orders and Documentation Failures
Penalty
Summary
The facility failed to adhere to professional standards of practice for several residents, leading to medication errors and unmet care needs. For Resident 21, the facility did not follow physician orders for Lisinopril, administering it despite a systolic blood pressure below the ordered threshold. Additionally, the facility failed to obtain an A1C test as ordered, with no documentation explaining the missed attempts. Furthermore, Resident 21 received aspart insulin multiple times outside the prescribed blood glucose parameters. Resident 1's care was compromised by the facility's failure to record and report daily weights as ordered. Weights were not documented on several occasions, and a nurse erroneously signed off on a weight that was not recorded in the electronic health record. This lack of documentation and adherence to orders could lead to unmonitored weight changes, which were critical for Resident 1's care. Resident 331 received insulin Lispro after meals instead of before, contrary to the physician's orders. Additionally, hydralazine was administered despite a blood pressure reading below the hold parameter, and a lidocaine patch was applied without a specified location. Resident 59's oxygen was administered at a higher rate than ordered, with no documentation of physician notification or order updates. These actions reflect a pattern of non-compliance with physician orders and inadequate documentation, potentially impacting resident safety and care quality.
Failure to Implement Bowel Protocol for Residents
Penalty
Summary
The facility failed to implement or document the bowel protocol for two residents, leading to a deficiency in care. Resident 59, who was admitted with a diagnosis of constipation and severe cognitive impairment, did not have a bowel movement recorded for seven days. Despite having orders for Milk of Magnesia, Bisacodyl, and Fleet Enema to be administered sequentially after specific days without a bowel movement, there was no documentation of these interventions being carried out. Staff interviews confirmed that the bowel protocol was not followed, and there was no documentation of refusal or bowel assessments during this period. Similarly, Resident 1, who was cognitively intact and assessed to be constipated, did not receive the prescribed Milk of Magnesia after four days without a bowel movement. The facility's MAR showed that the as-needed bowel medications were not offered or administered as ordered. Staff acknowledged the failure to administer the medication on the fourth day, as per the resident's bowel management orders. These lapses in following the bowel protocol placed the residents at risk for discomfort and diminished quality of life.
Deficiencies in Pressure Ulcer Monitoring and Documentation
Penalty
Summary
The facility failed to appropriately monitor and document pressure ulcers for two residents, leading to deficiencies in care. Resident 59, who had chronic venous insufficiency, malnutrition, and an unstageable pressure ulcer on the left heel, was not properly assessed or documented. Despite having a scabbed area on the heel, there were no consistent measurements or staging of the wound. The facility's staff did not follow up with weekly assessments or involve the wound care team, resulting in a lack of documentation on the wound's progression or response to treatment. Resident 44, who was moderately cognitively impaired and at risk for pressure ulcers, developed a pressure ulcer on the left ear from nasal cannula straps. The facility's records showed inconsistencies in documenting the presence and treatment of the ulcer. Skin prep orders were not properly managed, leading to multiple administrations within short intervals and incorrect documentation of treatment on both ears instead of the affected one. Observations indicated that the resident was not consistently on oxygen, and staff failed to document the resolution of the ulcer accurately. Interviews with staff revealed a lack of understanding and adherence to the facility's policies on wound care documentation and assessment. Staff members admitted to not following through with expected documentation practices, such as weekly measurements and staging of pressure ulcers. The Director of Nursing Services acknowledged the deficiencies in documentation and the failure to meet expectations for wound care management, highlighting a systemic issue in the facility's approach to pressure ulcer care.
Failure to Adhere to Insulin Administration Orders
Penalty
Summary
The facility failed to ensure that a resident, who was cognitively intact and diagnosed with diabetes, was free from significant medication errors related to insulin administration. The resident had specific physician orders for insulin administration, which included holding Aspart insulin if blood glucose (BG) levels were below 150 and holding Lantus insulin if BG levels were below 100. However, the facility nurses administered insulin on multiple occasions despite BG levels being below the ordered parameters, as evidenced by the Medication Administration Records for January and February 2025. The report highlights 20 instances where insulin was administered contrary to the physician's orders, placing the resident at risk for adverse health outcomes. These errors were confirmed by the Resident Care Manager, who acknowledged that the facility nurses did not adhere to the prescribed insulin administration guidelines. This oversight in following physician orders for insulin administration constitutes a significant medication error, as it directly contravenes the established medical directives for the resident's diabetes management.
