Life Care Center Of Skagit Valley
Inspection history, citations, penalties and survey trends for this long-term care facility in Sedro Woolley, Washington.
- Location
- 1462 West State Route 20, Sedro Woolley, Washington 98284
- CMS Provider Number
- 505318
- Inspections on file
- 33
- Latest survey
- February 23, 2026
- Citations (last 12 mo.)
- 5
Citation history
Health deficiencies cited at Life Care Center Of Skagit Valley during CMS and state inspections, most recent first.
A resident with impaired mobility and multiple comorbidities was admitted with blanchable redness to the buttocks and was identified as at risk for PU development, but the care plan contained only minimal interventions such as weekly skin checks and incontinence care, without individualized measures for the existing redness or documented education on repositioning or support surfaces. Despite facility policies requiring pressure redistribution mattresses, wheelchair cushions, and regular repositioning for at‑risk residents, there were no orders for a pressure‑reducing mattress or wheelchair cushion even after an outside wound care provider diagnosed an unstageable sacral PU and recommended such support surfaces. Wound care orders for cleansing, Santyl application, and foam dressings every three days were not reliably implemented, as evidenced by a dressing observed eight days after its date with moderate drainage, conflicting TAR entries, and an RN who could not recall performing the documented dressing changes or explain the outdated dressing. CNAs reported inconsistent repositioning practices and no specific documentation of repositioning, and a family member learned of the PU only after the resident complained of sacral pain, while staff interviews showed limited awareness of the PU and lack of a system to document positioning, resulting in an avoidable unstageable PU that caused pain and discomfort.
The facility did not ensure that window locks and screens were properly maintained in multiple resident rooms. A family member reported that a resident’s room had a broken window lock and no screen, and that the facility used a screw and later a wooden dowel instead of repairing the locking mechanism, while still communicating that the window was secured. Surveyor observations confirmed one room with no screens, no functional lock on one window panel, and a dowel between windows; another room with intact locks and screens; and a third room with a missing lock knob on one window and a screen with a hole. The Maintenance Director acknowledged using a screw in place of a proper lock, confirmed the window could still be tilted to bypass it, and reported there were no documented maintenance requests, only verbal reports.
A resident with severe cognitive impairment and complex medical needs did not receive adequate social services or advocacy regarding advanced directives. Facility staff failed to document discussions about the resident's wishes, did not facilitate communication with the resident's contacts, and did not provide sufficient assistance in obtaining legal support for a POA, resulting in the resident's preferences not being properly addressed.
A resident's care plans were not updated to reflect their current urinary status and discharge goals, resulting in outdated interventions such as continued catheter care instructions after the catheter had been removed. Staff interviews and documentation confirmed the care plans did not accurately represent the resident's needs.
Two residents with wounds experienced significant gaps and inconsistencies in their clinical records, including missing or delayed weekly skin assessments and incomplete wound documentation. Staff interviews confirmed that required documentation was not consistently completed, leading to records that did not accurately reflect the residents' conditions or care provided.
Multiple areas, including shared bathrooms, a community shower room, and the main dining room, were found to be unclean, poorly maintained, and lacking a homelike atmosphere. Bathrooms had strong odors, broken and stained tiles, and poor lighting, while the shower room had missing tiles, an uneven floor, and was dirty and disorganized. The dining room lacked decor, music, and staff engagement, leaving residents sitting alone and unassisted during meals. Staff and residents confirmed these conditions, which did not meet the facility's policy for a clean and homelike environment.
Several residents who required staff assistance for ADLs, including showering, were observed with poor hygiene such as greasy hair, and records showed they did not consistently receive showers as scheduled. Staff interviews revealed that aides responsible for showers were often reassigned to other duties, leading to missed care, and that lack of documentation indicated showers were not provided. Residents had varying cognitive and physical needs, but all were dependent on staff for hygiene support.
Multiple residents reported dissatisfaction with meal quality, taste, and temperature, citing issues such as tough meats, lack of variety, and cold or unappetizing food. Observations confirmed that meals were served below recommended temperatures and were not visually appealing. Grievances about food quality and temperature were not fully addressed, and staff confirmed limitations in reheating and food preparation due to equipment and menu constraints.
Several residents with intact cognition and specific dietary needs were denied the ability to have outside food items, such as frozen meals and microwave popcorn, heated by staff after the facility changed its policy. The administration cited concerns about food safety, staff workload, and storage limitations, resulting in residents losing the ability to choose and enjoy their preferred meals and snacks. Staff confirmed the directive to stop heating food, and residents and families expressed dissatisfaction with the loss of choice.
The facility did not follow its policy for handling and storing food brought in by family and visitors, as staff were instructed not to heat up food items for residents and only limited storage was provided. The Administrator and DON confirmed these restrictions, which were not consistent with the facility's written procedures for safe food handling.
A resident with severe cognitive impairment was found with a bruise and abrasion on the forehead, but the facility's investigation was limited to a single LPN statement, basic notifications, and a skin check. No neurological assessment or witness interviews were conducted, and the DON acknowledged the investigation was incomplete.
A resident was discharged without the required MDS discharge assessment being completed or transmitted to CMS within the mandated timeframe. The omission was identified after the CMS system flagged the absence of any assessment for over 120 days, and the MDS Coordinator acknowledged the assessment was missed despite daily audit procedures.
A resident with hemiplegia and hemiparesis did not consistently receive prescribed splint and brace interventions to maintain range of motion, as staff only applied splints during restorative therapy sessions and not daily as ordered. Staff interviews revealed confusion about responsibility for splint application when restorative aides were unavailable, and documentation showed minimal evidence of splint use or monitoring.
A resident with malnutrition and dysphagia, who had documented allergies and food dislikes, was served meals containing gluten, mayonnaise, and tomato products despite these being listed as allergies or dislikes. Staff interviews confirmed that limited gluten-free options and lack of alternatives led to the resident receiving inappropriate food items, contrary to facility policy.
Surveyors observed that expired food items were not removed from a nourishment refrigerator, and a cook failed to follow proper hand hygiene and glove use during meal preparation, including handling clean plates and food with bare hands. These lapses in food safety and sanitation were acknowledged by staff and management.
Staff did not follow infection control protocols for three residents requiring different levels of precautions. One resident with a Foley catheter did not receive proper Enhanced Barrier Precautions, as a nursing assistant failed to wear a gown during catheter care. Another resident receiving pericare was assisted by a nursing assistant who did not change gloves between tasks, leading to potential cross-contamination. Additionally, a resident under investigation for C. Diff was not placed on the correct Contact Enteric precautions due to incorrect signage, resulting in staff not using the required PPE or hand hygiene methods.
The facility administration failed to manage resources effectively, leading to deficiencies in care planning, resident environment, and staffing. A resident with chronic pain experienced severe discomfort due to delayed medication administration. Staff interviews revealed issues with medication pass timing and lack of a restorative program. Additionally, the facility struggled with infection control and tuberculosis testing.
The facility did not initiate a grievance process for concerns raised by the Resident Council about call light wait times. Despite residents voicing these issues, the facility failed to log or investigate the grievances, preventing trend identification and resolution. Staff directed residents to submit forms but did not assist, and the administrator noted challenges in addressing grievances without resident participation.
The facility failed to develop comprehensive care plans for several residents, including those with amputations, smoking cessation needs, and nephrostomy care. Observations showed residents without access to call lights and unaddressed pain issues. Staff interviews revealed a lack of awareness and time constraints affecting care plan completion.
The facility failed to update care plans for several residents, leading to discrepancies in care. A resident's care plan was not updated after transitioning to restorative services, another's did not reflect hospice care, and a third's did not address smoking risks. Additionally, a resident was observed using a straw despite care plan restrictions, with staff unaware of this precaution.
