Life Care Center Of Port Townsend
Inspection history, citations, penalties and survey trends for this long-term care facility in Port Townsend, Washington.
- Location
- 751 Kearney Street, Port Townsend, Washington 98368
- CMS Provider Number
- 505306
- Inspections on file
- 19
- Latest survey
- March 13, 2026
- Citations (last 12 mo.)
- 10
Citation history
Health deficiencies cited at Life Care Center Of Port Townsend during CMS and state inspections, most recent first.
PASRR screening was not completed accurately for two residents before admission. One resident had anxiety disorder documented in the MDS and an order for PRN lorazepam, but the initial PASRR did not include the anxiety diagnosis. Another resident was admitted with no mental health diagnosis listed, yet the med list included an antidepressant and an antianxiety med, and the hospital record showed anxiety; the PASRR still indicated no mental health concerns.
Psychotropic meds were not properly monitored or justified for three residents. One resident with dementia and depression had quetiapine and trazodone ordered, but there was no target behavior monitoring for the antidepressant. Another resident had escitalopram and PRN lorazepam for anxiety despite no MH dx listed in the facility record, and the DNS said the diagnosis and justification should have been documented. A third resident with Alzheimer’s, anxiety, and physical aggression received PRN risperidone, lorazepam, and haloperidol for agitation or care-related behaviors, but the TARs did not document the behaviors or non-drug interventions attempted before the meds were given, and the resident also showed oral-facial movements consistent with tardive dyskinesia that were not documented on the TAR.
Failure to follow up on PASRR Level 2 evaluations for two residents with serious mental illness indicators. One resident had PASRR findings for psychotic, depressive, delusion, and Lewy body neurocognitive disorders, and another had findings for major depressive disorder and anxiety disorder. Both residents’ EHRs lacked Level 2 evaluations, and staff reported limited or no follow-up with the state regarding the referrals.
Call Light and Water Left Out of Reach: A cognitively intact resident who needed assistance with eating was found with the call light hanging out of reach and the water container placed too far away to access. The resident said they sometimes had to wait for help to reach the call light or get a drink, and staff later assisted with water and moved the call light into reach after it was identified as out of place.
Failure to prevent new pressure ulcers was cited for a resident who was severely cognitively impaired, had communication deficits, and was at risk for skin breakdown. The resident initially had two Stage 2 pressure ulcers that healed, but later developed two Stage 1 coccyx ulcers that progressed to two Stage 2 ulcers. Documentation noted an air overlay mattress, barrier cream, and later an air mattress, while the DON confirmed the resident’s wounds worsened during the stay.
A resident with severe cognitive impairment and communication deficits experienced progressive weight loss from 108 lbs to 90.8 lbs over about five months, while the facility continued the same general supplement regimen and did not document food preference evaluations or a change to NEM, fortified foods, or calorie-dense meals. Meal records showed the resident usually ate only 0-25% of meals, and MNA findings documented worsening intake and malnutrition, but no follow-up recommendations were recorded. Staff confirmed the resident’s preferred foods were known but not documented, and no additional nutritional interventions were identified.
Three residents had their beds positioned against the wall, and one also had a mobility bar, without proper restraint assessments, care plans, or documentation. Staff interviews confirmed that required evaluations and consents were not completed for these arrangements, despite facility expectations.
Several residents received opioid pain medications without documented attempts at non-pharmacological interventions as ordered, and pain medications were administered outside of prescribed pain score parameters. Additionally, some residents received antihypertensive and diuretic medications despite low blood pressure readings, without appropriate reassessment or provider notification. Staff confirmed that documentation and adherence to medication protocols were lacking.
The facility did not obtain updated PASRR assessments for two residents with significant mental illness diagnoses. Despite Level 1 PASRR screenings indicating serious mental illness, no referrals for Level 2 PASRR evaluations were made, as confirmed by record review and staff interviews.
Surveyors found that the facility did not include resident-specific interventions in care plans for multiple residents, such as management of chronic diarrhea, oral hygiene needs, bed positioning, diuretic use, edema, and dental issues. These omissions were confirmed through staff interviews and record reviews, indicating that care plans did not accurately reflect assessed needs or provide necessary direction to staff.
The facility did not consistently perform daily weights or notify the provider when weights could not be obtained for a resident with CHF, failed to document side effects of an antidepressant as ordered, did not implement hospice recommendations for wound care for a resident with oral cancer, and did not initiate required monitoring after a resident's hospital readmission. Staff interviews confirmed these lapses in following physician orders and professional standards.
Two residents who required assistance with oral hygiene did not receive necessary support, resulting in poor oral hygiene and lack of access to supplies. Staff interviews and record reviews revealed that oral care was not consistently provided, not documented, and not included in care plans or the EHR task system. Supplies for oral care were not accessible, and staff were unaware of the need to assist or document oral care for these residents.
Surveyors identified that an open insulin pen on a medication cart was not dated as required, and a medication room refrigerator log was missing multiple temperature entries despite being used for medication storage. Additionally, food was found left on top of a medication cart with no staff intervention, and facility leadership confirmed these practices did not meet expectations.
