Orchard Park Health Care & Rehab Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Tacoma, Washington.
- Location
- 4755 South 48th, Tacoma, Washington 98409
- CMS Provider Number
- 505093
- Inspections on file
- 51
- Latest survey
- March 26, 2026
- Citations (last 12 mo.)
- 9
Citation history
Health deficiencies cited at Orchard Park Health Care & Rehab Center during CMS and state inspections, most recent first.
Two residents experienced unwitnessed falls that were documented in nursing notes and reviewed by the IDT, but the facility failed to enter these incidents into the incident reporting log and did not report them to the State Survey Agency within the required timeframe. One resident, alert and oriented after recent hip/femur surgery, fell while attempting to transfer to a chair and had subsequent hip imaging, while another bedridden resident with dementia and multiple comorbidities was found on the floor next to the bed and could not explain the fall. In both cases, staff later acknowledged the falls were recorded in the internal system but not added to the State reporting log, resulting in noncompliance with required reporting standards.
A resident with a history of stroke, contractures, and limited mobility was discharged from skilled PT with goals and recommendations to continue splinting, ROM techniques, and use of a splint and brace. The care plan later identified limited physical mobility related to contractures and included a referral to a Restorative Nurse Assistant, but staff could not locate the written restorative program or any documentation that restorative services, including right knee splinting three times per week, were provided during the period after therapy discharge. This failure to implement and document the restorative nursing program for ROM and mobility resulted in a cited deficiency.
Facility staff did not incorporate a wound care specialist’s ten documented recommendations for PI prevention and treatment into the comprehensive care plan or CNA Kardex for a resident admitted with diabetes, malnutrition, muscle weakness, existing PIs, and total dependence for turning and repositioning. Despite facility policy requiring development and revision of interdisciplinary care plans for skin integrity, the specialist’s directives—such as q2h turning, maintaining clean and dry skin, avoiding massage of bony prominences, using positioning devices, minimizing HOB elevation, keeping sheets wrinkle-free, eliminating fragranced products, and implementing aggressive offloading—were never translated into provider orders or care plan entries. The DON later verified that none of these interventions appeared in the resident’s care plan or Kardex and acknowledged that CNAs rely on the Kardex and verbal report to obtain resident care instructions.
A resident with bilateral heel wounds and dependence for repositioning did not receive adequate PI prevention and treatment. The care plan lacked a turning schedule and pressure-relief mattress, and the Kardex used by CNAs did not reflect needed interventions. A contracted wound care provider documented a worsening Stage 4 right heel PI with increasing necrotic tissue, maceration, and a large increase in wound size, and issued multiple recommendations, including aggressive offloading, but none were entered as orders or care-planned. Additional PIs, including an unstageable left 4th toe PI, a deep tissue PI on the left lateral ankle, and an unstageable sacral PI, were later identified at the hospital but were not documented or treated by facility staff prior to transfer. Facility provider notes recorded escalating foot and heel pain without documented wound examination, and no further antibiotics were ordered despite later hospital findings of calcaneal osteomyelitis and a non-salvageable right lower extremity.
Multiple residents experienced harm due to the facility's failure to provide adequate supervision and follow care plans, including incidents of elopement, falls, and injuries. Residents at risk for wandering were not properly monitored or equipped with required safety devices, and staff did not consistently follow protocols for assistance during transfers and repositioning. Care plans were not timely updated after incidents, and required safety interventions were not always implemented.
The facility did not thoroughly or promptly investigate falls and injuries for multiple residents, including those with dementia and mobility issues. Several incidents, such as repeated falls, a head injury during repositioning, and a hip dislocation during transfer, were either not documented, not investigated, or not followed by timely care plan updates. Staff confirmed that required investigations and care plan revisions were not completed as expected.
Several residents were not accurately assessed for dental conditions, respiratory care, and restraint use. Two residents with missing or broken teeth had their dental issues omitted from the MDS, while a resident on oxygen therapy for COPD was not coded for oxygen use in the MDS despite having a provider order and being observed on oxygen. Another resident was incorrectly documented as using a trunk restraint. Staff interviews confirmed these assessment errors.
Two residents received oxygen therapy at flow rates higher than ordered by their providers, as observed and confirmed by staff interviews. Documentation did not reflect the actual oxygen settings, and there was no evidence of provider notification or order clarification. The deficiency involved failure to follow physician orders and monitor oxygen settings as required.