The facility failed to provide adequate assistance with ADLs for several residents, particularly in bathing and toileting. A resident with a fracture and chronic conditions was not assisted with toileting due to equipment limitations. Other residents, dependent on staff for bathing, did not receive showers as per their preferences due to staffing issues. Documentation and staff interviews revealed systemic issues in scheduling and providing showers, with the DON and Administrator unaware of the missed care.
The facility experienced significant staffing shortages, resulting in delayed assistance with activities of daily living and medication administration. Residents reported long wait times for help, particularly during nights and weekends. A resident with chronic pain did not receive timely pain medication, and another resident missed scheduled showers due to staff being reassigned to cover floor duties.
The facility failed to administer scheduled medications on time for several residents, resulting in significant delays. A resident with chronic pain reported severe pain due to not receiving their morning medications, while others received essential medications, such as antipsychotic and anticoagulant drugs, hours after the scheduled time. Staff interviews indicated that the medication pass took longer than expected.
The facility failed to maintain sanitary conditions in the kitchen, as staff were observed not wearing required hair and beard restraints. This non-compliance with the facility's policy placed residents at risk of food contamination.
The facility failed to ensure proper infection control practices, as observed with a NAC not performing hand hygiene during meal service and another NAC not changing gloves or washing hands after peri-care. Additionally, incorrect transmission-based precautions were in place for a resident with c. diff, with signage instructing the use of ABHR instead of soap and water. These lapses in protocol were not recognized by the Infection Preventionist or DON.
A facility failed to obtain and maintain Advance Directives for a resident with multiple health conditions, despite the care plan indicating a Power of Attorney (POA) for healthcare. The electronic medical record lacked POA documentation, confirmed by staff interviews. The Admissions Director did not obtain the POA documents at admission, and the Medical Records Director confirmed the absence of the document. An RN-Staff Development Coordinator also could not locate the document, although the resident's daughter had signed the POLST as the POA.
The facility failed to provide a homelike environment and maintain cleanliness for three residents and the conference room. A resident with severe cognitive impairment had a stark room lacking personal decor, while another resident reported unclean windows that had not been addressed despite requests. A third resident's window and TV screen were observed to be dusty and streaked. The conference room also had dirty windows and screens, indicating a broader issue with maintaining a clean environment.
A facility failed to conduct a Significant Change in Status Assessment (SCSA) for a resident who elected Hospice services, as required by the Resident Assessment Instrument (RAI) guidelines. The resident elected Hospice on a specific date, but no SCSA was completed within the required 14-day period. An LPN/MDS Nurse was unaware that the election of Hospice services alone required a SCSA.
A resident was discharged without a complete discharge summary, missing essential components such as a recapitulation of their stay and a final status summary. The facility's policy requires both social services and nursing staff to contribute to the discharge summary, but interviews revealed that the summary was incomplete, and staff were unclear about the resident's post-discharge needs.
The facility failed to provide adequate care for three residents with limited ROM and mobility issues. A resident with rheumatoid arthritis wore a sling without an order, and no follow-up on ROM assessment was conducted. Another resident, at risk for skin breakdown, was left in a wheelchair for hours without repositioning. A third resident with contractures did not consistently receive prescribed brace and splint applications, with documentation gaps and confusion over program oversight.
A resident with malnutrition and bipolar disorder experienced significant weight loss due to the facility's failure to implement nutritional interventions and monitor weight changes. Despite the care plan identifying a risk for weight loss, the facility did not consistently obtain weights or notify appropriate parties. Staff interviews revealed a lack of awareness and communication regarding the resident's weight loss and refusal to be weighed.
A resident with a PEG tube experienced a deficiency in enteral tube feeding management due to the facility's failure to label, date, and replace feeding supplies as required. Observations showed that feeding bags and syringes were not properly managed, and interviews with staff revealed a lack of physician orders and care plan directives for these tasks. This oversight placed the resident at risk for infection and complications.
The facility failed to provide appropriate respiratory care for two residents. One resident with COPD and other conditions was not using prescribed oxygen therapy and CPAP, as observed multiple times, with the concentrator set to zero liters. Another resident used oxygen without a documented physician's order, despite stating its use for sleep apnea. Staff interviews confirmed these deficiencies, highlighting a failure to adhere to professional standards of practice.
A resident with chronic pain syndrome did not receive their scheduled morning pain medications, including Gabapentin, Acetaminophen, and Suboxone, due to delays in the medication pass. The resident reported severe pain levels, and staff confirmed the delay in administering medications, leading to avoidable pain and diminished quality of life.
A resident with Parkinson's disease and moderate cognitive impairment was not provided with care planning meetings to address their care preferences, including bathing frequency and wheelchair comfort. The facility failed to conduct required quarterly care conferences, and staff were unaware of the resident's concerns due to the lack of meetings and documentation.
A facility failed to implement its Antibiotic Stewardship Program effectively, leading to continuous antibiotic administration for a resident without proper documentation or communication with the infectious disease provider. The resident, with a history of kidney stones and antibiotic-resistant infection, received antibiotics without a documented stop date. Staff interviews revealed a lack of awareness and follow-up, indicating a failure in the facility's ASP.
A resident with a history of recurrent UTIs was not adequately monitored or assessed, leading to a lack of a care plan addressing their condition. Despite showing symptoms of a UTI, such as dark amber urine and confusion, vital signs were not consistently documented, and the resident's representative or provider was not notified. The resident's condition escalated to a UTI with sepsis, resulting in hospitalization.
The facility failed to provide timely pharmaceutical services for three residents upon admission, resulting in missed medications. A resident with Bipolar Disorder and Seizure Disorder did not receive prescribed medications due to a lack of verification and notification processes. Another resident with a recent fall and cardiac issues did not receive several medications, including pain ointment, due to pending delivery. A third resident with encephalopathy and psoriasis also missed medications that were on order. There was no documentation of provider notification for any of these cases.
The facility failed to ensure proper nail care for three residents, leading to discomfort and potential injury. One resident with contractures experienced significant pain due to long nails digging into their palms, while two other residents had long, dirty, and jagged nails despite expressing a preference for having them cut. Staff interviews revealed inconsistencies in understanding and executing nail care responsibilities.