Surveyors found that kitchen staff did not consistently wear required hair restraints while working, and the facility's dishwasher repeatedly failed to reach the necessary wash and rinse temperatures for proper sanitization over several months. The Dietary Manager confirmed both the lack of PPE use and the ongoing temperature issues with the dishwasher.
The facility failed to ensure proper infection control practices, including improper storage and handling of oxygen equipment for a resident on oxygen therapy, lack of hand hygiene by staff during dining services, failure to use PPE as required for a resident on enhanced barrier precautions, and improper handling and storage of linens by laundry staff. These actions did not follow facility protocols and were confirmed by facility leadership as not meeting expectations.
The facility failed to verify a CNA's credentials through the nurse aide registry before allowing them to provide care. The CNA was hired without proper documentation, and the facility's Administrator confirmed the oversight, which placed residents at risk for abuse and unmet care needs.
PASRR screening missed anxiety diagnoses before admission
Penalty
Summary
The facility failed to screen residents for mental health conditions prior to admission for 2 of 5 sampled residents reviewed for PASRR. Resident 12 was admitted with a diagnosis of anxiety disorder documented in the MDS and had a physician order for lorazepam as needed for anxiety. The resident’s Level 1 PASRR, completed before admission, indicated no serious mental illness indicators and did not document anxiety disorder. The Social Service Director later stated the PASRR had been reviewed and found to be incorrect because of the anxiety disorder, and that a corrected PASRR was not completed until 03/11/2026 because staff had been busy. Resident 47 was admitted with no mental health diagnoses listed on the diagnosis list and the admission MDS documented the resident as cognitively intact with no mental health diagnoses or history. The PASRR Level I completed on admission stated there were no mental health diagnoses or concerns and that a Level II was not required. During review, the DON confirmed the diagnosis list did not show a mental health diagnosis, but the medication list included an antidepressant and an antianxiety medication, and the hospital discharge record showed a diagnosis of anxiety. The DON stated the resident had been admitted on both medications and the diagnoses should have been identified so a new PASRR could have been completed and submitted with the correct diagnoses.
Psychotropic medications lacked monitoring, justification, and documented non-drug interventions
Penalty
Summary
The facility failed to ensure psychotropic medications were regularly monitored for side effects and target behaviors, and failed to provide justification for use and documentation that non-pharmaceutical interventions were attempted before psychotropic medications were used for three sampled residents. The facility policy stated psychotropic medications may be used only after non-drug approaches and interventions were attempted and that all medications should be monitored for harm and adverse consequences. Resident 22 had diagnoses including depression and unspecified dementia with behavioral disturbances and was severely cognitively impaired on the admission MDS. Physician orders showed quetiapine for dementia and trazodone for depression, but the record contained no documentation of target behavior monitoring for trazodone. The DNS reviewed the record and confirmed there was no target behavior monitoring in place or documented for the antidepressant medication. Resident 47 was cognitively intact and had no mental health diagnoses listed on the facility diagnosis list, although the hospital discharge record included anxiety. The resident was prescribed escitalopram routinely for anxiety and lorazepam as needed for anxiety. The DNS reviewed the record and confirmed the diagnosis list did not include a mental health diagnosis and said the diagnoses should have been listed with justification for use of the medications. Resident 12 had Alzheimer’s disease with behavior disturbances and anxiety disorder and was severely cognitively impaired, physically aggressive during care, and dependent on staff for activities of daily living. The care plan and physician orders directed staff to document agitation or anxiety episodes, behavioral interventions attempted, and outcomes before giving PRN risperidone, lorazepam, or haloperidol. The record showed multiple administrations of these medications before care, during agitation, or for anxiety, but the TARs did not document the episodes or behavioral interventions attempted. Staff also increased risperidone after discussing the resident’s grabbing during care, but the record showed staff had not analyzed the behavior patterns or reassessed which non-pharmacological interventions were effective before the increase.
Failure to Follow Up on PASRR Level 2 Evaluations
Penalty
Summary
The facility failed to coordinate and follow up on PASRR Level 2 evaluations for two residents with serious mental illness indicators. Resident 3 was admitted to the facility and had a Quarterly MDS showing the resident was cognitively intact and required assistance with oral hygiene, dressing, and showering. Resident 3’s PASRR, dated 07/03/2025, checked serious mental illness indicators for psychotic disorder, depressive disorder, delusion disorder, and neurocognitive disorder with Lewy bodies, and the Level 2 evaluation referral was checked. However, the EHR contained no Level 2 evaluation, and a progress note documented that a request for Level II PASRR review was emailed to Acentra Health on the resident. Resident 4 was admitted to the facility and had an Annual MDS showing the resident was cognitively intact and needed setup to supervision assistance with hygiene and dressing and partial to moderate assistance with bathing. Resident 4’s PASRR, dated 04/30/2025, checked serious mental illness indicators for major depressive disorder and anxiety disorder, and the Level 2 evaluation referral was checked. The EHR showed no Level 2 evaluation. Staff stated they had not received an invalidation, that an email was sent to the state, and that the resident was in the queue for an evaluation. The Administrator stated there had been follow-up in July 2025 for Resident 4 but no follow-up since, and that follow-up should have occurred to ensure the resident remained on the list for a Level 2 evaluation.
