Madison Post Acute
Inspection history, citations, penalties and survey trends for this long-term care facility in Everett, Washington.
- Location
- 2520 Madison, Everett, Washington 98203
- CMS Provider Number
- 505463
- Inspections on file
- 26
- Latest survey
- November 24, 2025
- Citations (last 12 mo.)
- 47
Citation history
Health deficiencies cited at Madison Post Acute during CMS and state inspections, most recent first.
The facility did not complete required PASRR Level 2 evaluations for a resident with anxiety and depression prior to admission, and failed to update or conduct Level 2 evaluations for two residents with serious mental illness who remained beyond their 30-day exemption period. Staff interviews confirmed a lack of awareness and follow-through on PASRR requirements.
The facility assigned an unqualified individual as the Director of Food and Nutrition Services, who was not a certified Dietary Manager and was only enrolled in a certification program. The facility used the certification of the previous manager in place of the current director's required credentials, as confirmed by staff interviews and record review.
Surveyors identified unsanitary conditions in the kitchen and food storage areas, including a leaking handwashing sink, food debris, improper dishwashing temperatures, ice buildup in the freezer, poor hand hygiene, and unlabeled or undated food items. Staff were aware of these issues, but proper cleaning and maintenance had not been completed.
The facility did not have an effective system to document, track, or resolve grievances raised by residents during Resident Council meetings, including repeated complaints about loud TV noise, staff disturbances at night, and cold food. Staff responsible for grievance resolution were not informed of these concerns, and no formal grievance forms or follow-up actions were documented, resulting in unresolved issues affecting residents' quality of life.
The facility did not provide updated or complete Notification of Medicare Non-Coverage (NOMNC) forms to four residents, using outdated forms that lacked the required appeal organization contact information and failing to document that residents or their representatives received an explanation of the form or appeal process. The Social Service Director was unaware of the need to update the forms or include the necessary information.
The facility did not consistently provide or document required written notices of bed hold, transfer, and discharge to residents, their representatives, and the State Ombudsman during hospitalizations and discharges. Staff interviews revealed confusion about notification responsibilities, and EMR reviews showed missing documentation for several residents who were hospitalized or discharged.
The facility did not ensure that required PASRR Level II evaluations were completed or that recommendations from completed evaluations were incorporated into care plans for several residents with mental health diagnoses. Staff failed to refer residents for further review, did not document communication with the state PASRR evaluator, and were unaware of specific care recommendations, resulting in incomplete care planning.
Two residents requiring hemodialysis did not have consistent pre- and post-dialysis assessments completed, and there was a lack of ongoing communication and documentation from the dialysis center. Staff interviews confirmed missing documentation, incomplete communication packets, and absent after-visit summaries, with no contracts in place between the facility and the dialysis providers.
Several residents reported and were observed receiving meals that were lukewarm, overcooked, or unappetizing, with some meals lacking proper temperature control and palatability. Test trays confirmed issues such as dry and bland food, and a grievance documented a foreign object in a meal. The administrator was unaware of these ongoing food quality concerns.
A resident's trust account balance was not reimbursed to the state Office of Financial Recovery within the required 30 days after the resident's death. The Business Office Manager confirmed the delay, resulting in the account not being reconciled as mandated.
Two residents did not have individualized, comprehensive care plans implemented as required. One resident with severe dementia and Dutch as a primary language lacked the Dutch-to-English signage intervention specified in their care plan, and staff were unaware of this intervention. Another resident with a urinary catheter had a care plan that did not document the clinical reason for the catheter or necessary follow-up, and staff could not explain the rationale for its continued use.
Two residents did not receive care in accordance with professional standards: one did not have required blood pressure monitoring or bowel protocol interventions documented when receiving antihypertensive medication and experiencing constipation, and another did not have provider notification documented when blood glucose readings exceeded ordered parameters. Staff interviews confirmed that these protocols were not followed or documented as required.
Two residents did not receive respiratory care in accordance with physician orders and professional standards. One resident's oxygen was consistently set below the prescribed rate, and staff were unaware of the discrepancy. Another resident's CPAP machine lacked active orders for use and maintenance, and the mask was observed to be unclean, with staff unable to confirm cleaning or proper care.
Staff did not follow infection prevention protocols, including failing to use PPE for a resident on Enhanced Barrier Precautions during toileting, neglecting hand hygiene during perineal care for another resident, and not using barriers or proper disinfection when handling medical equipment and medications. These lapses were confirmed by staff and the facility's infection preventionist.
Seven rooms were found to house two residents each despite not meeting the minimum square footage requirement of 80 square feet per resident. Each room measured between 142 and 154 square feet, and staff confirmed that an exemption request was pending but not approved.
A resident's grievances regarding a noisy roommate, missing personal items, and dissatisfaction with a nursing assistant's care were not properly documented or addressed by the facility. Despite the resident's complaints, only one grievance was logged, and the facility failed to ensure the resident's concerns were resolved, as evidenced by continued care from the nursing assistant in question. Staff interviews revealed a lack of awareness and communication regarding the resident's grievances, indicating a failure to adhere to the facility's grievance policy.
A resident with swallowing difficulties was unable to receive daily recreational meals due to staffing limitations, as the facility only provided 1:1 supervision for meals on weekdays. Despite the resident's preference for daily meals, the scheduling practices did not accommodate their needs on weekends, leading to a deficiency in honoring resident choice.
A registered nurse administered medications to a resident with dementia during their meal in the dining room, contrary to facility policy requiring privacy for medication administration. The resident had cognitive impairments and did not request this practice. The Director of Nursing acknowledged the need for further education.
A facility failed to conduct a comprehensive Resident Assessment Instrument (RAI) for a resident with a leg fracture and on hospice care. The Care Area Assessment (CAA) lacked a thorough analysis, missing the resident's goals, preferences, and input. The contracted RN responsible for the MDS and care plans did not complete the necessary comprehensive analysis, risking inadequate service provision.
A facility failed to implement care plan interventions for a resident at high risk for falls, leading to a deficiency. The resident, with a history of falls and poor trunk control, was observed using a positioning wedge improperly without the required strap. Staff interviews revealed a lack of awareness about the wedge's purpose, and the care plan did not address the resident's trunk control issues. This was a repeat citation.
The facility failed to update care plans for two residents, one with discharge planning issues and another with dental care needs. A resident's care plan was not revised despite changes in their discharge situation, while another's dental care plan did not reflect the absence of their upper partial dentures, affecting their ability to chew properly.
The facility failed to implement professional standards of practice for two residents, leading to potential risks. A resident with swallowing difficulties did not receive proper cues during meals, as recommended by the SLP. Another resident's blood pressure was not monitored as required before administering medication, and a lab test was delayed due to errors in the electronic health record system. These deficiencies highlight the facility's failure to adhere to professional standards.