Surveyors found that a resident's IV nutrition, infuvite vials, and infusion kit were stored in a food refrigerator instead of the medication refrigerator, and multiple expired medical supplies—including viral transport kits, peroxide test strips, cleansing towelettes, and a wound vac therapy system—were kept in the medication room. Both an LPN and the DON confirmed these practices did not meet facility expectations.
Several residents reported that their food preferences, including specific meal choices and requests for double portions, were not consistently honored. Despite filing grievances, residents continued to experience issues with not receiving their preferred foods or portions, and staff interviews revealed gaps in communication and follow-through regarding dietary changes.
The facility did not report a Covid-19 outbreak involving two residents to the local health department as required, and failed to maintain complete infection surveillance for two of three months reviewed. Additionally, a resident with an open wound and chronic kidney disease did not receive timely urine testing for infection, and their infection was not tracked on the facility's infection control line list.
Two CNAs did not receive required training in abuse prevention, dementia care, or annual competency assessments. Training records showed one CNA had no documented training, while another had only a single in-service session. The Administrator confirmed the lack of completed education and competencies for these staff members.
A resident with cerebral palsy and other medical conditions was unable to set their own shower schedule, and showers were not provided as planned despite being scheduled. Staff assigned showers based on room location, and documentation confirmed missed showers. Staff interviews indicated that resident preferences were not honored as expected.
A resident with dementia and psychotic disturbance was prescribed antipsychotic medication, but staff failed to complete or document a baseline abnormal involuntary movement (AIM) assessment as required. Despite the medication administration record indicating the need to monitor for extrapyramidal symptoms, no AIM assessment was found in the electronic health record. Both an LPN and the DON confirmed the assessment should have been completed and acknowledged the deficiency.
Two residents with mental health diagnoses did not receive required PASARR Level II referrals. One resident with dementia and depression, unable to communicate needs and receiving multiple antidepressants, had indications for serious mental illness but no Level II referral was completed. Another resident with anxiety, depression, and PTSD was admitted under a hospital exempt discharge but remained in the facility beyond 30 days without a corrected PASARR or Level II referral, contrary to facility policy.
Surveyors found that the facility did not develop or implement individualized care plans for three residents, including one receiving oxygen therapy for COPD and two with significant oral or dental issues. Staff confirmed that care plans lacked necessary details about oxygen use and dental status, despite provider orders and resident reports.
Three residents did not receive care in accordance with professional standards: a resident did not have protective boots applied as ordered and refusals were not documented; another received midodrine outside of provider-specified blood pressure parameters; and a third, dependent on a central line for nutrition, had no provider orders or care for the line. Staff interviews confirmed these lapses in following provider orders and documentation.
A resident with encephalopathy, diabetes, and dementia was admitted without an activities assessment or an activity-focused care plan. The resident was repeatedly observed sitting in a wheelchair near the nurse's station, and staff interviews revealed that no recreation assessment or activity care plan was completed due to the resident's isolation status at admission, with uncertainty about the current isolation status. The Administrator confirmed that activity care plans should be completed within 72 hours and that isolated residents should receive one-on-one or in-room activities.
The facility did not properly document or care plan for non-pressure skin injuries in two residents, including missing wound type documentation, lack of weekly assessments, and absence of treatment orders. Additionally, a resident receiving Hospice care did not have a comprehensive care plan reflecting their end-of-life needs. Staff interviews confirmed these omissions and acknowledged that expectations were not met.
A resident with diabetes, obesity, and chronic pain reported needing new glasses, as their current pair was four years old. Although the resident had previously seen an eye doctor, there was no follow-up to obtain new glasses. Staff, including an LPN and the DON, confirmed that the resident was not seen during the most recent eye doctor visit, which did not meet facility expectations.
A resident with cerebral palsy, muscle weakness, and a urinary tract infection, who was able to express their needs, was observed to have multiple broken and discolored upper front teeth and reported ongoing dental issues. The resident's health record showed no dental consultation, plan, or treatment, and staff indicated the resident could not see the facility dentist due to their temporary status. Social services could not provide information about the resident's dental appointment status.
Two residents did not receive necessary dental services or follow-up. One resident with quadriplegia and other complex conditions had missing and stained teeth but had not seen a dentist since admission, despite provider orders and documentation of dental issues. Another resident, dependent on artificial feeding, needed lower dentures, but there was no care plan or dental consult in place. Staff interviews confirmed that the process for arranging dental care was not followed.
Two residents who were dependent on staff for bathing did not consistently receive showers or bed baths as per their care plans and facility policy. One resident reported going up to two weeks without a bath or shower, especially on weekends when the shower aide was not available, and documentation of bathing was incomplete. Another resident with moderate cognitive impairment received only one shower in a two-week period, with staff unable to consistently locate records of care provided.
