North Valley Hospital
Inspection history, citations, penalties and survey trends for this long-term care facility in Tonasket, Washington.
- Location
- 22 W 1st Street, Tonasket, Washington 98855
- CMS Provider Number
- 505454
- Inspections on file
- 26
- Latest survey
- March 5, 2026
- Citations (last 12 mo.)
- 7
Citation history
Health deficiencies cited at North Valley Hospital during CMS and state inspections, most recent first.
A resident with atrial fibrillation was receiving Eliquis daily and was later started on Naproxen 250 mg BID for pain, ordered by the MD as a two-week short course. The RCM entered the Naproxen order into the MAR without an end date, and the medication continued to be administered BID until the resident was discharged. Staff later identified extensive bruising to the resident’s inner thighs, buttocks, and perineal area, and the DON acknowledged that the ongoing concurrent use of Eliquis and Naproxen, despite the intended time-limited order, could have contributed to the bruising.
Improper Hand Hygiene During Meal Service: Two dietary staff were observed preparing lunch without performing hand hygiene when changing gloves or after touching non-food surfaces. A Dietary Aide plated food, opened the heated food cart and cooler doors, and resumed plating with the same gloves, while a Cook handled cheesecake, touched the cooler handle, removed items, and continued food prep without hand hygiene during glove changes. The RD stated staff were expected to wash hands or use hand sanitizer with every glove change and change gloves after touching other surfaces.
A resident with Parkinson’s disease was prescribed Carbidopa-Levodopa, and pharmacy review noted it was being given during flexible med times instead of at specific times. The MAR showed the medication continued on flexible timing for months, with no documentation that the MD was informed of the pharmacy recommendation until the administration time was later changed.
The facility failed to adhere to food safety standards, with expired and undated food items found in storage areas. Staff transported uncovered food without proper hand hygiene, and food temperatures were not consistently monitored. These actions were acknowledged by staff, highlighting risks of food-borne illnesses.
The facility did not repair damaged paint and drywall from a water leak over a year ago, leaving large sections of puffed-up paint and sagging drywall near dining rooms. Additionally, hazardous chemicals were found unsecured in a shower room, posing a risk to residents. Staff interviews confirmed the need for timely repairs and securing of chemicals.
The facility failed to conduct required Level II PASRR evaluations for two residents with serious mental illness indicators. One resident was prescribed antipsychotic and antidepressant medications for hallucinations and depression, while another had severe cognitive impairment and depression. Despite these conditions, no referrals for Level II evaluations were made, as acknowledged by the Social Service Director.
The facility failed to maintain standard precautions and proper hand hygiene during medication administration. An LPN did not perform hand hygiene before entering a resident's room and administered medications without cleansing hands. Another instance involved a nurse administering an insulin injection without cleansing the site or wearing gloves. Staff interviews confirmed these actions violated infection prevention policies.
A facility failed to accurately document a resident's dental status in the MDS, despite the resident having severe cognitive impairment and being dependent on staff for oral hygiene. Observations showed poor dental condition, which was not reflected in the MDS, as confirmed by the DON and Resident Care Manager.
A resident with Alzheimer's and dementia experienced a decline in physical abilities, requiring total assistance for ADLs and a mechanical lift for transfers. Despite these changes, the facility failed to conduct a significant change assessment or update the care plan, as confirmed by staff observations and interviews.
A facility failed to develop a comprehensive care plan for a resident's dental needs, despite the resident's dependency on staff for oral hygiene and a diagnosis of periodontal disease. The care plan lacked documentation of the resident's dentation status, and staff interviews confirmed the oversight.
A resident with impaired vision required assistance with ADLs, including personal hygiene. Despite needing supervision, the resident's nails were observed to be unclean with a brown substance, as staff failed to clean under the nails after meals. Interviews with staff confirmed that nail care was not consistently provided after meals, which is crucial to prevent bacteria. The DON acknowledged the importance of this practice.