Failure to Prevent and Properly Treat an Avoidable Unstageable Pressure Ulcer
Penalty
Summary
The deficiency involves the facility’s failure to implement adequate pressure ulcer (PU) prevention measures and to provide ordered wound treatment for a resident at risk for skin breakdown. The resident was admitted with diagnoses including history of falls, muscle weakness, osteoarthritis, and scoliosis, and the hospital discharge summary documented impaired mobility and recent falls but no skin issues. On admission, the facility’s nursing assessment noted blanchable redness to the buttocks, and the admission MDS and CAA identified the resident as at risk for PU development due to limited ability to participate in incontinence care and physical dependence on staff for position changes and offloading. The care plan documented risk for skin integrity breakdown with a goal to maintain intact skin, but interventions were limited to keeping skin clean and dry after incontinence and weekly skin checks, with no individualized interventions addressing the existing buttock redness or the resident’s identified PU risk. Over the ensuing months, Braden Scale scores consistently indicated mild risk for PU development, yet the record from admission through early January contained no documentation of education to the resident or representative regarding repositioning, mattress type, wheelchair cushion use, or other PU prevention measures. Facility policy required, at minimum, a pressure redistribution mattress, wheelchair cushion, and repositioning for residents at risk, but the resident’s medical record from mid-January through mid-February showed no physician orders for a pressure-reducing mattress or wheelchair cushion, despite an outside wound care company’s recommendation for these support surfaces. When the resident’s sacral PU was later assessed by the outside wound company, it was documented as an unstageable PU on the bilateral sacrum, and the plan included specific wound care with Santyl and foam dressings, as well as pressure-reducing support surfaces. The facility’s implementation of ordered wound care was also deficient. A weekly skin integrity assessment on a January date documented a small opening at the top of the gluteal fold, and a provider note the same day described a small, deep, painful open area with surrounding blanchable redness. Subsequent wound care orders directed cleansing with normal saline, application of skin prep and Santyl, and coverage with foam dressing every evening shift every three days. However, when surveyors observed the resident in late February, the resident was on a standard, approximately three‑inch mattress, wearing an incontinent brief, and the sacral PU dressing was wrinkled, clumped, and dated eight days earlier, with moderate red/green/brown drainage. Although the TAR showed that an RN had documented completing dressing changes on two dates after the dressing date, the RN later stated they could not remember performing the dressing changes, reported difficulty finding supplies, and could not explain why the dressing remained dated from the earlier date. Nursing staff interviews revealed inconsistent knowledge of the PU, lack of specific documentation for repositioning, and no charting system to record monitoring of the resident’s positioning, while the ADON could not provide details on the type of mattress or wheelchair cushion used prior to PU development and stated the resident’s PU was considered unavoidable. The report states that this failure resulted in the resident developing an avoidable unstageable PU that caused pain and discomfort and placed residents at risk for skin breakdown, unmet care needs, and diminished quality of life. Additional observations and interviews further illustrated the gaps in PU prevention and care. During the wound observation, the sacral PU measured 1.0 cm by 1.5 cm with 0.3 cm depth, with light pink wound bed and visible slough, and no odor or signs of infection. A bruise was also noted on the resident’s thigh. A CNA familiar with the resident’s care reported assisting with toileting and pericare, stated they had no knowledge of any PU, and indicated they did not reposition the resident when sleeping but did assist with repositioning when the resident was awake. Another CNA stated they repositioned the resident with pillows and that the resident did not refuse repositioning, but confirmed there was no specific charting for repositioning. A family member reported learning of the sacral PU only after hearing the resident complain of sacral pain while being assisted in the bathroom, and staff then attributed the pain to the PU. Overall, the documented and observed inactions included lack of individualized preventive interventions despite identified risk, absence of ordered pressure‑reducing support surfaces, failure to consistently perform and/or document ordered dressing changes, and lack of systematic documentation of repositioning and monitoring, culminating in the development and inadequate treatment of an avoidable unstageable PU. The report explicitly states that the facility failed to implement measures to prevent development of an avoidable PU and failed to provide ordered treatment for the PU for this resident. It further states that the resident experienced harm when they developed an avoidable unstageable PU that caused pain and discomfort, and that this failure placed residents at risk for skin breakdown, unmet care needs, and diminished quality of life. The findings are referenced to WAC 388‑97‑1060(3)(b).
Failure to Maintain Functional Window Locks and Screens in Resident Rooms
Penalty
Summary
The facility failed to maintain safe, functional, and comfortable resident rooms by not repairing broken window locking devices and not ensuring the presence and integrity of window screens in 2 of 3 rooms reviewed. A family member of a resident reported that upon the resident’s move-in, the left window panel in the resident’s room had a broken locking mechanism and no window screen, leaving the window unsecured. The family member stated that instead of replacing the locking mechanism, the facility initially placed a screw in the window frame to limit how far the window could open, but the window could still be tilted to bypass the screw. The family member further reported that the facility later placed a wooden dowel between the sliding windows and had communicated via email that the window lock was secured, despite the ongoing concerns. During observations of three rooms, one room was found to have a screw in the left window frame, no window screens, no locking mechanism on the left side, and a wooden dowel between the windows. Another room had window screens and functional locking mechanisms on both sides. A third room had an intact and functional locking mechanism on the left window, but the right window’s locking mechanism was missing the knob used to operate it, leaving the window in a locked position; the screens were present, but one had a hole in the bottom left corner. The Maintenance Director reported learning of the missing locking mechanism only a few weeks prior and confirmed placing a screw in the frame where the lock would engage, acknowledging that the window could still be tilted to bypass the screw. The Maintenance Director also stated there were no written maintenance requests or documentation for these issues, only verbal communications with nursing staff and the Administrator.
Failure to Provide Social Services and Advocacy for Advanced Directives
Penalty
Summary
The facility failed to provide medically related social services and to advocate for a cognitively impaired resident regarding the development and documentation of advanced directives. The facility's policy required review and updating of advanced directives upon admission, quarterly, and with any change in condition, with the social services director or designee responsible for documenting conversations and assisting with revisions. Despite these requirements, there was a lack of documented conversations with the resident or their collateral contacts about advanced directives, wishes, or rights, and insufficient assistance was provided in obtaining appropriate legal support for the development of a power of attorney (POA). The resident in question had a history of developmental and intellectual disability, anxiety, depression, and significant urinary tract issues, with cognitive assessments indicating severe impairment at multiple points. The resident's mental status fluctuated, and during periods of decline, they became non-communicative and unable to make informed decisions. Despite these challenges, there was minimal documented engagement by social services with the resident or their contacts regarding the resident's wishes for care, advanced directives, or the POA process. Attempts by a family friend to coordinate POA paperwork and discuss advanced directives were not adequately supported or facilitated by facility staff, and care conferences did not consistently include relevant parties or discussions about the resident's preferences. Interviews with staff and collateral contacts revealed that the resident required significant support to make decisions and that there was confusion and lack of clarity regarding who was responsible for advocating for the resident's wishes. The facility did not ensure that the resident's rights and preferences were thoroughly explored, documented, or honored, as evidenced by the absence of care conference notes addressing advanced directives and the lack of communication with the resident's contacts. This failure to provide comprehensive social services and advocacy placed the resident at risk of not having their rights and wishes respected.
Failure to Update and Revise Care Plans to Reflect Resident's Current Needs
Penalty
Summary
The facility failed to ensure that care plans were reviewed, revised, and accurately reflected the current care needs of a resident. Specifically, a resident admitted with perineal and sacral wounds, urinary incontinence, and cognitive impairment had discrepancies in their care documentation. The Quarterly Minimum Data Set (MDS) assessment indicated the resident was continent of bowel and bladder and did not have an indwelling urinary catheter. However, the resident's care plan for an indwelling urinary catheter, last revised months after the catheter was removed, still directed staff to perform catheter care every shift. Nursing assistant documentation for the last 30 days showed the resident was incontinent of bladder with no mention of a catheter, and direct observation confirmed the absence of a catheter. Interviews with staff revealed that the care plan had not been updated to reflect the resident's current status. The MDS Coordinator acknowledged that the care plan should have been updated, and the Social Service Director confirmed that the discharge care plan did not reflect the resident's current discharge goal. These failures resulted in care plans that did not accurately represent the resident's needs or status, as evidenced by outdated interventions and goals.
Inaccurate and Incomplete Wound Documentation for Residents with Skin Integrity Issues
Penalty
Summary
The facility failed to ensure that clinical records were accurate and maintained according to accepted professional standards for two residents with wounds. For one resident, there were significant gaps and inconsistencies in the documentation of weekly skin assessments and wound observations. The resident was admitted with multiple pressure ulcers and moisture-associated skin damage, but the required weekly skin assessments were either missing, marked as refused without follow-up, or left blank for extended periods. Wound observation tools were not completed at the required frequency, with some assessments delayed by several weeks. Observations and interviews confirmed that the documentation did not consistently reflect the resident's actual wound status or the care provided. Another resident with multiple chronic conditions, including multiple sclerosis and malnutrition, also had inconsistent and unclear documentation regarding skin integrity. Weekly skin checks noted open areas on the coccyx, but there was a lack of detailed wound notes or measurements for an extended period. The care plan indicated the presence of a pressure ulcer and follow-up by a wound care clinic, but the medical record did not contain corresponding wound documentation during a critical month. Staff interviews revealed that a new nurse was responsible for some of the incomplete documentation and that there was confusion and inaccuracy in the records related to the resident's skin condition. The facility's own policies required weekly head-to-toe skin inspections and timely, detailed documentation of any wounds or skin alterations. However, the records reviewed showed multiple instances where these requirements were not met, including late entries, missing assessments, and lack of clear wound descriptions. These documentation failures resulted in clinical records that did not accurately reflect the residents' conditions or the care provided, as confirmed by staff interviews and record reviews.