The facility failed to report and investigate neglect allegations for two residents, one of whom experienced delayed administration of pain medication post-amputation, and another who did not receive requested Tylenol for chronic pain. Both residents were alert and able to communicate their needs, yet their grievances were not logged or reported to the State Agency.
The facility failed to manage pain effectively for two residents, leading to unmanaged and increased levels of pain. A resident with a history of leg amputation experienced a delay in receiving oxycodone, despite multiple reminders to the responsible RN. Another resident with chronic pain reported not receiving Tylenol and tramadol in a timely manner during the night shift, often waiting three to four hours. The DON confirmed that pain medication should be administered promptly according to provider orders.
A facility failed to provide consistent restorative care for three residents, leading to avoidable declines in their range of motion and mobility. One resident experienced worsening contractures due to the lack of splint application, another was not placed on a restorative program despite referrals, resulting in decreased joint flexibility, and a third did not receive follow-up on referrals for a prosthetic leg and hand surgery. These deficiencies were due to the facility's failure to implement and follow through with necessary care plans and referrals.
The facility did not have a written transfer agreement with a local hospital approved for Medicare/Medicaid, as revealed during a documentation review. The Administrator confirmed the absence of such documentation, risking delayed hospital transfers for residents.
The facility, with 145 beds, failed to employ a qualified social worker as required for facilities with more than 120 beds. The Director of Social Services did not hold a bachelor's degree, and both the Director and the Administrator were aware of the requirement but confirmed non-compliance.
The facility failed to maintain a safe and homelike environment, with broken blinds compromising privacy and unsanitary conditions in resident rooms and bathrooms. Staff were aware of these issues but cited budget restrictions and lack of follow-up as barriers to resolution.
A facility failed to thoroughly investigate incidents involving three residents, including falls and alleged abuse. For one resident, staff interviews were not conducted after a fall, and interventions were not documented. Another resident's unwitnessed fall was not investigated, and required monitoring was not documented. A third resident's abuse allegation was inadequately investigated, with delayed and insufficient interviews, and the alleged staff member was not suspended. These deficiencies indicate a failure to follow proper investigation protocols.
The facility failed to ensure accurate MDS assessments for three residents, leading to potential risks for unmet care needs. A resident with foot drop had an MDS showing no impairment despite evidence of chronic ankle contractures. Another resident's MDS did not document antipsychotic medication use, and a third resident's MDS failed to reflect dental issues and nutritional concerns. The MDS Nurse acknowledged incorrect coding, and the DNS expected accurate assessments.
The facility failed to accurately complete PASRR assessments for four residents, risking unidentified mental health needs. One resident's PASRR lacked necessary documentation, while others required Level II evaluations that were not conducted. Staff acknowledged the inaccuracies, and the need for updated assessments was confirmed.
The facility failed to review and revise care plans for several residents, leading to deficiencies in care. A resident with paraplegia lacked a restorative nursing program, while another with a rash had an inaccurate care plan. Two residents did not have timely care conferences, and a resident with anxiety lacked a care plan addressing mental health needs. Staff acknowledged these deficiencies, which did not meet expectations.
The facility failed to provide necessary interventions for a resident at risk of skin breakdown, did not coordinate hospice care for two residents, and neglected bowel management for three residents. Additionally, the facility did not promptly notify a provider about a resident's change in condition.
The facility failed to provide safe dialysis care for two residents due to inaccurate documentation and poor communication with the dialysis provider. Resident 308's care plan and orders were not updated to reflect the correct dialysis schedule, and communication forms were incomplete. Resident 60's records contained incorrect information about dialysis access type and pick-up times, and there was a lack of documentation for medication administration during dialysis. Staff interviews confirmed these deficiencies.
The facility failed to provide non-pharmacological interventions before administering pain medications to several residents, as required. Residents with chronic conditions received pain medications without documented attempts of alternative interventions. Additionally, a resident received blood pressure medication outside of specified parameters, and orders for topical medications lacked specific application locations. These deficiencies risked adverse side effects and diminished quality of life.
The facility failed to properly monitor and justify the use of psychotropic medications for two residents. One resident was given quetiapine for dementia with agitation without a defined psychotic disorder, and the facility did not follow the pharmacist's recommendation for dose reduction. Another resident was prescribed Seroquel for insomnia without evaluating the cause or monitoring sleep hours, despite recommendations for dose reduction. Staff interviews confirmed the lack of necessary monitoring and dose adjustments.