Two residents in an LTC facility did not receive adequate assistance with activities of daily living, including meal assistance and oral hygiene. One resident, with a leg fracture and dementia, was left unattended with meal trays untouched and no oral care provided. Another resident, with a history of stroke and a gastrostomy tube, had dry, coated lips and tongue due to infrequent oral care. Staff interviews revealed inconsistencies in understanding and executing care plans.
The facility failed to provide care according to professional standards for two residents. One resident's alternating air mattress was not set to the prescribed settings, risking skin breakdown. Another resident, admitted to hospice with a leg fracture, was not repositioned as required, lacking a specific schedule in their care plan. Staff interviews revealed a lack of adherence to care interventions, increasing the risk of unmet care needs.
The facility did not complete annual performance reviews for NAC staff, specifically for one NAC whose file was reviewed. Staff K, hired in July 2023, lacked a current evaluation. A change in ownership on May 1 led to confusion about hire dates, contributing to the oversight.
The facility failed to maintain sanitary conditions in food storage, preparation, and service, with undated and expired items found in the kitchen and unit refrigerators. The dishwasher did not reach the required temperature, and meal trays were delivered with uncovered desserts. Staff interviews revealed a lack of adherence to food labeling and temperature monitoring protocols, placing residents at risk of consuming contaminated or spoiled food.
The facility failed to adhere to infection control practices, including improper PPE use for a resident on COVID-19 precautions and inadequate storage of O2 tubing for another resident. Staff entered a resident's room without proper PPE and disposed of it incorrectly. Additionally, clean linens were transported uncovered, increasing infection risk.
The facility failed to ensure that a NAC received the required 12 hours of training per year, with only 6.3 hours documented. The Staff Development Coordinator acknowledged the shortfall and was unable to provide evidence of the required training for the NAC, highlighting a lapse in maintaining comprehensive training records.
The facility failed to meet regulatory requirements for room size in six resident rooms, with multiple rooms not providing the required 80 square feet per resident. Despite this, surveyors found no compromise to resident health or safety. This was a repeat citation.
Failure to Complete Required PASRR Evaluations for Residents with Mental Health Needs
Penalty
Summary
The facility failed to ensure that required Pre-Admission Screening and Resident Review (PASRR) processes were completed for three out of five residents reviewed. For one resident with diagnoses of anxiety and depression, the PASRR Level 1 screen indicated the need for a Level 2 evaluation prior to admission, but there was no evidence in the electronic health record that this evaluation was completed. Staff interviews revealed a lack of awareness regarding the requirement for a Level 2 evaluation before admission when indicated by a positive Level 1 screen. For two other residents, the PASRR Level 1 screens documented indicators of serious mental illness and granted a 30-day exemption from Level 2 evaluation, contingent on discharge within that period. However, when these residents remained beyond 30 days, there was no evidence that updated PASRR Level 1 screens or required Level 2 evaluations were completed. Staff confirmed that no requests for Level 2 evaluations were submitted for these residents, despite the extended stays.
Unqualified Dietary Manager Serving as Director of Food and Nutrition Services
Penalty
Summary
The facility failed to ensure that the individual designated as the Director of Food and Nutrition Services possessed the required qualifications. The person serving in this role, identified as the Dietary Manager, confirmed during interview that they were not a certified Dietary Manager and were only enrolled in an educational program to obtain certification. The facility was using the certification of the Assistant Dietary Manager, who previously held the position, in place of the current director's required certification. Review of the staff roster and facility assessment documented the current director as the certified dietary manager, despite the lack of certification. The facility administrator acknowledged that the previous manager's certification was being used until the current director became certified.
Deficient Sanitary Practices in Food Storage, Preparation, and Service
Penalty
Summary
Surveyors observed multiple failures in the facility's kitchen and food storage areas regarding sanitary food storage, preparation, and service. The dishwashing area had a large hole in the wall, a rusty can supporting a pipe, and a pool of discolored liquid beneath a leaking handwashing sink. Food debris and cracker wrappers were present on the floor. Staff interviews confirmed awareness of these issues, including reports of cockroaches and ongoing pest control measures. The dishwashing temperature log had missing entries, and recorded temperatures were below the required level for proper sanitation. Staff operating the dishwasher indicated that the machine was a low-temperature chemical model and described running it empty to reach the correct temperature, but logs showed temperatures as low as 116-127 degrees Fahrenheit. The freezer had significant ice buildup due to missing door seals, which staff acknowledged were pending replacement. Hand hygiene practices were not followed, as staff were observed changing gloves without performing hand hygiene between tasks. The nourishment refrigerator contained opened and undated beverage items, and the dry storage area had multiple opened and unlabeled food items, including cereals and pasta. Staff interviews confirmed awareness of the need for deep cleaning and equipment replacement, but these actions had not yet been completed at the time of the survey. No specific residents were identified as being directly affected in the report.
Failure to Address and Resolve Resident Grievances from Resident Council Meetings
Penalty
Summary
The facility failed to implement a system to ensure that grievances voiced by residents, particularly through Resident Council meetings, were properly documented, tracked, investigated, and resolved. Residents repeatedly reported issues such as loud TV noise, staff being boisterous at night, and cold food during meals. These concerns were consistently brought up in Resident Council meetings over several months, but there was no documentation of resolutions or evidence that grievance forms were completed or logged. The facility's grievance log did not reflect these ongoing concerns, and there was no follow-up or investigation into the issues raised. Interviews with staff revealed a lack of clarity and communication regarding the grievance process. The Activity Director, who assisted with Resident Council meetings, did not consider concerns raised in these meetings as formal grievances and therefore did not complete grievance forms or track the issues. The Social Service Director, designated as the Grievance Officer, was not notified of any concerns from the Resident Council meetings and had not received any related grievance forms. The Administrator expected that grievances from Resident Council meetings would be documented and processed, but acknowledged that this was not occurring and that there was no established process for handling these concerns. Specific residents reported ongoing disturbances at night due to loud TVs and staff noise, which affected their ability to sleep. Observations confirmed that noise levels were high, including loud communication from staff devices. Despite these repeated complaints and direct observations, there was no evidence that the facility took appropriate steps to address or resolve the grievances, and staff members responsible for resolving such issues were unaware of the ongoing concerns.
Failure to Provide Updated and Complete NOMNC Forms
Penalty
Summary
The facility failed to provide complete and updated Notification of Medicare Non-Coverage (NOMNC) forms to four sampled residents. For each resident, the NOMNC form used was outdated, having last been approved by CMS in 2011 rather than the most recent version. Additionally, the forms lacked required information, specifically the name and telephone contact of the appeal organization. There was also no documentation in the residents' electronic health records indicating that the residents or their representatives were given an explanation of the NOMNC form or the appeal process. Interviews with the Social Service Director revealed a lack of awareness regarding the need to update the NOMNC form and include the appeal organization's contact information. The Social Service Director stated they were responsible for issuing and explaining the NOMNC form but was unaware that the forms in use were outdated and missing required information. This deficiency was identified through both record review and staff interviews.