Failure to Maintain Clean, Comfortable, and Homelike Environment in Resident Areas
Penalty
Summary
The facility failed to provide a clean, comfortable, and homelike environment in multiple areas, including two shared resident bathrooms, a community shower room, and the main dining room. Observations revealed that the shared bathrooms had strong, unpleasant odors, sticky floors, broken and stained tiles, poor lighting, and damaged walls. Staff and residents confirmed these conditions, noting persistent odors, moldy or stained areas, and a lack of cleanliness and comfort. The community shower room was found to have missing tiles, no grout, an uneven and sunken floor, dust and dirt accumulation, disorganized medical equipment, overflowing trash cans, and a strong musty odor suggestive of mold or mildew. Staff interviews corroborated these findings, describing the room as dirty, in need of cleaning, and not homelike. In the main dining room, observations during multiple meal services showed that residents often sat alone at bare tables with minimal decor, no music or television, and little to no engagement from staff. Residents were observed waiting for meals in silence, with some staring at the walls or at each other, and staff either absent or standing at a distance without interacting with residents. Staff interviews indicated that music or movies were previously provided but were no longer offered, and that the dining room atmosphere was described as "dead." Residents reported difficulty obtaining assistance in the dining room due to staff inattention. The facility's own policy requires staff to provide a clean, safe, and homelike environment, but observations and interviews demonstrated that these standards were not met in the identified areas. The lack of cleanliness, maintenance, and engagement in these common areas contributed to an environment that was not comfortable or homelike for residents, as confirmed by both staff and resident statements.
Failure to Provide Consistent ADL Assistance and Hygiene Care
Penalty
Summary
The facility failed to provide adequate assistance with activities of daily living (ADLs), specifically showering and personal hygiene, for four residents who required varying levels of staff support. Observations over several days revealed that these residents consistently had greasy hair, indicating a lack of proper hygiene care. Documentation in the electronic medical record showed that showers were not provided according to the residents' stated preferences, with some residents receiving fewer showers than scheduled and others having missed or refused showers without evidence of appropriate follow-up or re-approach by staff. Interviews with staff confirmed that shower aides were frequently reassigned to other duties, which contributed to missed showers, and that if care was not documented, it was likely not performed. The residents involved had different cognitive and physical abilities, ranging from cognitively intact but physically dependent to severely cognitively impaired and fully dependent on staff for showers. Despite facility policy requiring assistance with ADLs as needed, the lack of consistent showering and hygiene support was evident through both staff interviews and resident reports. One resident reported being denied a shower due to staff being busy, and another was found to have received only two showers in a 30-day period. The facility's documentation practices and staff allocation contributed to the failure to meet residents' ADL needs.
Failure to Provide Palatable and Properly Heated Meals
Penalty
Summary
The facility failed to provide meals that were palatable, attractive, and served at an appetizing temperature, as evidenced by multiple resident interviews, observations, and review of dietary grievances. Residents reported dissatisfaction with the quality, taste, and temperature of the food, noting issues such as tough meats, lack of variety, overuse of certain seasonings, and inability to access or use a microwave for reheating food. During a group meeting, all residents in attendance expressed that meals were often cold, unappetizing, and not visually appealing, with specific complaints about soggy or hard French fries, smashed buns, and excessive barbecue sauce. Observations of meal service confirmed that food items, such as burgers and fries, were served below recommended temperatures and were not palatable. Review of the facility's grievance log revealed that concerns about undercooked or cold food were not adequately addressed in the facility's responses, which focused on updating preferences or communication rather than resolving the underlying issues. Staff interviews confirmed that the kitchen does not reheat resident foods and that certain equipment, such as a toaster, was unavailable for a period. The Food Services Director acknowledged limitations in food preparation methods due to lack of equipment and noted that menus were determined by corporate, sometimes including items not suitable for the available kitchen setup. The Administrator was aware of some complaints but had not personally evaluated the food quality.
Failure to Honor Resident Food Preferences and Choices
Penalty
Summary
The facility failed to honor and facilitate resident preferences for food, specifically by not allowing residents to have food items from outside sources heated up, despite previous practices and resident requests. This change affected at least four residents, all of whom had intact cognition and specific dietary needs or preferences, such as altered taste due to stroke, diabetes, malnutrition, and personal snack choices. The facility's policy previously allowed for the safe heating of outside food using food thermometers and staff education, but this was discontinued. Residents and their families reported that the facility stopped heating up food items, including frozen meals and microwave popcorn, citing state regulations, staff workload, and concerns about food safety and potential burns. Residents expressed dissatisfaction, noting that the inability to heat up their preferred foods negatively impacted their meal enjoyment and choice. Staff interviews confirmed that management had directed them to stop heating food for residents, and staff expressed difficulty in denying these requests, acknowledging the impact on residents' quality of life. Administrative staff explained that the policy change was implemented due to an increase in outside food being brought in, lack of storage space, and concerns about staff capacity to safely heat food according to guidelines. The facility communicated this change to residents and families through a letter, stating that only small amounts of perishable food could be stored and that no food requiring heating would be accommodated. This resulted in residents losing the ability to choose their preferred meals and snacks, contrary to facility policy and resident rights.
Failure to Implement Policy for Outside Food Brought by Visitors
Penalty
Summary
The facility failed to implement its policy regarding the safe and sanitary storage, handling, and consumption of foods brought in by family and visitors for residents. The policy required that when food needed to be heated, staff should use a food thermometer and alcohol wipes to ensure proper heating, and that staff should be educated on required food temperatures and the use of thermometers. However, a letter from the Administrator to residents, staff, and family members stated that staff would no longer heat up food items for residents, including frozen foods, hot dogs, and microwave popcorn, and that only a small number of food items could be stored for residents due to limited space. In interviews, the Administrator and DON confirmed that residents were not allowed to have food heated up and cited concerns about staff being able to safely heat food and the burden it placed on staff. These actions were not in accordance with the facility's written policy.
Failure to Thoroughly Investigate Injury of Unknown Source
Penalty
Summary
The facility failed to conduct a thorough investigation of an injury of unknown source for one resident with severely impaired cognition, memory, and decision-making abilities. The resident was found with a bruise and small abrasion on the forehead by an LPN, who documented that the resident denied abuse or neglect but was unable to recall the incident. The investigation consisted only of a statement from the LPN, notification of the provider and the resident's son, a skin check, and monitoring of the bruise. No neurological assessment was performed despite the unwitnessed head injury, and there was no follow-up with the son regarding the time frame or circumstances of the injury. Additionally, the investigation did not include statements from potential witnesses, other staff, or residents who may have had relevant information. Interviews with facility staff revealed that the process for investigating such incidents was not fully followed, as no additional data gathering or witness statements were obtained. The Director of Nursing acknowledged that the investigation was incomplete and lacked thorough data collection as required by facility policy.