Call Light and Water Left Out of Reach
Penalty
Summary
The facility failed to provide necessary ADL assistance for Resident 3, who was admitted to the facility and assessed on the Quarterly MDS as cognitively intact and needing set-up or clean-up assistance with eating. During interview, Resident 3 said they sometimes could not reach their call light and had to wait when that happened. Resident 3 also said they needed staff help to drink and sometimes had to wait for a drink, adding that they were told they were dehydrated and wanted to drink more. During observation, Resident 3 was found in bed with the call light hanging down the side of the bed from the bed rail and out of reach, and the water container with a straw was placed at the far edge of the bedside table and also out of reach. When Resident 3 awoke, they said they could not reach the call light. A CNA then helped Resident 3 drink water, and an LPN moved the call light into Resident 3's lap after being asked where it should be placed. The DON stated staff should ensure the resident's call light and water were within reach before leaving the room and said she would add that instruction to the care plan.
Failure to Prevent New Pressure Ulcers
Penalty
Summary
Provide appropriate pressure ulcer care and prevent new ulcers from developing was not met for one resident who was severely cognitively impaired, had communication deficits, and was at risk for pressure ulcers. The resident was admitted with two Stage 2 pressure ulcers that were documented as healed shortly after admission, and the quarterly MDS later documented no pressure ulcers at the time of assessment. The skin integrity care plan noted use of an air overlay mattress, and wound documentation showed a Stage 2 pressure ulcer on the left ischium that was dry, intact, flaky, and appearing to heal, followed by a healed Stage 2 pressure ulcer on the right ischium. Later in the stay, the resident developed two new Stage 1 pressure ulcers on the central coccyx and left coccyx, with barrier cream and an air mattress documented in the treatment plan. Within three days, progress notes documented that both areas had opened and were now two new Stage 2 pressure ulcers. The wound observation tools documented the central coccyx wound measuring 2 cm by 1 cm and the left coccyx wound measuring .5 cm by .3 cm by .1 cm. A nutrition note later documented the resident was receiving house nourishments three times daily for weight gain and skin healing of the coccyx, and the DON stated the resident had admitted with two Stage 2 pressure ulcers that healed shortly after arrival and later developed two Stage 1 pressure ulcers that progressed to two Stage 2 pressure ulcers.
Failure to Reassess Nutritional Interventions for Resident With Significant Weight Loss
Penalty
Summary
The facility failed to reassess and update nutritional interventions for a resident who experienced significant weight loss. Resident 6 was admitted on a regular diet with thin liquids and finger foods when available. The record showed the resident was severely cognitively impaired, had communication deficits, and by the quarterly MDS was documented with a 5% weight loss and not on a prescribed weight loss regimen. Over the following months, the resident’s weight declined from 108 lbs to 90.8 lbs, a 15.93% loss in about five months. The record showed the resident continued to receive nutritional supplements, but the orders changed only in product name and volume range and remained essentially the same support throughout the period. The EHR did not document a change in diet type to nutritionally enhanced meals, fortified foods, or calorie-dense meals, and no food preference evaluations had been completed. Meal documentation showed the resident usually ate only 0-25% of meals, while snacks were limited and were often consumed when offered. Mini Nutritional Assessments documented worsening intake and weight loss, including one assessment identifying malnutrition, but no follow-up or recommendations were documented. The care plan, revised by the DON, identified the resident as at risk for unavoidable fluctuations/loss related to continued decline in health status and included interventions such as dining hall encouragement, supervision, oral care, and diet as ordered. However, it did not document food preferences or alternate interventions for weight gain. Staff interviews confirmed the resident liked sweets, chips, ice cream, soup in a mug, sandwiches, and cookies, but these preferences were not documented in the EHR. Staff also confirmed the resident’s supplements had not been increased beyond the same general range since admission and could not identify additional nutritional interventions that had been implemented for the resident’s continued weight loss.
Failure to Assess and Document Potential Physical Restraints
Penalty
Summary
The facility failed to ensure that potential physical restraints, specifically beds positioned against the wall and the use of mobility bars, were properly assessed, care planned, and documented for three residents. For one resident who was cognitively intact and dependent on staff for toileting and dressing, the bed was observed against the wall without a physical restraint evaluation or care plan in place. Staff confirmed that there was no assessment or care plan for this setup, and acknowledged that these should have been completed. Another resident with a right femur fracture and moderate cognitive impairment was observed with both their bed against the wall and a mobility bar attached, but there was no documentation of a restraint evaluation for either device. Staff interviews confirmed that assessments and orders were missing for these arrangements. A third resident, who had dementia, depression, anxiety, and muscle weakness, also had their bed against the wall without a completed restraint assessment or care plan. Staff interviews consistently indicated that restraint assessments and consents were expected but not completed for these residents.