Failure to Provide Required Bed Hold and Transfer/Discharge Notices
Penalty
Summary
The facility failed to provide required written notices of bed hold, transfer, and discharge to residents, their representatives, and the State Ombudsman in cases of hospitalization and discharge. For three residents reviewed, documentation was missing regarding the issuance of bed hold policies and transfer/discharge notifications during hospital transfers or discharges. Specifically, one resident was hospitalized and re-admitted without any progress notes or EMR documentation indicating that a bed hold or transfer/discharge notice was offered or provided. Staff interviews revealed confusion and inconsistent practices regarding who was responsible for completing and sending these notifications, with some staff unaware of the requirement to notify the State Ombudsman for hospital transfers or unplanned discharges. Additionally, for another resident who was sent to the emergency room, there was no evidence in the EMR that the State Ombudsman was notified. In the case of a resident discharged to an adult family home, the EMR lacked documentation of notification to the State Ombudsman. Staff reported that notifications for planned discharges were sent monthly, but could not provide documentation that notifications were sent for each individual discharge as required. The facility's own policy required timely notification and documentation, but these procedures were not consistently followed.
Failure to Complete and Implement PASRR Evaluations and Recommendations
Penalty
Summary
The facility failed to ensure proper coordination and completion of the Preadmission Screening and Resident Review (PASRR) process for four out of six residents reviewed. Specifically, residents with diagnoses including depression, major depressive disorder, anxiety disorder, dementia, and borderline personality disorder were either not referred for required Level II PASRR evaluations or had recommendations from completed Level II evaluations omitted from their care plans. Documentation showed that Level I PASRR screenings indicated the need for Level II evaluations for several residents, but there was no evidence that these evaluations were completed or that the state PASRR evaluator was contacted as required. For one resident with a diagnosis of depression, the Level I PASRR indicated a need for a Level II evaluation, but no such evaluation was found in the electronic health record, and the state PASRR evaluator confirmed no referral was received. Another resident with major depressive disorder also required a Level II evaluation, but staff could not locate documentation of its completion. A third resident with dementia, anxiety disorder, and depression had an invalidated Level II PASRR and, after a repeat Level I PASRR, again required a Level II evaluation, but there was no documentation of follow-up or communication with the state evaluator. A fourth resident with depression and borderline personality disorder had a completed Level II PASRR evaluation with specific recommendations for care, including environmental modifications and trauma-informed approaches. However, none of these recommendations were incorporated into the resident's care plan, and staff were unaware of the evaluation's findings or the resident's trauma history. Interviews with staff revealed a lack of awareness and follow-through regarding PASRR requirements and care plan updates, and management was unaware of the deficiencies until informed during the survey.
Failure to Ensure Communication and Documentation for Dialysis Services
Penalty
Summary
The facility failed to ensure ongoing communication and collaboration with the hemodialysis center and did not consistently complete pre- and post-dialysis assessments for two residents requiring hemodialysis services. For one resident with end stage kidney disease and diabetes, the care plan required monitoring for complications and regular dialysis attendance, but documentation revealed missing post-dialysis assessments on multiple dates and a lack of after-visit summaries from the dialysis center. Staff interviews confirmed that communication packets were inconsistently managed, and necessary documentation from the dialysis center was often not received or completed. For another resident with similar diagnoses, the care plan also required monitoring and regular dialysis, but there were no completed pre- or post-dialysis assessments for an extended period, and specific assessments were missing on additional dates. Progress notes indicated that the resident was sent to the hospital from dialysis without timely communication. Staff acknowledged gaps in documentation and communication with the dialysis center, including missing run sheets that contained critical clinical information. The facility did not have contracts with the dialysis centers providing care to these residents, and no additional documentation was provided regarding their dialysis care.
Failure to Provide Palatable and Properly Tempered Food
Penalty
Summary
Surveyors identified that the facility failed to provide appetizing and palatable food at safe and appetizing temperatures to several residents. Multiple residents reported that their meals were served lukewarm or only warm, rather than hot, and observations confirmed that plates were cool to the touch and lacked heated plate warmers. Residents described the food as overcooked, dry, or difficult to chew, with specific complaints about sausage patties, salmon, and macaroni salad. Test tray observations further revealed issues such as dry salmon, bland soup, overcooked and lukewarm asparagus, and macaroni salad with an unappealing taste. Additionally, a grievance was documented regarding a foreign object (bread tie) found in a sandwich. Resident council meeting minutes indicated that the kitchen was aware of temperature issues and was working on acquiring temperature-controlled carts, but at the time of the survey, these issues persisted. The facility administrator was unaware of the food concerns raised by residents and the lack of palatable meals. The findings were based on interviews, direct observations, and review of resident council minutes and grievances, demonstrating a pattern of inadequate food quality and temperature control for multiple residents.
Delayed Reimbursement of Resident Trust Funds After Death
Penalty
Summary
The facility failed to reimburse funds from a resident's trust account to the appropriate party within 30 days following the resident's death, as required by regulation. Record review showed that a resident who had passed away had a remaining trust account balance of $378.67, which had not been submitted to the state Office of Financial Recovery (OFR) within the required timeframe. During an interview, the Business Office Manager confirmed that the funds had not yet been submitted as required. This delay resulted in the resident's account not being reconciled within the mandated 30-day period.
Failure to Develop and Implement Individualized Comprehensive Care Plans
Penalty
Summary
The facility failed to develop and implement individualized, comprehensive care plans for two residents, one with dementia and one with a urinary catheter. For the resident with dementia, the care plan noted severe cognitive impairment, depression, and anxiety, and included interventions such as asking yes/no questions, cueing, and monitoring cognitive changes. A separate care plan addressed the resident's primary language, Dutch, and called for the use of Dutch-to-English signage provided by the family. However, during observation, no such signage was present in the resident's room, and staff were unaware of this intervention, indicating the care plan was not fully implemented. For the resident with a urinary catheter, the care plan documented the presence of the catheter but did not specify the clinical reason for its use, whether it was unavoidable, or the required follow-up care. Interviews with staff revealed a lack of awareness regarding the rationale for the catheter and acknowledged that the care plan was vague and incomplete. The absence of individualized and comprehensive care planning for both residents was confirmed through observation, interviews, and record review.