Failure to Complete and Transmit Discharge MDS Assessment
Penalty
Summary
The facility failed to ensure the timely completion and transmission of the required Minimum Data Set (MDS) discharge assessment for one resident. According to the report, a resident was admitted and later discharged, but review of the clinical record revealed that no discharge MDS assessment was completed or transmitted to CMS within the required 14-day period following discharge. The CMS system flagged the resident's file as lacking any type of assessment for over 120 days. During an interview, the MDS Coordinator stated that although daily audit reports and discussions occur during stand up meetings, this particular assessment was missed.
Failure to Provide and Document Splint Application for Resident with Limited ROM
Penalty
Summary
The facility failed to provide appropriate interventions to maintain or prevent decline in range of motion (ROM) for a resident with a history of stroke resulting in hemiplegia and hemiparesis. Physician orders specified that the resident was to wear a left wrist splint in the morning and remove it at bedtime, and a left ankle splint for six hours daily. Multiple observations over several days revealed that the resident was not wearing the prescribed splints, and the resident reported that splints were only applied during restorative therapy sessions, which occurred twice a week. The resident denied refusing the splints when offered. Interviews with nursing assistants, restorative aides, and nursing staff indicated confusion and lack of clarity regarding responsibility for applying the splints when restorative aides were reassigned to other duties. Documentation review showed that splint or brace assistance was recorded on only seven of the last thirty days, and there was no documentation of splint or brace application in the resident's Medication and Treatment Administration Records for several months. Facility leadership confirmed that nurses were supposed to apply the splints when restorative aides were unavailable, but there was no evidence of this being done or documented.
Failure to Accommodate Resident Food Allergies and Preferences
Penalty
Summary
The facility failed to ensure that a resident's menu and individual food plan met their documented nutritional needs and preferences. The resident, who had diagnoses including malnutrition and dysphagia and received extra calories via a PEG tube, was noted to have allergies and dislikes including gluten, eggs, mushrooms, mayonnaise, and tomato products. Despite this, observations showed that the resident was served a hamburger with mayonnaise and battered onion rings, which contained gluten, as well as gluten-free pasta with tomato sauce, which the resident disliked and refused to eat. The resident expressed dissatisfaction and concern about the presence of gluten and other disliked items in their meals. Interviews with staff revealed that meal tray cards listing allergies and dislikes were used to guide food preparation, but limitations in available gluten-free options from the food vendor resulted in the resident receiving inappropriate food items. The Food Services Director acknowledged that alternatives were not available for certain menu items, leading to the resident being served foods containing allergens or items they disliked. The facility's policy required accommodation of allergies and preferences, but this was not consistently implemented for the resident in question.
Failure to Maintain Sanitary Food Preparation and Storage Practices
Penalty
Summary
The facility failed to ensure that food was prepared and stored under sanitary conditions, as evidenced by multiple observations in the kitchen and nourishment areas. During an inspection of the nourishment refrigerator, an opened carton of thick and easy supplement was found with a manufacturer expiration date that had already passed, and the carton had been opened after its expiration. This indicates that expired food items were not consistently removed from storage, contrary to facility policy and food safety standards. Additionally, during meal preparation and tray line observation, a cook was seen engaging in unsanitary practices. The cook changed gloves multiple times without performing required hand hygiene between changes and was observed handling clean plates and food items with bare hands. Specifically, the cook touched a clean plate and a sandwich with bare hands and did not replace the contaminated plate. These actions were acknowledged by the staff involved and the food services manager, who noted that the staff member was working too quickly and that expired items should have been removed but were missed.
Noncompliance with Infection Control Precautions and PPE Use
Penalty
Summary
Staff failed to comply with infection prevention and control guidelines for multiple residents requiring different levels of precautions. For a resident with an indwelling Foley catheter on Enhanced Barrier Precautions (EBP), a nursing assistant emptied the catheter bag while wearing only gloves and not a gown, despite facility policy requiring both gown and gloves for high-contact activities involving indwelling devices. The staff member stated they did not believe a gown was necessary for this task, even though the EBP signage indicated otherwise. During personal care for another resident with hemiplegia and hemiparesis, a nursing assistant did not change gloves after providing pericare and continued to assist the resident with dressing and handling the resident's wheelchair with the same soiled gloves. The staff member later acknowledged that the gloves were dirty and should have been changed after pericare, but stated they typically only change gloves when visibly soiled. For a resident under investigation for Clostridium difficile (C. Diff), the room was posted with EBP signage instead of the required Contact Enteric precautions. Staff followed the posted EBP instructions, which did not require gown and glove use for all room entry or soap and water hand hygiene, as would be necessary for C. Diff. The error in signage led to staff not following the appropriate level of precautions until the signage was corrected.
Resource Mismanagement and Care Deficiencies
Penalty
Summary
The facility administration failed to effectively manage resources and maintain compliance with federal and state regulations, resulting in multiple deficiencies. These included inadequate administrative oversight and monitoring of personnel, systems, and policies related to care planning, resident environment, activities of daily living, range of motion services, respiratory care, nursing staff sufficiency, social services, pharmacy services, food service procedures, infection control, and tuberculosis testing. The administration's failure to ensure a homelike environment, proper maintenance, and timely comprehensive assessments after significant changes in residents' conditions contributed to these deficiencies. Specific incidents highlighted in the report include the failure to provide adequate care for dependent residents, such as bathing and toileting, leading to poor hygiene and unmet care needs. The facility also lacked a restorative program for residents needing range of motion and splint care, as acknowledged by the Director of Rehabilitation. Additionally, there were issues with respiratory care, where staff failed to administer oxygen as per the ordered dosage, and insufficient nursing staff led to delays in medication administration, affecting residents' pain management and overall care. One resident, admitted with chronic pain syndrome, experienced significant pain due to delayed administration of pain medications. Despite being scheduled for morning medication, the resident did not receive their pain relief until much later, resulting in severe discomfort. Interviews with staff revealed that the medication pass often extended beyond the scheduled time, affecting multiple residents. The administration also failed to ensure proper infection control practices and tuberculosis testing, further compromising resident safety and care quality.
Failure to Address Resident Grievances
Penalty
Summary
The facility failed to initiate a grievance process for concerns raised by the Resident Council, which included issues with call light wait times during nights and weekends. Despite residents voicing these concerns in meetings, the facility did not log or investigate these grievances, nor did they inform the residents of any findings or actions taken. This lack of action prevented the facility from identifying trends in grievances and addressing them effectively. Interviews revealed that staff directed residents to submit a concern or comment form, but did not assist in completing these forms, relying instead on residents to do so. The Activities Director provided resident council minutes to the administrator and director of nursing but did not ensure grievances were logged. The administrator expressed that grievances from the resident council were challenging to address if residents were not willing to participate in finding solutions, which limited the facility's ability to resolve the issues.
Deficiencies in Comprehensive Care Planning
Penalty
Summary
The facility failed to develop and implement comprehensive person-centered care plans for six residents, leading to potential risks for these individuals. Resident 6, who had a history of amputations and used limb prosthetics, did not have these needs addressed in their care plan. Similarly, Resident 53, who was undergoing smoking cessation treatment, lacked a care plan that included their smoking history and current treatment. Staff interviews revealed that the Resident Care Managers (RCMs) were responsible for ensuring care plans were completed, but they felt overwhelmed due to staffing issues. Resident 5, who had severe cognitive impairment and required assistance for mobility, was observed multiple times without access to their call light, contrary to their care plan instructions. Resident 8, who had a nephrostomy, had a care plan that did not reflect the necessary care for this condition. Staff interviews indicated that the care plan was supposed to guide the care provided, but there was a lack of awareness and information regarding the specific needs of Resident 8's nephrostomy. Resident 49, who experienced pain in their left knee and lower back, did not have these issues documented in their care plan, which only mentioned pain related to hip surgery. Resident 168, who was prescribed antibiotics for presumed pneumonia, did not have this condition or treatment reflected in their care plan. The Director of Nursing Services (DNS) acknowledged that care plans should address all resident needs and that there were missing items in the care plans reviewed by the interdisciplinary team.