A facility failed to adequately monitor a resident's use of psychotropic medications, leading to unnecessary drug administration. The resident, with diagnoses including dementia and bipolar disorder, was on antidepressant and antipsychotic medications. Despite policy requirements, there was insufficient documentation of behaviors or symptoms of depression. Medication adjustments were made without proper documentation, and staff acknowledged the lack of detailed behavior records.
A resident with severe cognitive impairment and diagnosed with periodontal disease did not receive necessary dental care due to the facility's failure to follow up on a provider's referral for a dental evaluation. Despite being dependent on staff for oral hygiene, the resident had not been seen by a dentist since admission, leading to poor oral health conditions observed by surveyors.
The facility failed to maintain the stove hood in a safe and clean condition, with a section falling and grease buildup observed. The Dietary Manager was unaware of the issue until the surveyor's observation, and maintenance was only notified afterward. The stove hood was previously cleaned quarterly but had shifted to twice a year, and the issue might have occurred during the last cleaning.
Failure to Discontinue Naproxen Ordered as Short Course in Resident on Eliquis
Penalty
Summary
The facility failed to ensure a resident’s drug regimen was free from unnecessary drugs when an anti-inflammatory medication, Naproxen, ordered for a limited duration, was entered and administered without an end date while the resident was also receiving the anticoagulant Eliquis. The resident had been admitted with atrial fibrillation and was taking Eliquis daily to reduce the risk of stroke or heart attack. On 12/02/2025, the physician documented that the resident had knee and shoulder pain and could start Naproxen 250 mg twice daily for two weeks, as a short course if renal and gastrointestinal status allowed. The resident care manager (Staff B) reviewed this note and entered the Naproxen order into the MAR on the same date but omitted the two-week stop date, resulting in an open-ended order. The MAR showed that Eliquis was ordered once daily to continue until discharge, and Naproxen, entered on 12/02/2025 without an end date, was administered twice daily through the resident’s discharge on 02/25/2026. On 02/23/2026, staff identified significant dark blue/purple bruising on the resident’s inner thighs, buttocks, and perineal region, which was documented in a skin check and subsequent skin assessment with measurements of multiple bruised areas. During interviews, Staff B confirmed they had entered the Naproxen order without an end date despite the physician’s two-week limitation and could not recall why the end date was omitted. The DON (Staff A) confirmed the resident had been on Eliquis since admission and that Naproxen, intended as a two-week course, continued until discharge, and stated that the interaction between Eliquis and Naproxen could have caused the bruising identified on 02/23/2026.
Improper Hand Hygiene During Meal Service
Penalty
Summary
The facility failed to follow food code regulations during lunch meal service by not correctly performing hand hygiene when indicated for 2 of 2 dietary staff observed. On 02/26/2026, Staff D, a Dietary Aide, plated the main dish while wearing gloves, then unlatching and opening the heated food cart door twice and opening the cooler door to remove needed items without changing gloves, washing hands, or using hand sanitizer before resuming food plating with the same gloves. During the same meal service, Staff E, a Cook, plated cheesecake with caramel drizzle and apple topping, then touched the cooler handle, removed items from the cooler, touched the cheesecake to nudge it to the center of the plate, and squeezed the caramel bottle while wearing the same gloves. Staff E changed gloves during food service, but did not perform hand hygiene with the glove changes. Neither Staff D nor Staff E washed their hands at the sink until food service was completed or used hand sanitizer during any glove changes. Staff E stated gloves should be changed after touching anything other than serving utensils, Staff D agreed they should have changed gloves after touching cooler handles, and both stated hand hygiene should have been done whenever gloves were changed. Staff C, Registered Dietician, stated dietary staff were expected to perform hand hygiene with every glove change and change gloves after touching other surfaces during meal preparation.