Failure to Provide and Document Non-Pharmacological Interventions and Adhere to Medication Parameters
Penalty
Summary
The facility failed to ensure that residents' drug regimens were free from unnecessary medications by not providing or documenting non-pharmacological interventions prior to administering pain medications, not following medication parameters, and not reassessing the necessity of medications when abnormal vital signs were present. For one resident who was cognitively intact and receiving opioid medication for pain, physician orders required non-pharmacological interventions such as repositioning and diversional activities before medication administration. However, medication and treatment records showed no documentation that these interventions were offered or completed, and staff confirmed that this documentation was missing. Another cognitively intact resident with congestive heart failure had orders for Oxycodone with specific pain level parameters and required non-pharmacological interventions before administration. The medication administration record showed that higher doses were given for pain levels below the ordered threshold, and there was no documentation that non-pharmacological interventions were attempted prior to medication administration. Additionally, this resident was on multiple antihypertensive medications and diuretics, but there were no parameters in place for holding these medications despite documented low blood pressure readings. A third resident, who was moderately cognitively impaired, had orders for hydromorphone for severe pain with instructions to attempt non-pharmacological interventions first. The medication was administered for pain scores below the ordered threshold, and there was no documentation of non-pharmacological interventions. This resident also received a diuretic despite low blood pressure readings, without provider notification or reassessment. Staff interviews confirmed that expectations for documentation and adherence to medication parameters were not met in these cases.
Failure to Refer Residents with Serious Mental Illness for Level 2 PASRR Evaluation
Penalty
Summary
The facility failed to obtain updated Pre-Admission Screening and Resident Review (PASRR) assessments for two residents who had diagnoses of significant mental illness. One resident was admitted with Alzheimer's disease, anxiety, depression, and bipolar disorder, and their Level 1 PASRR indicated serious mental illness, but no referral for a Level 2 PASRR was made. Another resident was admitted with major depressive disorder, and their Level 1 PASRR also indicated a serious mental illness, yet no Level 2 PASRR referral was placed. These findings were confirmed through interviews and record reviews, where the Social Services Director acknowledged that referrals for Level 2 PASRR evaluations should have been made according to updated regulatory guidance. The deficiency was identified through review of resident records and staff interviews, which showed that the required coordination with the PASRR program and appropriate referrals for further mental health assessment were not completed for residents with identified serious mental illness.
Failure to Individualize and Update Resident Care Plans
Penalty
Summary
The facility failed to develop and implement comprehensive, individualized care plans for several residents, as evidenced by direct observations, staff interviews, and record reviews. For one resident with rectal cancer and chronic diarrhea, the care plan did not address the chronic diarrhea or the resident's refusals of prescribed medications for this condition. Additionally, the same resident required assistance with oral hygiene due to being bedbound and visually impaired, but there was no care plan in place for oral hygiene needs. Another resident, who was cognitively intact, had their bed positioned against the wall, but this intervention was not included in their care plan. Similarly, a resident with chronic heart failure who was receiving a diuretic and had documented edema did not have care plan interventions addressing diuretic use or edema management. A further resident, also cognitively intact and missing natural teeth, did not have this dental issue addressed in their care plan, despite expressing a desire to see a dentist. Additionally, a resident with dementia, depression, anxiety, and muscle weakness had a physician's order for their bed to be placed against the wall to increase environmental space, but this was not reflected in their care plan. Staff interviews confirmed that these omissions were not in line with facility expectations and that the care plans should have included these resident-specific interventions.
Failure to Meet Professional Standards in Weight Monitoring, Medication Documentation, Hospice Recommendations, and Change of Status Monitoring
Penalty
Summary
The facility failed to ensure that services provided met professional standards of practice in several areas. For one resident with congestive heart failure, there was a physician order for daily weights to monitor for fluid retention, with instructions to report significant weight changes to the provider. However, the resident's weight record showed that weights were only recorded on two occasions over a two-week period, with multiple days missing. Staff acknowledged that weights were not consistently obtained and that there was no documentation of provider notification when weights could not be taken, as required by the order. Additionally, the same resident had an order for Trazodone with instructions to monitor and document side effects every shift. Staff documented positive side effects on several dates but failed to write corresponding progress notes as required. The Resident Care Manager confirmed that positive side effects were likely documented in error and that there was no supporting documentation in the progress notes for those dates. For another resident receiving hospice care for oral cancer, hospice recommended the application of A&D ointment to oral lesions to prevent drying and cracking. This recommendation was not transcribed into the provider orders, and there was no documentation or order for wound care to the cancer lesions. Staff interviews confirmed that only pain management and oral care were being provided, and the Director of Nursing acknowledged that the hospice recommendations were not reviewed, reported, or transcribed as expected. In a separate case, a resident readmitted after hospitalization for a gastrointestinal bleed and pneumonia was not placed on alert charting as required after a change in status, and staff confirmed that this monitoring should have occurred.