Care Plan Deficiencies in Resident Management
Penalty
Summary
The facility failed to ensure that care plans were accurately reviewed and revised to reflect the current status and needs of four residents. Resident 6, who was admitted with a history of stroke, diabetes, and bilateral below-knee amputations, had their skilled therapies discontinued and transitioned to restorative services. However, their care plan was not updated to reflect these changes. Resident 43, who elected hospice care, did not have their care plan updated to include hospice services and coordination with the hospice care team. Resident 53, with a diagnosis of tobacco use disorder and an order for nicotine patches, was found smoking outside the facility, yet their care plan did not reflect their smoking history, risk, or current treatment. Resident 2, admitted with a history of stroke, left hemiparesis, dysphagia, and Type 2 Diabetes Mellitus, was observed using a straw despite their care plan indicating they should not have one. Staff were unaware of this restriction, and no signs were posted in the resident's room to remind staff and visitors of the precaution. Interviews with staff revealed a lack of awareness and communication regarding the resident's care plan, leading to the resident being served drinks with a straw, contrary to their care plan instructions.
Deficiencies in ADL Assistance for Residents
Penalty
Summary
The facility failed to provide adequate assistance with activities of daily living (ADLs) for several residents, specifically in the areas of bathing and toileting. Resident 24, who was admitted with a fracture of the right femur, chronic heart failure, and kidney disease, was not provided with the necessary assistance for toileting. Despite being aware of their need to have a bowel movement, the resident was unable to be transferred to the bathroom due to the mechanical lift not fitting into the bathroom. The care plan for Resident 24 did not address their continence needs, and staff failed to offer alternative solutions such as a bedside commode. Residents 7, 8, 23, and 28, who were dependent on staff for bathing, did not receive showers or bathing assistance as per their preferences and needs. Resident 7, with moderate cognitive impairment, reported only being bathed every two or three weeks despite preferring weekly baths. Resident 28, who had a stroke and hemiplegia, was supposed to be bathed twice a week but experienced inconsistent bathing schedules due to staffing issues. Resident 8, with a history of stroke and muscle weakness, was observed with greasy, uncombed hair and reported receiving showers only once a week, although they preferred twice weekly showers. The facility's documentation and staff interviews revealed systemic issues in scheduling and providing showers. Staff members indicated that shower aides were responsible for bathing, and if they were unavailable, showers were often missed without proper documentation or follow-up. The Director of Nursing Services and the Administrator were unaware of the missed showers and the lack of adherence to residents' bathing preferences, highlighting a breakdown in communication and care planning within the facility.
Staffing Shortages Lead to Delayed Care and Unmet Needs
Penalty
Summary
The facility failed to provide sufficient staffing to meet the needs of its residents, as evidenced by multiple resident interviews and observations. Residents reported long wait times for assistance with activities of daily living, such as getting out of bed, attending activities, and receiving help with grooming and showers. Some residents expressed concerns about the lack of staff available to respond to call lights, particularly during nights and weekends, leading to delays in receiving necessary care. The report highlights specific instances where residents did not receive timely medication administration, which is critical for managing their health conditions. For example, Resident 16, who suffers from chronic pain syndrome, did not receive their morning pain medications on time, resulting in severe pain. The delay in medication administration was attributed to the heavy workload and insufficient staffing on the unit, as confirmed by staff interviews. Additionally, the facility's staffing issues affected the provision of showers and restorative services. Staff interviews revealed that shower aides were often pulled to cover floor duties due to staffing shortages, leading to missed showers for residents like Resident 28, who preferred twice-weekly showers. The facility's inability to maintain adequate staffing levels compromised the quality of care and residents' quality of life, as documented in the report.
Delayed Medication Administration
Penalty
Summary
The facility failed to ensure the timely administration of scheduled medications for four residents, resulting in significant delays in receiving essential medications. The scheduled AM Medication Pass was supposed to occur between 6:00 AM and 10:00 AM, but residents did not receive their medications until much later. Resident 16, who suffers from chronic pain syndrome, reported severe pain levels of 10/10 on two consecutive mornings due to not receiving their morning pain medications, including Gabapentin, Acetaminophen, and Suboxone, within the scheduled time. Interviews with staff revealed that the delay was due to the medication pass taking longer than expected. Other residents also experienced delays in receiving their medications. Resident 38 received seven morning medications, including pain and antipsychotic medications, over two hours after the scheduled time. Similarly, Resident 7 received their morning medications, including antidiabetic and anticoagulant medications, as late as 12:15 PM. These delays were documented in incident investigations, and the facility acknowledged the need for improvement in the efficiency of medication administration.
Failure to Ensure Sanitary Food Handling
Penalty
Summary
The facility failed to ensure that food was stored, prepared, and served under sanitary conditions in its kitchen, as observed by surveyors. Specifically, staff members were not wearing required hair and beard restraints while working in the kitchen, which is a violation of the facility's policy. On multiple occasions, staff members, including the Dietary Manager and Dietary Aides, were observed without hair or beard restraints. The Dietary Manager acknowledged that staff were supposed to wear these restraints upon entering the kitchen but noted that a new staff member was still in training. This lack of compliance with sanitary protocols placed residents at risk of receiving contaminated food.
Infection Control Deficiencies in Hand Hygiene and Precautions
Penalty
Summary
The facility failed to ensure compliance with infection prevention and control guidelines during meal service, peri-care, and transmission-based precautions. Specifically, Staff F, a Nursing Assistant Certified (NAC), did not perform hand hygiene before and after delivering meal trays to residents' rooms. This was observed multiple times as Staff F handled meal trays and residents' personal items without washing hands or using alcohol-based hand rub (ABHR). Staff F acknowledged the responsibility to perform hand hygiene but was unaware of the lapses during the breakfast meal tray pass. Additionally, Staff P, another NAC, was observed providing peri-care to a resident without changing gloves or performing hand hygiene afterward. Staff P used the same gloves to dress the resident and then moved the bedside commode and wheelchair without washing hands or using ABHR. This failure to adhere to hand hygiene protocols was noted despite recent training sessions on proper handwashing techniques. The facility also failed to implement appropriate transmission-based precautions for a resident with Clostridium difficile (c. diff) infection. The contact isolation sign outside the resident's room incorrectly instructed staff and visitors to use ABHR instead of washing hands with soap and water, which is necessary to remove c. diff spores. Staff H followed these incorrect instructions, and the Infection Preventionist and Director of Nursing Services were unaware of the signage error. The facility's policies require handwashing with soap and water for residents with c. diff, but this was not enforced, leading to potential infection risks.
Failure to Maintain Advance Directives Documentation
Penalty
Summary
The facility failed to obtain and maintain Advance Directives (AD) for Resident 24, who was admitted with diagnoses including a fracture of the right femur, chronic heart failure, and kidney disease. The care plan indicated that Resident 24 had a Power of Attorney (POA) for healthcare, with their daughter specified as the POA. However, a review of the electronic medical record revealed no documentation of the POA paperwork. This oversight was confirmed during an interview with Staff W, a Licensed Practical Nurse, who was unable to locate the POA documentation in the resident's chart. Further interviews revealed that Staff X, the Admissions Director, did not obtain the POA documents at the time of admission, despite the presence of Resident 24's daughter. Staff X was unsure of the process to follow up if the POA paperwork was not provided. Staff Z, the Medical Records Director, confirmed that if the POA document was not in the electronic medical record, it was not given to them. Staff AA, an RN-Staff Development Coordinator, also could not locate the document and noted that Resident 24's daughter had signed the Physician's Order for Life Sustaining Treatment (POLST) as the POA. The deficiency was identified as a failure to ensure the resident's healthcare preferences and decisions were documented and honored.