Delayed Follow-Up on Pharmacy Recommendation for Parkinson’s Medication
Penalty
Summary
The facility failed to ensure that pharmacy recommendations were followed up on for one sampled resident who was reviewed for unnecessary medication. The resident had diagnoses including Parkinson’s disease, a progressive brain disorder that causes problems with movement, balance, and coordination, and was prescribed Carbidopa-Levodopa for symptoms of the disease. A pharmacy consultation report dated 09/29/2025 documented that the resident was receiving Carbidopa-Levodopa during flexible medication times, and recommended that it be administered at specific times instead. Review of the MAR showed that the Carbidopa-Levodopa continued to be given during flexible medication times through October 2025 and November 2025. No documentation was found showing that the physician had been informed of the pharmacy recommendation. A later pharmacy consultation report dated 11/24/2025 repeated the recommendation to change the medication to a specific administration time, and the December 2025 MAR showed the administration time was changed on 12/26/2025, almost three months after the initial recommendation. In interview, the Resident Care Manager stated the facility had identified issues with timely follow-up on pharmacy recommendations.
Food Safety and Sanitation Deficiencies
Penalty
Summary
The facility failed to store food in accordance with professional standards for food service safety, as observed during a tour of the kitchen and storage areas. Expired and undated food items were found in three refrigerators and one dry storage area. Items such as nut mix, trail mix, brown rice, instant mashed potatoes, and toasted seeds were either expired or lacked open or expiration dates. Similarly, the refrigerator and freezer contained undated cheese, grapes, bacon, crescent rolls, and various other food items. Staff I, the Dietary Manager, acknowledged the need for food to be dated for quality and safety. During dining room observations, Staff M, a Dietary Aide, was seen transporting uncovered plates of food across a common hall without removing gloves or performing hand hygiene. This practice was repeated multiple times, and food was not covered during transport, which was acknowledged by Staff N, an LPN, and Staff C, a Resident Care Manager, as a potential risk for bacterial contamination. Staff B, the Director of Nursing, noted that the common hall was considered part of the dining room area, which led to the oversight. The facility also failed to consistently monitor food and equipment temperatures. During a tray line observation, Staff O, a Cook, attempted to serve a chicken breast that did not meet the required temperature of 165 degrees. Cold food items were also found to be above the required temperature of 41 degrees. Additionally, refrigerator and dishwasher temperature logs showed multiple omissions, with no corrective actions documented for out-of-range temperatures. Staff I emphasized the importance of monitoring temperatures to ensure food safety and sanitation.
Facility Fails to Repair Water Damage and Secure Hazardous Chemicals
Penalty
Summary
The facility failed to ensure the timely repair of damaged paint and drywall following a water leak in one of the halls. Observations revealed large sections of puffed-up paint and sagging drywall near the dining rooms, with dried brown discolored drip streaks and bubbled wallpaper. Staff interviews indicated that the damage was a result of a water leak that occurred over a year ago, yet the necessary repairs had not been completed. Staff members, including a Licensed Practical Nurse, a Registered Nurse, and a Maintenance Assistant, were unsure of the duration of the disrepair, but acknowledged the damage and its origins. Additionally, the facility did not secure hazardous chemicals in a shower room, posing a risk to residents. During observations, an unlocked cabinet containing disinfectant cleansers was found in the shower room on the east hall. Staff interviews confirmed that the chemicals should have been locked to prevent potential harm to residents, particularly those who are cognitively impaired. The Director of Nursing acknowledged the importance of securing these chemicals to avoid potential ingestion by residents.
Failure to Conduct Required PASRR Level II Evaluations
Penalty
Summary
The facility failed to ensure that the Level I Preadmission Screening and Resident Review (PASRR) was accurately completed for Resident 6, who was admitted with diagnoses including chronic pain. Despite the initial assessment indicating no serious mental illness, subsequent documentation revealed that Resident 6 was prescribed antipsychotic and antidepressant medications for visual hallucinations and moderate recurrent major depression. The facility did not conduct a Level II PASRR evaluation, which is required when a resident shows signs of serious mental illness. This oversight was evident in the quarterly assessment, which noted Resident 6 felt down, depressed, or hopeless, yet no referral for a Level II evaluation was made. Similarly, Resident 31, who was admitted with depression and a psychotic disorder, was not referred for a Level II PASRR evaluation despite having severe cognitive impairment and experiencing feelings of depression. The facility's Social Service Director acknowledged that no referrals for Level II evaluations had been made in several years, even though the process requires it when a positive Level I PASRR is identified. The Director of Nursing expected staff to follow the appropriate PASRR process, but the lack of referrals indicates a failure in adhering to these requirements.