The facility failed to follow the posted menu during a lunch service, serving half portions of macaroni with ham instead of the full portion specified. This was due to staff using a scoop that provided only half a cup instead of the required full cup. Resident feedback indicated concerns about menu adherence and sudden changes, which were acknowledged by the Dietary Manager and Administrator.
The facility failed to provide palatable food at appetizing temperatures, affecting several residents. Observations revealed issues with food preparation and serving, including cold, bland, and unappetizing meals. Resident council minutes indicated ongoing grievances about food quality, which were not resolved despite monthly meetings and interviews.
The facility failed to safely prepare and store food, with dented cans found in storage and improper hand hygiene observed. Additionally, resident refrigerators were not monitored correctly, with temperatures consistently above safe levels. These actions did not meet the expected standards for food safety.
The facility's QAPI program failed to self-identify and sustain corrections for deficiencies, resulting in repeated and widespread issues. The administrator admitted the QAPI process was ineffective, leading to risks for residents. Deficiencies included maintaining a safe environment, accurate assessments, and proper nutrition.
The facility failed to implement transmission-based precautions for five residents, including those with indwelling catheters and wounds, by not providing proper signage and PPE. Staff entered rooms without required PPE, citing misunderstandings of precaution requirements. Additionally, laundry staff did not sanitize washing machines between loads, despite visible soil, increasing infection risk.
A resident was administered hydroxyzine for anxiety without informed consent for three days. The facility's policy requires informed consent before administering psychotropic medications, but this was not followed. Staff acknowledged the oversight.
The facility failed to maintain privacy for residents during medication administration and personal calls. A resident expressed concerns about a lack of privacy due to a roommate's yelling, which staff reportedly dismissed. Two residents were observed receiving topical medications without adequate privacy measures, exposing their bodies to others. The DNS acknowledged these practices were unacceptable.
The facility failed to address grievances for two residents, one experiencing sleep disturbances due to a noisy roommate and another with a missing personal item. Despite complaints, no formal grievances were initiated or resolved in a timely manner, contrary to the facility's policy requiring resolution within 72 hours.
A facility failed to provide written notification of a hospital transfer to a resident or their responsible party. The resident, diagnosed with multiple sclerosis, heart failure, and diabetes, was hospitalized and readmitted without documented transfer notice. Interviews with staff confirmed the lack of required documentation.
A facility failed to provide a written bed hold notice for a resident hospitalized with multiple sclerosis, heart failure, and diabetes. The resident's EHR showed hospitalization and readmission, but lacked bed hold documentation. Interviews with staff confirmed the absence of the required notice, which was expected to be documented and scanned into the EHR.
The facility failed to develop baseline care plans within 48 hours for two residents admitted with dementia and hospice needs. One resident had multiple diagnoses, including Alzheimer's, and required monitoring and medication for dementia, but lacked a care plan focus. Another resident, receiving hospice care, also lacked a care plan for hospice services. Staff interviews confirmed delays and omissions in care plan development.
A resident with multiple health issues was subject to unprofessional documentation by a registered nurse, who described them as 'annoying' and 'difficult' in progress notes. Interviews with staff confirmed that such subjective documentation was inappropriate and did not meet professional standards.
The facility failed to provide adequate pressure ulcer care for two residents, leading to deficiencies. One resident had an undocumented and untreated wound on the ischium, despite being at high risk for pressure injuries. Another resident experienced multiple pressure injuries, with improper positioning and an outdated care plan. The DON acknowledged the failure to follow care plans and prevention measures.
Failure to Report Unwitnessed Falls to State Agency and Incident Log
Penalty
Summary
The deficiency involves the facility’s failure to report unwitnessed falls to the State Survey Agency within 24 hours and to enter these incidents into the facility’s incident reporting log for two residents. One resident, admitted for nursing care and rehabilitation after a fall requiring hip and femur surgery, was alert, oriented, and able to make their needs known. This resident reported attempting to transfer into a chair at night, falling to the floor, and being unable to reach the call light, then crawling to the door to yell for help. A nurse’s progress note documented hearing the resident calling for help, finding the resident on the floor, and noting that the wheelchair and walker were far from the fall position, consistent with the resident’s report of having pulled themself to the door. The resident was assisted back to bed, had a hip x-ray, and the fall was documented by the provider and reviewed by the interdisciplinary team, but there was no corresponding entry in the facility’s incident reporting log and no report submitted to the State Survey Agency for this unwitnessed fall. The second resident, admitted with dementia, chronic kidney disease, and pressure ulcers for respite nursing and palliative care, was cognitively impaired but able to make needs known and required staff assistance with ADLs. A collateral contact stated the resident was bedridden, questioned how the resident could have fallen out of bed, and expressed concern that staff could not say how long the resident had been on the floor. A nursing note documented that the resident was found on the floor next to the bed, was unable to verbalize how the fall occurred, and was returned to bed via Hoyer lift with two-person assist, with no injuries identified. The provider and family were notified, and the fall was reviewed by the interdisciplinary team with care plan updates, but the incident was not entered into the facility’s incident reporting log and was not reported to the State Survey Agency. Staff later stated that both residents’ falls had been reported in the internal system but were not added to the State reporting log, resulting in the failure to meet the reporting requirements under WAC 388-97-0640(7)(a)(b)(i).