Failure to Maintain Homelike and Clean Environment
Penalty
Summary
The facility failed to ensure a homelike environment for three residents and maintain cleanliness in the facility's conference room. Resident 11, who had severe cognitive impairment, was observed to have a stark room lacking personal belongings or decor, with bare walls and minimal furnishings. Staff acknowledged the lack of homelike elements in the room. Resident 28, who had no cognitive impairment, expressed dissatisfaction with the cleanliness of their room windows, which had not been cleaned in over two years despite multiple requests. The maintenance staff confirmed that windows were cleaned quarterly and attributed wall damage to improper bed placement by nursing staff. Resident 17, who was hearing impaired but able to communicate, reported that their window and TV screen were dusty and streaked, which was confirmed by observation. Additionally, the conference room windows and screens were found to have extensive dirt and debris build-up. These deficiencies indicate a failure to provide a clean and homelike environment, as required by regulations, potentially impacting the residents' quality of life and the facility's overall environment.
Failure to Conduct Significant Change in Status Assessment for Hospice Election
Penalty
Summary
The facility failed to identify a Significant Change in Status for a resident who elected Hospice services, as required by the Resident Assessment Instrument (RAI) guidelines. The resident, who was not initially receiving Hospice services, elected their Hospice benefit on August 10, 2024. According to the RAI manual, a Significant Change in Status Assessment (SCSA) should have been conducted within 14 days of this election, by August 24, 2024. However, a review of the resident's Minimum Data Set (MDS) assessments on September 10, 2024, revealed that no SCSA had been completed. During an interview on September 11, 2024, the Licensed Practical Nurse/Minimum Data Set (MDS) Nurse, identified as Staff O, stated that the only change for the resident was the initiation of Hospice services and that the care plan had not been altered. Staff O was unaware that the election of Hospice services alone constituted a Significant Change requiring a SCSA, as per the RAI manual.
Incomplete Discharge Summary for Resident
Penalty
Summary
The facility failed to complete a discharge summary for a resident, identified as Resident 67, who was discharged to an assisted living facility. The discharge summary was missing a recapitulation of the resident's stay and a final summary of the resident's status, which are required components. The resident had been admitted with diagnoses including neutropenia, pulmonary fibrosis, and high blood pressure. The facility's policy on discharge summaries, dated May 6, 2019, requires participation from both social services and nursing staff in developing the summary, which should include a comprehensive overview of the resident's stay and status. Interviews with facility staff revealed gaps in the discharge process. Staff S, the Social Services Director, indicated that they were responsible for certain parts of the discharge summary but not for the recapitulation of the stay or physical assessment on discharge. Staff S also could not recall if any durable medical equipment or home health services were needed for Resident 67. Additionally, Staff A, the Administrator, and Staff B, the Director of Nursing Services, acknowledged that the discharge summary for Resident 67 was incomplete and should have been finalized on the day of discharge. This lack of a complete discharge summary placed residents at risk of post-discharge complications and delayed treatment.
Deficiency in ROM and Mobility Care for Residents
Penalty
Summary
The facility failed to provide necessary care and services to maintain or improve the range of motion (ROM) for three residents, leading to a deficiency in care. Resident 17, who had multiple diagnoses including rheumatoid arthritis and a history of shoulder issues, was observed wearing a sling without a corresponding order. Despite an order for occupational therapy to assess ROM, there was no follow-up, and the resident expressed interest in exercises that were not provided. The Director of Rehab acknowledged the oversight, indicating a lapse in the facility's process for monitoring and addressing potential declines in residents' activities of daily living. Resident 5, with severe cognitive impairment and limited mobility, was at risk for skin breakdown due to prolonged periods in a wheelchair without repositioning or a pressure-reducing cushion. Observations showed the resident remained in the same position for extended hours without staff intervention, contrary to the care plan that required repositioning every two hours. The lack of adherence to the care plan and absence of documentation of any refusals to reposition highlighted a significant gap in the facility's care practices. Resident 23, who had contractures and required a brace and splint for their right knee, was not consistently receiving the prescribed restorative nursing services. Documentation showed frequent refusals and incomplete application of the brace and splint, with significant gaps in the records. Staff interviews revealed that the restorative nursing program had been on hold, and there was confusion about who was responsible for overseeing the program. The lack of documentation and communication about the resident's refusals and the absence of the brace and splint during observations further underscored the facility's failure to implement and monitor necessary interventions for maintaining residents' mobility and function.
Failure to Implement Nutritional Interventions and Monitor Weight Loss
Penalty
Summary
The facility failed to develop and implement nutritional interventions and evaluate their effectiveness for a resident with nutritional needs. The resident, who was admitted with diagnoses including malnutrition, bipolar disorder, and cognitive communication deficit, experienced significant weight loss over several months. Despite the resident's care plan identifying a potential nutritional problem and risk for weight loss, the facility did not consistently obtain weights, notify appropriate parties, or implement the Registered Dietician's recommendations. The resident's medical records showed a decline in weight from 152.8 pounds to 135.6 pounds over a period of several months. The facility's policy required weekly reviews of residents at risk for nutritional issues, but there was no consistent method for weighing the resident or monitoring their weight loss. The resident frequently refused to be weighed, and there was no documentation of notification to the physician or power of attorney about these refusals or the weight loss. Interviews with staff revealed a lack of awareness and communication regarding the resident's weight loss and refusal to be weighed. Staff members indicated that they were not informed of the resident's weight loss and that the care plan was not updated to reflect the resident's refusal to be weighed. The facility's process for obtaining weights was not followed, and the care plan did not include updated interventions to address the resident's nutritional needs.
Deficiency in Enteral Tube Feeding Management
Penalty
Summary
The facility failed to ensure proper management of enteral tube feeding supplies for a resident with a PEG tube, leading to a risk of infection and complications. Resident 8, who was admitted with a history of stroke, dysphagia, and malnutrition, relied on a PEG tube for nutrition. Observations revealed that the tube feeding supplies, including bags and syringes, were not labeled or dated as required. The feeding bag was observed to be used beyond the recommended 24-hour period, and the water bag was unlabeled. These observations were made over several days, indicating a lack of adherence to proper protocols for tube feeding management. Interviews with facility staff, including a Registered Nurse, a Licensed Practical Nurse, and the Director of Nursing Services, confirmed that there were no physician orders or care plan directives for the replacement and labeling of tube feeding supplies. Staff members acknowledged that supplies should be replaced every 24 hours and properly labeled, but this was not being done. The care plan for Resident 8 was not updated to include the PEG tube until nearly a year after admission, and staff were unaware of the lack of orders for tube feeding supplies. This oversight in care planning and execution contributed to the deficiency identified by the surveyors.
Failure to Provide Ordered Respiratory Care
Penalty
Summary
The facility failed to provide appropriate respiratory care for two residents, leading to deficiencies in care. Resident 24, who was admitted with diagnoses including a fracture of the right femur, chronic heart failure, and COPD, had physician orders for oxygen therapy and CPAP use. However, observations revealed that the resident was not using the prescribed nasal cannula or CPAP mask, and the oxygen concentrator was set to zero liters and not running. Staff interviews confirmed that the resident was not receiving the ordered respiratory support, which was inconsistent with the facility's policy and physician orders. Resident 17, admitted with COPD, Reynaud's Syndrome, gangrene in the fingers, and atrial fibrillation, was observed using an oxygen concentrator without a physician's order documented in their electronic chart. The resident stated they used oxygen at night for sleep apnea, but staff were unable to provide documentation of an order for oxygen use. This lack of documentation and adherence to physician orders for oxygen therapy represents a failure to meet professional standards of practice for respiratory care.