Failure to Provide Oral Care Assistance to Dependent Residents
Penalty
Summary
The facility failed to provide necessary oral care assistance to two dependent residents, resulting in poor oral hygiene. One resident, who required supervision or assistance for oral hygiene and was visually impaired and unable to get out of bed, reported not having brushed their teeth in two months and only being offered help once. Observations confirmed yellow teeth with a whitish substance near the gums, and staff interviews revealed that oral care was not included in the resident's care plan, Kardex, or orders. Staff acknowledged that oral care should have been provided and documented, but it was not, and supplies were not made accessible to the resident. Another resident, dependent on staff for set up or clean-up assistance for oral hygiene and unable to get out of bed, did not have oral care supplies in their room and had not been observed performing oral care recently. Staff interviews indicated that oral care was not happening daily and there was no designated place for staff to document oral care. The care plan identified dental care as a concern and required staff to provide set up assistance after meals, but this was not consistently implemented, and supplies were not readily available.
Medication Storage and Labeling Deficiencies Identified
Penalty
Summary
Surveyors observed multiple deficiencies related to the storage and labeling of medications. On B Hall, a medication cart was found to contain an open insulin pen that was not dated, and the registered nurse present admitted to opening it that morning and forgetting to date it. The resident care manager confirmed that all insulin should be dated upon opening. Additionally, the medication room's refrigerator temperature log for March was missing documentation for 11 out of 62 required checks, despite the refrigerator being used to store medications and emergency supplies. The resident care manager stated that temperatures should be monitored and logged twice daily by nursing staff. Further observations revealed a cup with food items, partially covered with a paper towel, left on top of the B Hall medication cart, with crumbs present and several nurses nearby who did not intervene. The director of nursing services acknowledged that refrigerator temperatures should have been documented at assigned times and that food should not have been left on the medication cart, confirming these practices did not meet facility expectations.
Failure to Maintain Dishwasher Temperatures and Adhere to PPE Protocols in Food Service
Penalty
Summary
The facility failed to ensure that food service staff adhered to required personal protective equipment (PPE) protocols and that the dishwasher operated within the necessary temperature ranges for proper sanitization. Specifically, the Dietary Manager was observed multiple times in the kitchen without a hair restraint, despite facility policy requiring dietary staff to wear hairnets, hats, or beard restraints to prevent hair from contacting food. The Dietary Manager acknowledged the expectation for hair to be covered in the kitchen and confirmed the observations of non-compliance. Additionally, a review of dishwasher temperature logs for January, February, and March revealed repeated failures to meet the required wash and rinse cycle temperatures for effective sanitization. The logs showed numerous instances where both the wash cycle (required minimum 150°F) and rinse cycle (required minimum 180°F) temperatures were not achieved across all meal periods. During an observed test run, the dishwasher again failed to reach the necessary temperatures. The Dietary Manager confirmed awareness of the ongoing temperature issues and acknowledged that the dishwasher often required multiple cycles to reach the correct temperature.
Infection Control Failures in Oxygen Equipment, Hand Hygiene, PPE, and Laundry Handling
Penalty
Summary
The facility failed to properly store and handle oxygen equipment for a resident receiving oxygen therapy. During an observation, a staff member removed the resident's nasal cannula and placed it on the floor, then later picked it up and stored it on the oxygen concentrator without cleaning the equipment or the machine. Facility leadership confirmed that oxygen tubing should be stored in a clean bag and the concentrator should be wiped down before replacing equipment, and acknowledged that the observed actions did not follow protocol. Staff failed to perform hand hygiene during dining services, as observed with an activity assistant who repeatedly touched her eyeglasses, handled linens, food trays, and other items without performing hand hygiene between tasks. The dietary manager and infection preventionist both confirmed that hand hygiene should be performed after touching oneself or personal items and before serving food, and that the observed practices did not meet expectations or policy. The facility also did not ensure proper use of personal protective equipment (PPE) for residents on enhanced barrier precautions (EBP). A certified nursing assistant provided catheter care to a resident on EBP without wearing a gown and did not perform hand hygiene with every glove change. Additionally, laundry services were observed to have an open linen cart in the hallway with dirty hangers placed on top, and staff did not perform hand hygiene between handling dirty and clean items. Facility leadership confirmed that clean and dirty items should not be stored together and that the linen cart should remain closed except when in use in a resident room.
Failure to Verify Nurse Aide Registry for CNA
Penalty
Summary
The facility failed to ensure that nursing assistants were properly screened through the nurse aide registry before providing care to residents. This deficiency was identified for one of the two staff members reviewed for qualifications, specifically Staff B. Staff B was hired as a Certified Nursing Assistant on July 30, 2024, but their employee record lacked documentation from the nurse aide registry. On August 12, 2024, the facility's Administrator, Staff A, confirmed that Staff B was actively working as a nursing assistant without verification from the nurse aide registry. Staff A mentioned that they had sent another email to the registry requesting verification, but it had not yet been received. This oversight placed residents at risk for abuse and unmet care needs.