Failure to Follow Medication and Monitoring Protocols for Two Residents
Penalty
Summary
The facility failed to ensure that professional standards were met for two residents in relation to medication administration and monitoring. For one resident with heart failure, the facility did not document blood pressure readings as required when administering antihypertensive medication, despite provider orders specifying to hold the medication if blood pressure readings were below certain parameters. There were also periods where no blood pressure readings were documented at all, and staff interviews confirmed that the expectation was to follow the provider's orders and document the necessary parameters. Additionally, the same resident experienced constipation, and the facility did not follow its own bowel protocol. The resident went several days without a bowel movement, but the prescribed sequence of interventions—such as administering Milk of Magnesia, a glycerin suppository, and an enema—was not followed or documented. Staff interviews indicated that nurses were expected to monitor bowel movements and administer medications according to the protocol, but this did not occur. For another resident with diabetes, the facility failed to notify the medical provider when the resident's blood sugar levels exceeded the ordered parameters on multiple occasions. The resident's orders required provider notification for blood sugar levels above 400, but there was no documentation of such notifications in the medical record. Staff confirmed that they were educated to follow these parameters and document provider notifications, but this was not done in these instances.
Failure to Provide Respiratory Care per Physician Orders and Standards
Penalty
Summary
The facility failed to provide respiratory care and services in accordance with physician's orders and accepted professional standards for two residents requiring respiratory support. For one resident with an order for oxygen at 2 liters per minute (lpm) via nasal cannula to maintain oxygen saturation above 90%, observations showed the oxygen concentrator was set at 1.5 lpm on multiple occasions. The resident reported that the prescribed setting was 2 lpm and expressed reluctance to request an adjustment. Documentation confirmed the order for 2 lpm, and the care plan reflected this intervention, but staff were unaware of the discrepancy and could not explain how oxygen saturation was being maintained as ordered. For another resident using a CPAP machine, there were no active orders in the medication administration record regarding the CPAP, including settings, maintenance, or cleaning instructions. The resident reported that staff had never cleaned the CPAP mask, and repeated observations revealed visible debris and oily substances on the mask. Staff interviews confirmed a lack of knowledge and responsibility for CPAP care, and the Director of Nursing was unable to locate any active orders or confirm proper maintenance. These findings demonstrate a failure to ensure respiratory care was provided as ordered and according to facility policy.
Failure to Follow Infection Control Protocols During Resident Care and Medication Administration
Penalty
Summary
Staff failed to comply with infection prevention and control guidelines in several instances involving residents on transmission-based precautions, during perineal care, and while administering medications. For one resident with a right lower leg fracture and ankle wound, who was on Enhanced Barrier Precautions (EBP), a nursing assistant entered and exited the resident's room without donning any personal protective equipment (PPE) despite a posted EBP sign and available PPE cart. The nursing assistant later confirmed assisting the resident with toileting without PPE, and another staff member was unclear about the PPE requirements for this resident. During perineal care for another resident, a nursing assistant did not perform hand hygiene after removing gloves and before donning new ones, instead placing contaminated hands into the glove box and continuing care. The staff member acknowledged the lapse, and the facility's infection preventionist confirmed that hand hygiene should be performed each time gloves are removed during perineal care. In medication administration, a nurse used a glucometer in a resident's room and then placed the contaminated device and supplies on the medication cart without a barrier, disinfected the glucometer but not the cart, and repeated similar actions with an insulin pen. The nurse admitted that used equipment should be considered contaminated until disinfected and that barriers should have been used under the equipment both in the resident's room and on the medication cart. The infection preventionist confirmed that these steps were required by facility policy.
Resident Rooms Below Required Square Footage Standards
Penalty
Summary
The facility failed to ensure that seven resident rooms (107, 108, 110, 302, 305, 306, and 307) met the required minimum square footage per resident, as specified by regulatory standards. Observations and record reviews confirmed that each of these rooms contained two beds, but the measured square footage for each room ranged from 142 to 154 square feet, which is below the required 160 square feet for double occupancy rooms (80 square feet per resident). The facility census confirmed that these rooms were occupied by two residents each during the survey period. Staff interviews revealed that an exemption had been requested from the state for these rooms, but it had not been granted at the time of the survey.
Failure to Address Resident Grievances
Penalty
Summary
The facility failed to ensure that resident grievances were properly filed and addressed, as evidenced by the case of a resident who experienced multiple unresolved issues. The resident, who was alert and oriented, had previously stayed at the facility and reported several grievances during their stay. These included a noisy roommate, missing personal property, and dissatisfaction with a particular nursing assistant's care. Despite the resident's complaints, these grievances were not documented in the facility's grievance logs, except for one related to handwashing. The resident expressed concerns about a roommate's loud television and encroachment on personal space, which were verbally communicated to staff but not formally recorded as grievances. Additionally, the resident reported missing a pair of plaid lounge pants, which the laundry manager acknowledged but did not document as a grievance. Furthermore, the resident requested not to have a specific nursing assistant, Staff K, provide care due to unsanitary practices. However, Staff K continued to care for the resident on two occasions after the grievance was reported, and the grievance form lacked follow-up documentation to confirm the resident's satisfaction with the resolution. Interviews with facility staff revealed a lack of awareness and communication regarding the resident's grievances. The Director of Nursing Services was unaware of the missing item and noisy roommate issues, and the scheduler admitted to not properly reassigning Staff K despite knowing the resident's preference. The infection preventionist failed to document the resident's dissatisfaction with the resolution of their grievance. These oversights highlight the facility's failure to adhere to its grievance policy, which requires prompt resolution and follow-up with residents to ensure their concerns are addressed satisfactorily.
Failure to Honor Resident's Meal Preferences Due to Staffing
Penalty
Summary
The facility failed to honor the preferences of a resident, identified as Resident 26, regarding their Activities of Daily Living, specifically related to recreational meal intake. Resident 26, who was admitted with a stroke affecting their ability to swallow and maintain adequate nutrition, had physician orders for tube feeding to meet 100% of their nutritional needs. Despite being assessed as able to safely tolerate some oral intake with 1:1 supervision, the facility only provided this support for lunch from Monday through Friday, due to staffing limitations on weekends. This restriction was not aligned with the resident's preference to have a recreational meal every day, as they enjoyed the social aspect of the meals. Interviews with staff revealed that the scheduling practices did not account for the resident's needs on weekends. Staff G, the primary caregiver for Resident 26's meals, confirmed that the resident only received assistance during weekdays because they did not work on weekends, and no other staff were scheduled to provide this support. Staff I, responsible for scheduling, was unaware of any limitations affecting Resident 26's meal assistance. The Director of Nursing Services acknowledged the scheduling practices but did not provide further information on why the resident's meals were limited to weekdays. This oversight placed Resident 26 at risk for decreased quality of life, as their preference for daily social interaction during meals was not met.