Failure to Administer Timely Pain Management
Penalty
Summary
The facility failed to provide necessary pain management for Resident 16, who was admitted with chronic pain syndrome and was dependent on opiate medication for pain relief. The resident's Minimum Data Set assessment indicated frequent pain affecting their sleep, and they reported a pain level of 8 out of 10. On multiple occasions, the resident expressed experiencing severe pain, with a pain level of 10 out of 10, and had not received their scheduled morning pain medications, which included Gabapentin, Acetaminophen, and Suboxone. Observations and interviews revealed that the facility's medication administration schedule was not adhered to, as the resident did not receive their morning medications within the scheduled time frame of 6:00 AM to 10:00 AM. Staff interviews confirmed delays in medication administration, with staff members acknowledging that the medication pass was taking longer than expected. This failure to administer pain medications as scheduled resulted in the resident experiencing avoidable pain and a diminished quality of life.
Failure to Conduct Care Planning Meetings for Resident
Penalty
Summary
The facility failed to provide medically-related social services to help Resident 13 achieve the highest possible quality of life. Resident 13, who has Parkinson's disease and moderate cognitive impairment, expressed dissatisfaction with their bathing schedule, stating they were only able to bathe once a week instead of their preferred twice a week. Additionally, an observation revealed that Resident 13 was sitting uncomfortably in their wheelchair, with no right legrest or footrest, causing their right leg to be suspended in the air. The facility did not conduct care planning meetings for Resident 13, as required, to address their care preferences and needs. Staff S, the Social Services Director, and Staff V, the Social Services Assistant, admitted to not holding quarterly care conferences for the resident, citing the power of attorney's declination. However, they were unable to provide any information on how the resident's care was assessed without these meetings. A review of the resident's progress notes over the past year showed no documentation of any care conferences, and Resident 13 confirmed that the facility never offered a care conference to discuss their care, bathing preferences, or wheelchair comfort.
Failure to Implement Antibiotic Stewardship Program
Penalty
Summary
The facility failed to implement its Antibiotic Stewardship Program (ASP) effectively for a resident, increasing the risk of developing multidrug-resistant organisms. The facility had a document titled 'Statement of Leadership Commitment for Antibiotic Stewardship in a Skilled Nursing Facility,' which was signed by key personnel, including the Medical Director and Director of Nursing Services. This document outlined the facility's commitment to the CDC's core elements of antibiotic stewardship, including leadership, accountability, and drug expertise. However, the facility did not adhere to these elements in the case of a resident who was admitted with a history of kidney stones, surgery to the urinary system, and an antibiotic-resistant bacteria infection. The resident's physician orders included an antibiotic with a note indicating a need for a stop date, but the medication was administered continuously without documented communication with the infectious disease provider regarding the stop date. Interviews with facility staff revealed a lack of awareness and follow-up regarding the resident's antibiotic use. The Director of Nursing Services was initially unaware of the status of the resident's antibiotic treatment and had to contact the infectious disease provider to obtain documentation, which was not part of the medical record until requested. The Infection Preventionist, who was responsible for overseeing the ASP, was also unaware of the lack of documentation and follow-up in the medical record. This oversight indicates a failure in the facility's ASP, as there was no proper tracking or communication regarding the antibiotic's usage and stop date, leading to potential adverse outcomes for the resident.
Failure to Monitor and Address Recurrent UTIs in Resident
Penalty
Summary
The facility failed to provide resident-focused care by not consistently monitoring, assessing, and evaluating the condition of a resident with a history of recurrent urinary tract infections (UTIs). The resident, who was readmitted to the facility with diagnoses including recurrent UTI, type two diabetes mellitus, and Parkinson's disease, did not have a care plan addressing their history of chronic UTIs or their candidacy for timed/scheduled voiding. Despite being incontinent of urine and having a history of chronic UTIs, the care plan only noted the resident's risk for skin breakdown and required assistance for peri care and brief changes. Throughout the period from 08/16/2024 to 08/19/2024, the resident exhibited symptoms indicative of a UTI, such as dark amber urine with odor, confusion, and discomfort with urination. However, there was a lack of documentation of vital signs and no notification to the resident's representative or provider about these findings. The resident's condition escalated to a UTI with sepsis, as confirmed by an emergency department encounter, where they presented with fever, tachycardia, and confusion. Interviews with facility staff revealed gaps in the care planning and monitoring processes. Staff acknowledged that the resident's recurrent UTIs were not included in their care plan or diagnosis list, and vital signs were not consistently checked during the alert status. The facility's protocol for placing a resident on alert did not necessitate provider notification, and there was a lack of communication regarding the resident's change in condition. These oversights contributed to the resident's decline and subsequent hospitalization for UTI with sepsis.
Failure to Provide Timely Pharmaceutical Services for New Admissions
Penalty
Summary
The facility failed to provide adequate pharmaceutical services to meet the needs of three residents upon their admission. Resident 1, who was admitted with conditions including Bipolar Disorder and Seizure Disorder, did not receive prescribed medications such as Quetiapine, Benzatropine, and Lamotrigine on the day of admission. The Licensed Practical Nurse (LPN) documented the absence of these medications as 'new admit' without verifying their availability in the Omnicell or notifying the resident's provider. The Director of Nursing Services (DNS) confirmed that no medications were dispensed from the Omnicell for Resident 1 on the day of admission. Resident 2, admitted with conditions including a recent fall and cardiac issues, also did not receive several prescribed medications, including Memantine, Rosuvastatin, Symbicort, and Voltaren, due to pending delivery. Despite Memantine being available in the Omnicell, it was not administered. The resident expressed a need for pain ointment, which was not available until days after admission. There was no documentation indicating that the provider was notified about the unavailability of these medications. Resident 3, admitted with encephalopathy and psoriasis, did not receive Lactulose and Betamethasone as they were on order and not available in the Omnicell. Similar to the other cases, there was no documentation of provider notification regarding the unavailability of these medications. The DNS acknowledged the need to review the pharmacy delivery and admission process after receiving an updated list of medications available in the Omnicell.
Failure to Provide Adequate Nail Care
Penalty
Summary
The facility failed to ensure that three residents received proper nail care, leading to discomfort and potential injury. Resident 1, who had contractures, reported that their fingernails were so long they were digging into their palms, causing significant pain. Despite repeated requests, it took several days before the Activity Director filed the nails. Staff A confirmed that Resident 1's nails were long and causing discomfort, with reddened skin and callouses forming in their palms. Resident 2, who was dependent on staff for most activities of daily living, was observed to have long, jagged fingernails with dirty cuticles and debris under the nails. Resident 2 expressed a preference for having their nails cut, not just filed, but stated that staff did not comply with this request. Resident 3, who required maximum assistance for hygiene, also reported that staff had not been maintaining their fingernails properly. Their nails were long, with old polish and dirty cuticles, and the resident expressed a preference for having their nails cut rather than filed. Interviews with staff revealed inconsistencies in the understanding and execution of nail care responsibilities. Staff C, a Registered Nurse, stated that Nursing Assistants (NAs) were responsible for trimming nails unless the residents were diabetic or on blood thinners, in which case nurses were responsible. Staff B, a Licensed Practical Nurse, confirmed this protocol and added that nail care was usually documented in the resident's treatment administration record. However, Staff D, an NA, was unaware that NAs were responsible for trimming residents' fingernails. This lack of clarity and adherence to the facility's nail care policy resulted in inadequate care for the residents, leading to discomfort and potential injury.
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.
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