Latest citations in Washington
Inaccurate PASARR screening affected two residents. One resident with vascular dementia, depression, and adjustment disorder had a PASARR level one that did not reflect mental health diagnoses, and staff stated it was inaccurate. Another resident with PTSD had a PASARR level one that did not include the PTSD diagnosis, with no additional PASARR level one or level two found in the EHR; staff stated the screening was not accurate and should have been repeated.
Undated open meds were found on 2 medication carts, including an open insulin vial and multiple open eye drop bottles with no dates. An LPN and an RN both stated the items should have been dated when opened, and the DON stated open multidose vials or bottles found without a date should be discarded immediately.
A resident with respiratory failure, HTN, and anxiety became SOB and diaphoretic, received a breathing tx, and was sent by EMS to the hospital. The facility could not locate the required SNF/NF to Hospital Transfer form or other transfer records showing what information was communicated to the receiving provider.
Care plans for two residents were not updated to match their current status and care needs. One resident had PTSD and generalized anxiety disorder and was receiving a psychotropic medication, but the care plan listed monitoring for antipsychotic and anticonvulsant meds that were not prescribed and did not include the anxiety diagnosis or related behaviors and interventions. Another resident had new upper and lower dentures, but the oral/dental care plan only noted edentulous status and difficulty chewing, with no mention of dentures or denture-related interventions.
Failure to Provide Individualized Activities: A resident with anxiety, depression, and weakness was cognitively intact but said they could not attend group activities because of leg problems and wanted more in-room activities. The resident mostly stayed in bed watching TV, and staff documentation showed only limited room visits with no consistent activity documentation despite a care plan goal for participation two to three times per week.
Failure to maintain heel offloading for a resident with a reopened DFU. A resident with dementia and dependence for mobility had a left heel wound that had healed and then reopened; the wound care provider recommended heel floating and pressure relieving boots at all times, but observations showed the resident in bed with heels on the mattress and later reclined in a wheelchair with the heel resting on the footrest strap and no boots in place. Staff stated the resident had not refused the boots or heel floating, and the care plan was not updated after the wound reopened.
Failure to Address Hearing and Vision Services for a Resident: A resident with dementia, bilateral hearing loss, and impaired vision was observed without eyeglasses or a hearing device, despite records showing admission with eyeglasses and a personal sound amplifier. The care plan addressed vision only and did not include hearing-related interventions, while staff interviews confirmed the resident’s hearing was strained and that the resident’s device use and vision needs were not fully reflected in the plan of care.
Respiratory care was not provided consistently for two residents receiving O2. One resident with COPD and chronic respiratory failure had an O2 order missing the indication for use and Sats parameters, no MAR documentation of O2 therapy, and inconsistent Sats charting. Another resident with respiratory failure was observed on continuous O2 via NC, but provider orders for O2 therapy and tubing changes were not present after readmission, despite the care plan stating the resident was dependent on O2.
A resident with dementia, hearing loss, and missing lower teeth had an MDS showing obvious or likely cavities or broken natural teeth, and the care plan identified oral/dental health problems with an intervention to coordinate dental care and transportation. Staff stated the resident’s dental needs were captured on the MDS, but no referral was made for dental services or follow-up with the dentist, and the DON said the lack of referral did not meet expectations.
Inaccurate Meal Intake Documentation: A resident with DM, dysphagia, and protein-calorie malnutrition was observed eating less than 25% of a meal, but the POC documented 76-100% intake. The CNA said the resident usually ate only 25-50% of meals and that intake was sometimes documented based on what a coworker reported. The LPN/RCM and DON stated meal intake should be documented accurately.
Inaccurate PASARR Screening for Two Residents
Penalty
Summary
The facility failed to ensure that two residents were screened for additional mental health supports through the PASARR process. Resident 97 was admitted with diagnoses including vascular dementia, depression, and adjustment disorder, and was able to make needs known. Review of the PASARR level one dated 04/10/2026 showed no mental health diagnoses and no need for a PASARR level two, even though the resident’s record included mental health diagnoses. During interview, the Regional Social Services staff and the Administrator stated the PASARR was inaccurate, needed modifications, and did not meet expectations. Resident 6 was admitted with diagnoses including heart failure, respiratory failure, and PTSD, and was able to make needs known. Review of the PASARR level one dated 03/30/2026 showed no serious mental illness indicators marked and no PASARR level two indicated, and the EHR contained no other documented PASARR level one or level two. The Social Services Director stated the hospital-provided PASARR was reviewed for accuracy and, if inaccurate, another level one would be completed, and stated this resident’s PASARR did not include PTSD and should have had another level one completed. The Administrator also stated the PASARR was not accurate and another level one needed to be conducted, but none could be located in the EHR.
Undated Open Medications on Medication Carts
Penalty
Summary
The facility failed to ensure proper storage and labeling of medications for 2 of 3 sampled medication carts reviewed for medication storage and labeling, including carts on the 400 and 500 halls. On the 500 hall medication cart, an open vial of insulin and an open bottle of eye drops were observed with no dates. During interview, an LPN stated that when an insulin vial or bottle of eye drops is opened, it should be dated immediately and said both items should have been dated upon opening; the LPN stated they would dispose of the undated vial and bottle. On the 400 hall medication cart, two open bottles of eye drops were observed with no dates. During interview, an RN stated both bottles should have been dated as soon as they were opened and said they would get new eye drops and dispose of the undated bottles. The DNS/RN stated that if an eye drop was opened it should have been dated immediately and that any open multidose vial or bottle found without a date should be discarded immediately.