Medication Administration During Meals
Penalty
Summary
The facility failed to ensure a homelike dining environment by allowing a registered nurse to administer medications to a resident during their meal in the dining room. This action was observed during a dining observation where Staff C, a registered nurse, gave a spoonful of crushed medications to Resident 5 while they were eating. The facility's policy stated that medications should be administered in the privacy of the resident's room or another private area, unless the resident requested otherwise. However, there was no indication that Resident 5 had requested to receive medications in the dining room. Resident 5, who was admitted with a diagnosis of dementia, had cognitive impairments and was unable to complete interview questions related to cognition. The staff assessment confirmed memory impairment and impaired decision-making. Despite this, Staff C stated that administering medications during meals was their usual practice for cognitively impaired residents, as they were more likely to take them at that time. This practice was acknowledged by Staff B, the Director of Nursing Services, who recognized the need for further education on the matter.
Deficiency in Comprehensive Resident Assessment
Penalty
Summary
The facility failed to ensure that the Resident Assessment Instrument (RAI) for a resident was comprehensive and included thorough summaries of the Care Area Assessments (CAA). Specifically, for one resident who was admitted with a fracture of the right upper leg and later admitted to hospice services, the CAA assessment did not contain a comprehensive analysis of findings. The assessment lacked the resident's goals, preferences, strengths, needs, or input from the resident or their representative. Instead, the CAA contained a brief narrative that suggested continuing to care plan to slow or minimize decline in Activities of Daily Living (ADLs). The contracted Registered Nurse responsible for completing the Minimum Data Set (MDS), including the CAA and care plans, stated that the process involved reviewing gathered information and providing a shorter description to proceed to the care plan. Despite daily telephonic meetings with the facility's Resident Care Manager and Director of Nursing Services to discuss residents, the comprehensive analysis required for the CAA was not completed. This oversight placed the resident at risk of not receiving appropriate services based on their individualized needs.
Failure to Implement Care Plan Interventions for Fall Prevention
Penalty
Summary
The facility failed to implement care plan interventions for a resident who was at high risk for falls, which placed them at risk for injury and decreased quality of life. The resident, who had a history of falls and poor trunk control, was readmitted to the facility with diagnoses including a fall, high blood pressure, and a fracture of the right upper leg. An incident report from January 2024 indicated that the resident fell out of bed due to poor trunk control, and therapy recommended using a positioning wedge with a secure strap to prevent further falls. However, during observations in July and August 2024, the resident was seen using the wedge improperly, without the strap, and stated they did not use it the previous night. The care plan for the resident, updated in January and revised in June 2024, directed staff to ensure the wedge was secured with a strap for safety. However, the treatment administration record for July 2024 did not document the use of the wedge, and staff interviews revealed a lack of awareness and understanding of the wedge's purpose and the need for the strap. The Director of Nursing Services was unaware of the resident's refusal to use the strap, and the care plan did not address the resident's poor trunk control. This deficiency was a repeat citation from October 2023.
Failure to Revise Care Plans for Discharge and Dental Services
Penalty
Summary
The facility failed to revise comprehensive care plans for two residents, leading to potential risks for unmet care needs. Resident 20, who was admitted with conditions including an above-the-knee amputation, diabetes, and high blood pressure, had a care plan that was not updated to reflect changes in their discharge planning. Despite being over-resourced and unable to move to an Assisted Living Facility as initially planned, the care plan was not revised to address these changes, although progress notes were documented in the medical record. Resident 3, admitted with diagnoses such as congestive heart failure and sleep apnea, experienced issues with their dental care plan. The resident's care plan did not reflect the absence of their upper partial dentures, which had been sent for repair before the COVID pandemic and not returned. Despite staff acknowledging the issue and working to resolve it, the care plan remained outdated, failing to address the resident's current needs for dental care and assistance with oral hygiene.
Failure to Implement Professional Standards of Practice
Penalty
Summary
The facility failed to implement professional standards of practice for two residents, leading to potential risks for adverse outcomes. Resident 26, who had a stroke affecting their ability to swallow, was prescribed a tube feeding to meet their nutritional needs and was assessed to tolerate some oral intake with specific swallow strategies. However, the care plan and Kardex did not include these strategies, and staff failed to consistently cue the resident during meals, as observed on multiple occasions. This lack of adherence to the Speech Language Pathologist's recommendations placed Resident 26 at risk for swallowing difficulties. Resident 21, diagnosed with Diabetes Mellitus Type 2, chronic pain, and high blood pressure, was prescribed Amlodipine Besylate with specific parameters to hold the medication if their systolic blood pressure was below 100 mm Hg. The Medication Administration Record (MAR) for July and August 2024 showed no documented blood pressures, indicating a failure to follow the physician's orders. Additionally, an A1C lab test ordered on 07/18/2024 was not completed until 15 days later, due to the order being placed in the wrong section of the electronic health record, which was not processed by the nursing staff. Interviews with the Director of Nursing Services and a facility consultant revealed that the transition to an electronic medical record system contributed to these errors. The blood pressure monitor was inadvertently left off the MAR, and the provider's notes were not fully integrated into the system, causing delays in processing orders. These deficiencies highlight the facility's failure to ensure professional standards of practice, as required by regulations.
Deficiency in Assistance with Activities of Daily Living
Penalty
Summary
The facility failed to provide adequate assistance with activities of daily living for two dependent residents, leading to a deficiency in care. Resident 30, who was admitted with a fracture of the right upper leg, required supervision or touching assistance with eating and partial/moderate assistance for oral hygiene. Despite these needs, observations revealed that Resident 30 was left unattended for extended periods, with meal trays left untouched and no assistance provided for oral hygiene. Interviews with staff indicated a lack of clarity and consistency in the care provided, with some staff believing the resident required only setup assistance, while others noted the resident's increasing dementia and need for more supervision. Resident 26, who had a history of stroke, impaired swallowing, and required a gastrostomy tube for nutrition, also did not receive adequate oral care. The care plan indicated the need for one-person assistance with oral care using glycerin swabs, but observations showed the resident's mouth was dry and coated with white matter, and the resident reported infrequent assistance with mouth swabbing. Staff interviews revealed inconsistencies in the understanding and execution of the resident's oral care needs, with some staff unaware of the specific requirements for glycerin swabs and the frequency of care needed. The facility's failure to provide necessary assistance with activities of daily living for these residents, particularly in terms of meal assistance and oral hygiene, placed them at risk for diminished quality of life. The lack of clear communication and adherence to care plans among staff contributed to the deficiency, as evidenced by the observations and interviews conducted during the survey.