Infection Control Deficiencies in EBP and Contact Precautions
Penalty
Summary
The facility failed to enforce Enhanced Barrier Precautions (EBP) for Resident 331, who was on EBP due to having a urinary catheter/foley. During observations, staff members were seen providing care without wearing the required gown and gloves. Staff J, an LPN, administered insulin to Resident 331 without wearing a gown, and Staff L, a CNA, assisted the resident with movement without wearing a gown, despite acknowledging the requirement for gown and glove use in EBP rooms. The Infection Preventionist/Assistant Director of Nursing (IP/ADON) confirmed that staff were expected to wear gowns and gloves when providing care to residents on EBP. The facility also failed to prevent urinary catheter/foley bags from touching the ground for Residents 331 and 39. Observations showed that Resident 331's foley bag and tubing were repeatedly seen touching the ground while the resident was in a wheelchair. Similarly, Resident 39's foley bag was observed touching the ground multiple times, including when being moved through the hallway. Staff confirmed that foley bags should not touch the ground, and the IP/ADON stated that the expectation was for foley bags to be secured without touching the ground. Additionally, the facility did not ensure that contact precautions were understood and followed outside of resident rooms for Residents 39 and 131. Resident 39, who had a history of ESBL and E.coli, was observed with signage for both EBP and contact precautions, yet staff allowed the resident to leave the room without restrictions. Similarly, Resident 131, with a history of MRSA wound infections, was seen self-propelling in a wheelchair in the hallway without adherence to contact precautions. Staff expressed confusion about the implementation of precautions, and the IP/ADON provided inconsistent explanations regarding the necessity of precautions outside of resident rooms.
Delay in Obtaining Physician-Ordered X-Ray
Penalty
Summary
The facility failed to obtain a physician-ordered chest x-ray in a timely manner for a resident with a history of emphysema, COPD, and chronic respiratory failure. The resident was experiencing shortness of breath and a productive cough with thick yellow phlegm, prompting the provider to order a chest x-ray. Despite the order being faxed to the imaging provider, the x-ray was not performed promptly, and the resident's condition worsened, leading to a hospital admission for pneumonia. The delay in obtaining the x-ray was attributed to the facility's reliance on the radiology provider's availability, which was not communicated effectively to the provider or documented in the resident's health record. The staff did not follow up adequately with the radiology provider or the ordering provider to ensure the x-ray was performed in a timely manner. The resident's family expressed concern about the delay, and the resident's Power of Attorney eventually requested transport to the ER for evaluation.
Failure to Ensure Safe Transfers with Manufacturer-Recommended Equipment
Penalty
Summary
The facility failed to ensure safe transfers for a resident when they did not use the mechanical lift's manufacturer's recommended sling, resulting in the resident sliding from the sling. The resident, who was cognitively intact, medically complex, and dependent on staff for transfers, was admitted to the facility and required total assistance with an XL sling for transfers. During a transfer, the resident fell from the lift, leading to back pain and a subsequent hospital evaluation. The incident report documented that the lift and sling were inspected and found to be in working order, and the correct lift and sling were used. However, the fall occurred when the resident shifted her weight, causing the harness on the right shoulder to come off the hook. Staff involved in the transfer confirmed that they were using a purple XL sling from a different manufacturer than the lift, which was against the lift manufacturer's safety recommendations. Further investigation revealed that the facility's staff were not aware of the mechanical lift manufacturer's recommendation to use only their brand of slings. The Director of Nursing and the Administrator confirmed that they were working on implementing the manufacturer's recommendations but had not communicated with the sling company to ensure compatibility prior to the incident.
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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