Missing Hospital Transfer Documentation
Penalty
Summary
The facility failed to ensure hospital transfer documentation was completed for one resident who was transferred to the hospital after complaining of not being able to breathe and appearing diaphoretic. The resident had diagnoses of respiratory failure, high blood pressure, and anxiety disorder, and was able to make needs known. A breathing treatment was provided, and the provider agreed to send the resident out for further evaluation, after which emergency transportation took the resident to the hospital. Record review found no documentation showing what information was provided or communicated to the receiving facility for the transfer. Staff stated that transfer documentation should have included a SNF/NF to Hospital Transfer form, the resident's face sheet, and the medication and treatment administration records, but they were unable to locate documentation showing these items were completed or sent for the resident's hospital transfer.
Care plans did not reflect current diagnoses, medications, or denture status
Penalty
Summary
The facility failed to ensure that care plans were revised and accurately reflected residents’ current status and care needs for 2 of 21 sampled residents. Resident 6 was admitted with diagnoses including heart failure, respiratory failure, and PTSD, and was able to make needs known. The EHR showed Resident 6 also had generalized anxiety disorder and was receiving a psychotropic medication, but the current care plan dated 05/05/2026 documented monitoring for side effects of antipsychotic and anticonvulsant medications even though Resident 6 was not prescribed those medications. The care plan also identified PTSD but did not include generalized anxiety disorder or behaviors to monitor and interventions related to PTSD or anxiety disorder. Staff F, LPN/CC, stated the care plan did not accurately reflect the resident’s current status or prescribed medications, and Staff B, DNS, stated it did not meet expectations because it did not address the anxiety disorder or target behaviors and interventions. Resident 71 was admitted with diagnoses including PTSD, high blood pressure, and depression and was able to make needs known. Observation on 05/06/2026 showed a denture cup by the sink with the resident’s name on the lid and new upper and lower dentures dated 01/12/26. The resident stated the lower dentures did not fit well and that denture adhesive had been provided, but the dentures still did not fit right and the resident had not told staff yet. The focused oral/dental care plan, initiated on 06/23/2026, identified the resident as edentulous and having difficulty chewing, but did not show that the resident had dentures or include interventions related to denture use or maintenance. Staff E, CNA, stated they had not seen the resident wear dentures and were unaware of the new dentures, Staff C, LPN/CC, stated the care plan should have been updated when the dentures were obtained, and Staff B, DNS, stated the care plan should have reflected the dentures and interventions.
Failure to Provide Individualized Activities
Penalty
Summary
The facility failed to provide individualized activities for Resident 5, who was admitted with diagnoses including anxiety disorder, depression, and weakness. The admission MDS dated 01/14/2026 showed the resident was cognitively intact. During interviews on 05/03/2026 and 05/06/2026, Resident 5 stated they could not attend in-person activities because of their legs, wanted more activities to occupy them, mostly stayed in bed watching TV, and did not remember the last time activities staff visited to offer activities. The resident also stated activities staff would need to offer something they were able to do because they had difficulty doing some activities. The activities care plan dated 12/26/2026 showed a goal for Resident 5 to participate in activities two to three times per week. Progress notes documented one visit on 12/22/2026 to provide a welcome packet and encourage participation in daily activities, but no further activity documentation was found in the progress notes. Staff H stated room visits should include puzzles, arts and crafts, visiting, and chatting, and that documentation was placed in tasks, but the task record showed no documentation of activities for the past 30 days. Staff J stated paper documentation existed for room visits and that Resident 5 was on a list for room visits every Monday and Wednesday, while the room visit documentation showed only four visits on 01/26/2026, 02/06/2026, 03/10/2026, and 04/08/2026.
Failure to Maintain Heel Offloading for Reopened DFU
Penalty
Summary
The facility failed to consistently implement pressure reducing strategies for a resident with a left heel diabetic foot ulcer that had reopened. The resident was admitted with diagnoses including left hip fracture with surgical repair, a blood clot of the left lower leg, and dementia, and was dependent on staff for mobility and unable to make needs known. The baseline care plan and care plan both included heel offloading interventions, and the wound care provider initially recommended heel floating with pillows or wedge and pressure relieving boots. The wound later resolved, but a weekly skin assessment documented that the left heel wound reopened and was very painful to touch. After the wound reopened, the contracted wound care provider documented that the DFU to the left heel had reopened and recommended the resident wear pressure relieving boots at all times. The current care plan reviewed after the wound reopened did not include new interventions related to the reopened wound. Observations showed the resident seated in a reclined wheelchair with the left foot/heel resting on the footrest strap and no pressure relieving boots in place, and later lying in bed with both heels directly on the mattress without being floated and without boots. Staff interviews indicated the resident had not refused the boots or heel floating, and the LPN/CC and DON stated the resident should have been assessed and the plan of care updated when the wound reopened.