Deficiencies in Resident Care and Repositioning
Penalty
Summary
The facility failed to ensure that residents received care and treatment in accordance with professional standards of practice, specifically for two residents. Resident 21, who was at risk for pressure ulcer development due to immobility and other comorbidities, had an alternating air mattress that was not set to the prescribed settings. Despite the mattress being ordered for wound prevention, the settings were incorrectly set at 450/25 instead of the required 300/15, as indicated on the pump's sticker. This discrepancy was not identified by the staff responsible for monitoring the mattress settings, leading to a potential risk of skin breakdown. Resident 30, who was admitted to hospice services and had a fracture of the right upper leg, was not repositioned according to the facility's policy. Observations showed that Resident 30 spent extended periods in bed without assistance from staff for repositioning or care, despite requiring extensive assistance for repositioning due to impaired balance and pain. The care plan for Resident 30 did not include a specific repositioning schedule or address the positioning of the resident's heels, which could contribute to pressure-related issues. Interviews with staff revealed a lack of awareness and adherence to the required care interventions for both residents. Staff responsible for Resident 21's care were unaware of the incorrect mattress settings, and staff caring for Resident 30 did not consistently follow a repositioning schedule. These failures in care delivery placed both residents at increased risk of unmet care needs and potential skin breakdown.
Failure to Complete Annual NAC Performance Reviews
Penalty
Summary
The facility failed to ensure that annual performance reviews for Nurse Aide Certified (NAC) staff were completed, specifically for one of the four NACs whose files were reviewed. Staff K, who was hired on July 6, 2023, did not have a current employee evaluation in their file, and there was no evidence that an evaluation was completed or discussed with them. During interviews, it was revealed that the facility underwent a change in ownership on May 1, 2024, and all staff completed new hire paperwork on that date. However, there was confusion regarding whether staff should retain their original hire dates or adopt the new May 1st date, which contributed to the oversight in completing performance evaluations.
Sanitation Deficiencies in Food Handling and Storage
Penalty
Summary
The facility failed to maintain sanitary conditions in food storage, preparation, and service, as observed in the kitchen, snack/nourishment refrigerators, and during meal delivery. In the kitchen, undated and expired food items were found, including a sandwich, a thickened dairy beverage, and pitchers of lemonade and iced tea. Temperature logs for the kitchen refrigerator were incomplete, and the dishwasher was not reaching the required temperature of 120 degrees Fahrenheit, initially recorded at only 100 degrees Fahrenheit. Staff interviews revealed a lack of awareness and adherence to proper food labeling and temperature monitoring protocols. In the unit nourishment refrigerator, several items were found without labels or dates, including cheese slices, oats, and muffins, along with expired ketchup and Capri Sun drinks. Staff interviews indicated confusion about responsibility for checking and discarding expired or unlabeled items. During meal delivery, desserts such as Jello were observed uncovered on trays, contrary to sanitary serving practices. These deficiencies in food handling and storage practices placed residents at risk of consuming contaminated or spoiled food.
Infection Control Deficiencies in PPE Use and Linen Handling
Penalty
Summary
The facility failed to adhere to infection prevention and control practices, specifically in the use of personal protective equipment (PPE) and the handling of oxygen (O2) tubing. For Resident 23, who was on aerosol contact precautions due to COVID-19, staff did not properly don and doff PPE. Staff S entered the resident's room wearing only an N95 respirator, unaware of the need for additional PPE such as a gown and gloves. Staff P also failed to wear the appropriate mask and improperly doffed the gown and gloves outside the resident's room, disposing of them down the hallway. Resident 3, who used oxygen therapy at night due to obstructive sleep apnea, had their O2 tubing improperly stored. The tubing was observed lying on the floor and later rolled and placed on top of the concentrator, contrary to good practice. Staff interviews revealed that the tubing should be stored in a plastic bag when not in use, but this was not consistently done, as the bags often disappeared. Additionally, the facility did not cover clean linens during transport, as observed with Staff D and Staff U carrying uncovered clothing protectors and towels through the hallways. Interviews with staff confirmed that clean linens should be covered when transported, but this practice was not followed, contributing to the risk of infection spread within the facility.
Deficiency in Nurse Aide Training Hours
Penalty
Summary
The facility failed to develop, implement, and maintain an in-service training program to ensure that Nursing Assistants Certified (NACs) received the required 12 hours of training per year. This deficiency was identified during a review of the employee file for one of the NACs, referred to as Staff K, who had only completed 6.3 hours of training instead of the mandated 12 hours. The facility's assessment indicated that training topics included communication, resident rights, abuse prevention, infection control, and culture change, but there was no documented evidence of the required training duration or start times for Staff K. During an interview, the Staff Development Coordinator acknowledged the shortfall in training hours for Staff K and mentioned efforts to ensure compliance with the 12-hour training requirement. Although the facility was able to locate the necessary training documentation for other NACs, they could not provide evidence for Staff K, indicating a lapse in maintaining comprehensive training records. This failure placed residents at risk for potential unmet care needs due to insufficiently trained staff.
Deficiency in Resident Room Size Requirements
Penalty
Summary
The facility failed to ensure that six resident rooms met the regulatory requirements for square footage, with multiple resident rooms needing at least 80 square feet per resident and single resident rooms requiring at least 100 square feet. Specifically, rooms 107, 108, 302, 305, 306, and 307 did not meet these standards. Observations and record reviews revealed that rooms 107, 302, 305, and 307 each had two beds but did not provide the required space per resident, with room sizes ranging from 142 to 154 square feet for two beds. Despite these deficiencies, surveyor observations determined that the health and safety of the residents residing in these rooms were not compromised due to the size of the rooms. This issue was noted as a repeat citation from a previous survey conducted on October 16, 2023.
Latest citations in Washington
Inaccurate PASARR screening affected two residents. One resident with vascular dementia, depression, and adjustment disorder had a PASARR level one that did not reflect mental health diagnoses, and staff stated it was inaccurate. Another resident with PTSD had a PASARR level one that did not include the PTSD diagnosis, with no additional PASARR level one or level two found in the EHR; staff stated the screening was not accurate and should have been repeated.
Undated open meds were found on 2 medication carts, including an open insulin vial and multiple open eye drop bottles with no dates. An LPN and an RN both stated the items should have been dated when opened, and the DON stated open multidose vials or bottles found without a date should be discarded immediately.
A resident with respiratory failure, HTN, and anxiety became SOB and diaphoretic, received a breathing tx, and was sent by EMS to the hospital. The facility could not locate the required SNF/NF to Hospital Transfer form or other transfer records showing what information was communicated to the receiving provider.
Care plans for two residents were not updated to match their current status and care needs. One resident had PTSD and generalized anxiety disorder and was receiving a psychotropic medication, but the care plan listed monitoring for antipsychotic and anticonvulsant meds that were not prescribed and did not include the anxiety diagnosis or related behaviors and interventions. Another resident had new upper and lower dentures, but the oral/dental care plan only noted edentulous status and difficulty chewing, with no mention of dentures or denture-related interventions.
Failure to Provide Individualized Activities: A resident with anxiety, depression, and weakness was cognitively intact but said they could not attend group activities because of leg problems and wanted more in-room activities. The resident mostly stayed in bed watching TV, and staff documentation showed only limited room visits with no consistent activity documentation despite a care plan goal for participation two to three times per week.