Infection Control and Hand Hygiene Deficiencies
Penalty
Summary
The facility failed to ensure standard precautions and proper hand hygiene were maintained during medication administration, as observed in two separate instances. In the first instance, an LPN did not perform hand hygiene before entering a resident's room, touched various surfaces, and administered medications without cleansing hands. The LPN only used alcohol-based hand rub upon exiting the room. In the second instance, the same LPN washed hands before applying gloves but failed to change gloves or perform hand hygiene after obtaining a blood sample and before administering an injection. Additionally, a registered nurse administered an insulin injection to another resident without cleansing the injection site with an alcohol wipe and without wearing gloves. Interviews with staff, including the Director of Nursing, confirmed that these actions were against the facility's infection prevention policies, which require hand hygiene before and after resident contact, and the use of gloves and cleansing of injection sites to prevent infection.
Inaccurate MDS Documentation of Resident's Dental Status
Penalty
Summary
The facility failed to ensure the Minimum Data Set (MDS) accurately reflected the status of a resident, specifically regarding their dental condition. Upon admission, the resident was noted to have severe cognitive impairment and was dependent on staff for oral hygiene. However, the admission assessment did not document the status of the resident's own teeth, and the MDS did not accurately reflect the resident's dental status as of the assessment reference date (ARD). This oversight was confirmed by the Director of Nursing and the Resident Care Manager, who acknowledged that the MDS should have accurately reflected the resident's dental condition. Observations and interviews revealed that the resident had a thick layer of white debris along their bottom teeth, missing upper teeth, and jagged discolored front teeth. Staff members, including a Nursing Assistant and a Registered Nurse, were aware of the resident's poor dental condition but did not ensure it was accurately documented in the MDS. The failure to accurately assess and document the resident's dental status placed them at risk of unmet care needs and diminished quality of life.
Failure to Assess Significant Change in Resident's Condition
Penalty
Summary
The facility failed to recognize and assess a significant change in the condition of a resident, identified as Resident 27, who was diagnosed with Alzheimer's disease and dementia with anxiety. Initially, the resident required partial to moderate assistance for eating and substantial to maximum assistance for other activities of daily living (ADLs). However, a later assessment indicated that the resident required substantial to maximum assistance for eating and was totally dependent on staff for ADLs. Despite these changes, a significant change assessment was not completed, and the resident's care plan was not updated to reflect their increased needs. Observations and staff interviews revealed that Resident 27 was being fed by staff and required a mechanical lift for transfers, indicating a decline in their physical abilities. Staff members, including nursing assistants and the Resident Care Manager, acknowledged the resident's increased dependency but did not conduct a significant change assessment. The Director of Nursing admitted that internal audits had identified deficiencies in the comprehensive assessment process, which needed improvement.
Failure to Document and Address Resident's Dental Needs
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for a resident, specifically regarding their dentation status and needs. The resident, who was admitted with diagnoses including cancer and muscle wasting, was dependent on staff for oral hygiene. Despite the nursing admission assessment noting the presence of a partial denture and no immediate oral concerns, there was no documentation about the resident's own teeth or their status. The personal hygiene care plan also lacked goals or interventions related to the resident's dentation status. Further review of the resident's medical records revealed that a provider note indicated the resident had periodontal disease and was referred for a dental evaluation, yet this was not reflected in the care plan. Nursing progress notes documented issues with the resident's oral care, such as refusal to remove dentures and difficulty in cleaning food debris. Observations showed poor oral hygiene, with missing and discolored teeth. Interviews with staff confirmed the resident's dependency on staff for oral care and acknowledged the absence of documentation regarding the resident's dental status in the care plan.