Failure to Address Resident Hearing and Vision Needs
Penalty
Summary
The facility failed to address one resident’s hearing and vision needs. Resident 112 was admitted with diagnoses including a leg fracture, dementia, and hearing loss in both ears, and was able to make needs known. The record showed the resident lost their glasses and was given readers, but the resident did not wear them because they were concerned that wearing glasses that were not their prescription would further degrade their vision. Observation did not show glasses in the resident’s room, and the resident stated they did not use a hearing aid. The resident was observed to be hard of hearing, requiring an elevated voice and repeated questions to understand. The admission MDS dated [DATE] documented adequate hearing with hearing aid and adequate vision with corrective lenses, while the significant change MDS dated [DATE] documented moderate difficulty hearing without a hearing aid and impaired vision without corrective lenses. The care plan initiated 02/24/2026 addressed impaired vision with interventions to arrange consultation with eye care practitioners as needed and remind the resident to wear glasses, but it did not include a focus area or interventions for hearing loss or use of hearing aids. A resident clothing list showed the resident admitted with one pair of eyeglasses and one Super Ear headset personal sound amplifier, yet observation and interview showed the resident in bed without eyeglasses or a hearing device, with the amplifier stored in the bedside table drawer. Staff interviews confirmed the resident’s hearing was strained, that the hearing device and glasses were not being used, and that the resident’s hearing device use should have been included in the plan of care and the resident should have been referred for eye care assessment.
Respiratory Care Orders and Documentation Not Maintained
Penalty
Summary
The facility failed to provide respiratory care consistent with professional standards of practice for two residents receiving oxygen therapy. One resident with COPD and chronic respiratory failure with hypoxia was observed multiple times lying in bed receiving oxygen at 2 L via nasal cannula. The resident’s oxygen order, dated 02/15/2026, allowed 1 to 4 L per minute continuously via nasal cannula, but it did not include an indication for use or oxygen saturation parameters. The April and May 2026 MARs did not show documentation of oxygen therapy being provided, and the TARs showed only an order to change oxygen tubing if damaged or visibly soiled, not an order for oxygen therapy. Oxygen saturations were not documented consistently daily from 04/01/2026 through 05/04/2026. A second resident with respiratory failure, high blood pressure, and anxiety disorder was observed in the room receiving oxygen at 6 L via nasal cannula on multiple occasions. The resident stated they needed oxygen therapy to breathe, and the care plan identified the resident as dependent on oxygen and to receive oxygen per provider orders. However, provider orders reviewed on 05/04/2026 showed no orders for oxygen therapy or for changing oxygen tubing. Staff stated the oxygen and tubing-change orders had been discontinued when the resident went to the hospital and were not added back to the MAR or TAR when the resident readmitted to the facility.
Failure to Refer Resident With Identified Dental Needs
Penalty
Summary
The facility failed to ensure that Resident 112 received needed dental care. Resident 112 was admitted with diagnoses including a leg fracture, dementia, and hearing loss in both ears. Observation on 05/03/2026 showed the resident had missing lower teeth. The admission MDS, dated [DATE], documented obvious or likely cavities or broken natural teeth, and the care plan dated 02/24/2026 identified oral/dental health problems related to likely cavities or broken teeth with an intervention to coordinate dental care and provide transportation. During interviews, Staff G, Regional Social Services, stated Resident 112's dental needs were captured on the 02/24/2026 MDS and the resident was not referred for dental services. Staff M, Social Services Director, stated residents with dental needs should be referred to social services to be scheduled for assessment by a dental care practitioner, and that Resident 112 should have been referred after the MDS assessment. Staff B, DON, stated residents with identified dental needs should be referred for follow-up with a dentist and that Resident 112 should have been referred to the in-house dental provider; Staff B stated the lack of referral did not meet expectations.
Inaccurate Meal Intake Documentation
Penalty
Summary
The facility failed to accurately document the amount of food eaten for Resident 13, who was admitted with diagnoses including diabetes mellitus, dysphagia, and protein-calorie malnutrition. The quarterly MDS dated 02/12/2026 showed the resident was moderately cognitively impaired. During observation on 05/05/2026 at 12:09 PM, a meal tray was delivered to the resident’s room, set up on a bedside table, and the resident was observed eating slowly, eating less than 25% of the meal, then laying back in bed and closing their eyes while the tray remained in the room. Staff later removed the tray, but the POC documentation for lunch on 05/05/2026 recorded that Resident 13 ate 76-100% of the meal. During interview, the CNA stated the resident typically ate 25-50% of meals and never ate all of the food, and that if they did not pick up a tray they would ask a coworker what the resident ate before documenting it. The CNA stated they were told the resident ate 75-100% of lunch, so that is what was entered. The LPN/RCM stated staff should document meal intake accurately in POC, and the RN/DNS stated it was their expectation that all staff document meal intake accurately.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release June 24, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