Failure to maintain heel offloading for a resident with a reopened DFU. A resident with dementia and dependence for mobility had a left heel wound that had healed and then reopened; the wound care provider recommended heel floating and pressure relieving boots at all times, but observations showed the resident in bed with heels on the mattress and later reclined in a wheelchair with the heel resting on the footrest strap and no boots in place. Staff stated the resident had not refused the boots or heel floating, and the care plan was not updated after the wound reopened.
Failure to Address Hearing and Vision Services for a Resident: A resident with dementia, bilateral hearing loss, and impaired vision was observed without eyeglasses or a hearing device, despite records showing admission with eyeglasses and a personal sound amplifier. The care plan addressed vision only and did not include hearing-related interventions, while staff interviews confirmed the resident’s hearing was strained and that the resident’s device use and vision needs were not fully reflected in the plan of care.
Respiratory care was not provided consistently for two residents receiving O2. One resident with COPD and chronic respiratory failure had an O2 order missing the indication for use and Sats parameters, no MAR documentation of O2 therapy, and inconsistent Sats charting. Another resident with respiratory failure was observed on continuous O2 via NC, but provider orders for O2 therapy and tubing changes were not present after readmission, despite the care plan stating the resident was dependent on O2.
A resident with dementia, hearing loss, and missing lower teeth had an MDS showing obvious or likely cavities or broken natural teeth, and the care plan identified oral/dental health problems with an intervention to coordinate dental care and transportation. Staff stated the resident’s dental needs were captured on the MDS, but no referral was made for dental services or follow-up with the dentist, and the DON said the lack of referral did not meet expectations.
Inaccurate Meal Intake Documentation: A resident with DM, dysphagia, and protein-calorie malnutrition was observed eating less than 25% of a meal, but the POC documented 76-100% intake. The CNA said the resident usually ate only 25-50% of meals and that intake was sometimes documented based on what a coworker reported. The LPN/RCM and DON stated meal intake should be documented accurately.
Inaccurate PASARR Screening for Two Residents
Penalty
Summary
The facility failed to ensure that two residents were screened for additional mental health supports through the PASARR process. Resident 97 was admitted with diagnoses including vascular dementia, depression, and adjustment disorder, and was able to make needs known. Review of the PASARR level one dated 04/10/2026 showed no mental health diagnoses and no need for a PASARR level two, even though the resident’s record included mental health diagnoses. During interview, the Regional Social Services staff and the Administrator stated the PASARR was inaccurate, needed modifications, and did not meet expectations. Resident 6 was admitted with diagnoses including heart failure, respiratory failure, and PTSD, and was able to make needs known. Review of the PASARR level one dated 03/30/2026 showed no serious mental illness indicators marked and no PASARR level two indicated, and the EHR contained no other documented PASARR level one or level two. The Social Services Director stated the hospital-provided PASARR was reviewed for accuracy and, if inaccurate, another level one would be completed, and stated this resident’s PASARR did not include PTSD and should have had another level one completed. The Administrator also stated the PASARR was not accurate and another level one needed to be conducted, but none could be located in the EHR.
Undated Open Medications on Medication Carts
Penalty
Summary
The facility failed to ensure proper storage and labeling of medications for 2 of 3 sampled medication carts reviewed for medication storage and labeling, including carts on the 400 and 500 halls. On the 500 hall medication cart, an open vial of insulin and an open bottle of eye drops were observed with no dates. During interview, an LPN stated that when an insulin vial or bottle of eye drops is opened, it should be dated immediately and said both items should have been dated upon opening; the LPN stated they would dispose of the undated vial and bottle. On the 400 hall medication cart, two open bottles of eye drops were observed with no dates. During interview, an RN stated both bottles should have been dated as soon as they were opened and said they would get new eye drops and dispose of the undated bottles. The DNS/RN stated that if an eye drop was opened it should have been dated immediately and that any open multidose vial or bottle found without a date should be discarded immediately.
Missing Hospital Transfer Documentation
Penalty
Summary
The facility failed to ensure hospital transfer documentation was completed for one resident who was transferred to the hospital after complaining of not being able to breathe and appearing diaphoretic. The resident had diagnoses of respiratory failure, high blood pressure, and anxiety disorder, and was able to make needs known. A breathing treatment was provided, and the provider agreed to send the resident out for further evaluation, after which emergency transportation took the resident to the hospital. Record review found no documentation showing what information was provided or communicated to the receiving facility for the transfer. Staff stated that transfer documentation should have included a SNF/NF to Hospital Transfer form, the resident's face sheet, and the medication and treatment administration records, but they were unable to locate documentation showing these items were completed or sent for the resident's hospital transfer.
Care plans did not reflect current diagnoses, medications, or denture status
Penalty
Summary
The facility failed to ensure that care plans were revised and accurately reflected residents’ current status and care needs for 2 of 21 sampled residents. Resident 6 was admitted with diagnoses including heart failure, respiratory failure, and PTSD, and was able to make needs known. The EHR showed Resident 6 also had generalized anxiety disorder and was receiving a psychotropic medication, but the current care plan dated 05/05/2026 documented monitoring for side effects of antipsychotic and anticonvulsant medications even though Resident 6 was not prescribed those medications. The care plan also identified PTSD but did not include generalized anxiety disorder or behaviors to monitor and interventions related to PTSD or anxiety disorder. Staff F, LPN/CC, stated the care plan did not accurately reflect the resident’s current status or prescribed medications, and Staff B, DNS, stated it did not meet expectations because it did not address the anxiety disorder or target behaviors and interventions. Resident 71 was admitted with diagnoses including PTSD, high blood pressure, and depression and was able to make needs known. Observation on 05/06/2026 showed a denture cup by the sink with the resident’s name on the lid and new upper and lower dentures dated 01/12/26. The resident stated the lower dentures did not fit well and that denture adhesive had been provided, but the dentures still did not fit right and the resident had not told staff yet. The focused oral/dental care plan, initiated on 06/23/2026, identified the resident as edentulous and having difficulty chewing, but did not show that the resident had dentures or include interventions related to denture use or maintenance. Staff E, CNA, stated they had not seen the resident wear dentures and were unaware of the new dentures, Staff C, LPN/CC, stated the care plan should have been updated when the dentures were obtained, and Staff B, DNS, stated the care plan should have reflected the dentures and interventions.