Failure to Provide Adequate Grooming and Hygiene
Penalty
Summary
The facility failed to consistently provide grooming for a resident who was cognitively intact but had impaired vision and required assistance with activities of daily living (ADLs), including personal hygiene. According to the resident's care plan, they needed supervision and set-up assistance for ADLs. Despite this, observations and interviews revealed that the resident's nails were unclean with a brown substance underneath them, indicating a lack of proper grooming. The resident, who used their fingers to eat, reported that staff had not cleaned under their nails after meals, which is a necessary practice to prevent bacteria. Interviews with staff confirmed that nail care was typically completed after showers, but it should have also been provided after meals for residents who ate with their fingers. The Director of Nursing acknowledged the importance of this practice to prevent bacterial harboring under nails. The deficiency was identified through observations and interviews conducted over several days, highlighting the facility's failure to adhere to the resident's care plan and ensure proper hygiene practices.
Failure to Monitor Psychotropic Medication Use
Penalty
Summary
The facility failed to ensure that a resident's drug regimen was free from unnecessary medications, specifically psychotropic drugs. Resident 18, who had diagnoses including dementia, depression, bipolar disorder, and PTSD, was administered antidepressant and antipsychotic medications. Despite the facility's policy requiring documentation of behaviors and monitoring of residents on psychotropic medications, there was no documentation of behaviors or signs of depression for Resident 18 from April to July 2024. The resident's antipsychotic medication was decreased on April 30, 2024, without any observed changes in mood or behavior, and further orders were given to decrease the medication slowly due to the resident's stable bipolar disorder. However, on May 16, 2024, the resident reported feeling unmotivated, leading to an increase in both the antipsychotic and antidepressant medications. Despite this, there was no documentation of behaviors or symptoms of depression. The facility's staff, including the Social Service Director and Resident Care Manager, acknowledged that behaviors should have been documented in more detail. The Director of Nursing also confirmed that the resident's behaviors were inadequately documented, which contributed to the deficiency in monitoring and managing the resident's psychotropic medication regimen.
Failure to Provide Dental Services for a Resident
Penalty
Summary
The facility failed to assist a resident, identified as Resident 31, in obtaining necessary dental care, which was required as part of their routine health services. Resident 31, who was admitted with diagnoses including cancer and muscle wasting, was dependent on staff for oral hygiene due to severe cognitive impairment. Despite a provider's note on April 29, 2024, indicating that Resident 31 had periodontal disease and required a dental evaluation and treatment, there was no follow-up or documentation of a dental evaluation being conducted. The provider's order for a dental evaluation was not found in the records, and nursing progress notes from March to November 2024 did not indicate any dental visits or evaluations. Observations made in November 2024 revealed that Resident 31 had a thick layer of white debris along their lower teeth, and some missing and discolored upper teeth. Interviews with staff, including nursing assistants and resident care managers, confirmed that Resident 31 was dependent on staff for oral care and sometimes refused care. However, there was no record of a dental referral being processed, and the resident's representative confirmed that Resident 31 had not been seen by a dentist since admission. The Director of Nursing acknowledged the expectation for staff to follow up on provider referrals, which was not met in this case.
Failure to Maintain Safe and Clean Kitchen Equipment
Penalty
Summary
The facility failed to maintain kitchen equipment in a safe and clean operating condition, specifically concerning the stove hood. During an initial observation, a section of the stove hood was found to be falling, creating a four-inch gap from the hood to the ceiling, and had grease buildup along the edge of the opening. This condition remained unchanged during a second tour of the kitchen. The Dietary Manager, Staff I, acknowledged that the stove hood should have been closed and mentioned that it was previously cleaned quarterly but had shifted to twice a year. Staff I was unaware of the issue until the surveyor's observation and stated that maintenance should have been notified. The Maintenance Assistant, Staff J, confirmed they were only notified about the issue after the surveyor's observation and explained that maintenance requests are typically communicated through a work request line. Staff J speculated that the issue might have occurred during the last cleaning in October.
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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