Failure to Provide Individualized Activities
Penalty
Summary
The facility failed to provide individualized activities for Resident 5, who was admitted with diagnoses including anxiety disorder, depression, and weakness. The admission MDS dated 01/14/2026 showed the resident was cognitively intact. During interviews on 05/03/2026 and 05/06/2026, Resident 5 stated they could not attend in-person activities because of their legs, wanted more activities to occupy them, mostly stayed in bed watching TV, and did not remember the last time activities staff visited to offer activities. The resident also stated activities staff would need to offer something they were able to do because they had difficulty doing some activities. The activities care plan dated 12/26/2026 showed a goal for Resident 5 to participate in activities two to three times per week. Progress notes documented one visit on 12/22/2026 to provide a welcome packet and encourage participation in daily activities, but no further activity documentation was found in the progress notes. Staff H stated room visits should include puzzles, arts and crafts, visiting, and chatting, and that documentation was placed in tasks, but the task record showed no documentation of activities for the past 30 days. Staff J stated paper documentation existed for room visits and that Resident 5 was on a list for room visits every Monday and Wednesday, while the room visit documentation showed only four visits on 01/26/2026, 02/06/2026, 03/10/2026, and 04/08/2026.
Failure to Maintain Heel Offloading for Reopened DFU
Penalty
Summary
The facility failed to consistently implement pressure reducing strategies for a resident with a left heel diabetic foot ulcer that had reopened. The resident was admitted with diagnoses including left hip fracture with surgical repair, a blood clot of the left lower leg, and dementia, and was dependent on staff for mobility and unable to make needs known. The baseline care plan and care plan both included heel offloading interventions, and the wound care provider initially recommended heel floating with pillows or wedge and pressure relieving boots. The wound later resolved, but a weekly skin assessment documented that the left heel wound reopened and was very painful to touch. After the wound reopened, the contracted wound care provider documented that the DFU to the left heel had reopened and recommended the resident wear pressure relieving boots at all times. The current care plan reviewed after the wound reopened did not include new interventions related to the reopened wound. Observations showed the resident seated in a reclined wheelchair with the left foot/heel resting on the footrest strap and no pressure relieving boots in place, and later lying in bed with both heels directly on the mattress without being floated and without boots. Staff interviews indicated the resident had not refused the boots or heel floating, and the LPN/CC and DON stated the resident should have been assessed and the plan of care updated when the wound reopened.
Failure to Address Resident Hearing and Vision Needs
Penalty
Summary
The facility failed to address one resident’s hearing and vision needs. Resident 112 was admitted with diagnoses including a leg fracture, dementia, and hearing loss in both ears, and was able to make needs known. The record showed the resident lost their glasses and was given readers, but the resident did not wear them because they were concerned that wearing glasses that were not their prescription would further degrade their vision. Observation did not show glasses in the resident’s room, and the resident stated they did not use a hearing aid. The resident was observed to be hard of hearing, requiring an elevated voice and repeated questions to understand. The admission MDS dated [DATE] documented adequate hearing with hearing aid and adequate vision with corrective lenses, while the significant change MDS dated [DATE] documented moderate difficulty hearing without a hearing aid and impaired vision without corrective lenses. The care plan initiated 02/24/2026 addressed impaired vision with interventions to arrange consultation with eye care practitioners as needed and remind the resident to wear glasses, but it did not include a focus area or interventions for hearing loss or use of hearing aids. A resident clothing list showed the resident admitted with one pair of eyeglasses and one Super Ear headset personal sound amplifier, yet observation and interview showed the resident in bed without eyeglasses or a hearing device, with the amplifier stored in the bedside table drawer. Staff interviews confirmed the resident’s hearing was strained, that the hearing device and glasses were not being used, and that the resident’s hearing device use should have been included in the plan of care and the resident should have been referred for eye care assessment.
Respiratory Care Orders and Documentation Not Maintained
Penalty
Summary
The facility failed to provide respiratory care consistent with professional standards of practice for two residents receiving oxygen therapy. One resident with COPD and chronic respiratory failure with hypoxia was observed multiple times lying in bed receiving oxygen at 2 L via nasal cannula. The resident’s oxygen order, dated 02/15/2026, allowed 1 to 4 L per minute continuously via nasal cannula, but it did not include an indication for use or oxygen saturation parameters. The April and May 2026 MARs did not show documentation of oxygen therapy being provided, and the TARs showed only an order to change oxygen tubing if damaged or visibly soiled, not an order for oxygen therapy. Oxygen saturations were not documented consistently daily from 04/01/2026 through 05/04/2026. A second resident with respiratory failure, high blood pressure, and anxiety disorder was observed in the room receiving oxygen at 6 L via nasal cannula on multiple occasions. The resident stated they needed oxygen therapy to breathe, and the care plan identified the resident as dependent on oxygen and to receive oxygen per provider orders. However, provider orders reviewed on 05/04/2026 showed no orders for oxygen therapy or for changing oxygen tubing. Staff stated the oxygen and tubing-change orders had been discontinued when the resident went to the hospital and were not added back to the MAR or TAR when the resident readmitted to the facility.
Failure to Refer Resident With Identified Dental Needs
Penalty
Summary
The facility failed to ensure that Resident 112 received needed dental care. Resident 112 was admitted with diagnoses including a leg fracture, dementia, and hearing loss in both ears. Observation on 05/03/2026 showed the resident had missing lower teeth. The admission MDS, dated [DATE], documented obvious or likely cavities or broken natural teeth, and the care plan dated 02/24/2026 identified oral/dental health problems related to likely cavities or broken teeth with an intervention to coordinate dental care and provide transportation. During interviews, Staff G, Regional Social Services, stated Resident 112's dental needs were captured on the 02/24/2026 MDS and the resident was not referred for dental services. Staff M, Social Services Director, stated residents with dental needs should be referred to social services to be scheduled for assessment by a dental care practitioner, and that Resident 112 should have been referred after the MDS assessment. Staff B, DON, stated residents with identified dental needs should be referred for follow-up with a dentist and that Resident 112 should have been referred to the in-house dental provider; Staff B stated the lack of referral did not meet expectations.
Inaccurate Meal Intake Documentation
Penalty
Summary
The facility failed to accurately document the amount of food eaten for Resident 13, who was admitted with diagnoses including diabetes mellitus, dysphagia, and protein-calorie malnutrition. The quarterly MDS dated 02/12/2026 showed the resident was moderately cognitively impaired. During observation on 05/05/2026 at 12:09 PM, a meal tray was delivered to the resident’s room, set up on a bedside table, and the resident was observed eating slowly, eating less than 25% of the meal, then laying back in bed and closing their eyes while the tray remained in the room. Staff later removed the tray, but the POC documentation for lunch on 05/05/2026 recorded that Resident 13 ate 76-100% of the meal. During interview, the CNA stated the resident typically ate 25-50% of meals and never ate all of the food, and that if they did not pick up a tray they would ask a coworker what the resident ate before documenting it. The CNA stated they were told the resident ate 75-100% of lunch, so that is what was entered. The LPN/RCM stated staff should document meal intake accurately in POC, and the RN/DNS stated it was their expectation that all staff document meal intake accurately.
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