Failure to Implement Restorative Nursing Program for ROM and Mobility
Penalty
Summary
The deficiency involves the facility’s failure to initiate and provide a restorative nursing program for a resident with limited range of motion (ROM) and mobility needs after discharge from skilled therapy. The resident was admitted with diagnoses including stroke, aphasia, malnutrition, and depression, and the admission MDS documented that the resident did not walk, required partial to maximal assistance with ADLs, and was always incontinent of bowel and bladder. An observation showed the resident in bed with the right leg demonstrating full ROM while the left leg, hand, and arm appeared contracted. The PT discharge summary, dated mid-January, indicated that the resident was discharged from skilled PT services and had goals to improve active/passive ROM of the left hip and knee using splinting and ROM techniques, and to tolerate right knee splinting with functional ROM carryover. The PT discharge recommendations included continuing the resident’s splint and brace. The care plan, dated late February, identified the resident as having limited physical mobility related to contractures and documented a referral to a Restorative Nurse Assistant. However, during interviews, the COTA stated that although a restorative nursing program had been written for the resident, it could not be located. The DNS reported that there was a restorative nursing program referral for right knee splinting three times per week, but the facility was unable to locate the referral or any documentation showing that a restorative nursing program was implemented for the resident between the PT discharge date in mid-January and the early March observation. This lack of implementation and documentation of the restorative nursing program led to the cited deficiency for failure to provide appropriate care to maintain or improve ROM and mobility.
Failure to Integrate Wound Specialist PI Interventions Into Resident Care Plan
Penalty
Summary
Facility staff failed to develop and implement an individualized comprehensive care plan incorporating wound care specialist recommendations for a resident at risk for pressure injuries (PIs). The facility’s Skin Integrity Management policy, dated 05/26/2025, directed staff to develop comprehensive, interdisciplinary plans of care for prevention and wound treatments, including offloading devices, turning and repositioning, special wound care techniques, and appropriate support surfaces, and to review and revise care plans as indicated. The resident was admitted with diagnoses including diabetes, malnutrition, and muscle weakness, was identified on the admission MDS as being at risk for PIs, admitted with existing PIs, and totally dependent on staff for turning and repositioning in bed. A wound care specialist documented progress notes on 10/08/2025 listing nine specific recommended interventions and preventive measures related to the resident’s PIs, including turning every two hours, keeping skin clean and dry, avoiding massage of bony prominences, using positioning devices, keeping the head of bed as low as possible to reduce shearing, keeping sheets dry and wrinkle-free, and removing all fragranced products in favor of chemical-free, fragrance-free disposable washcloths. On 10/22/2025, the wound care specialist added a tenth recommendation for aggressive offloading. Review of the resident’s care plans and Kardex on 11/19/2025 showed that none of these ten recommendations had been added to the care plan or Kardex. On 12/17/2025, the DON confirmed that there were no provider orders for the recommended interventions, none of the ten recommendations were care planned or present on the Kardex, and stated that CNAs rely on the Kardex and verbal shift report to know resident care needs.
Failure to Implement Wound Care Recommendations and Prevent Worsening Pressure Injuries
Penalty
Summary
The deficiency involves the facility’s failure to provide adequate pressure injury (PI) prevention and treatment for a dependent resident with multiple existing wounds and high risk for skin breakdown. On admission, the resident had bilateral heel wounds and wounds to the right lower extremity and required substantial/maximal assistance for bed mobility and was totally dependent on staff for turning and repositioning. The MDS documented the resident was not on a turning/repositioning program, and the care plan, while noting bilateral heel pressure ulcers and wounds to the right lower extremity with a goal for healing, did not include a turning schedule or pressure-relieving mattress. Staff interviews confirmed the resident could not turn without assistance, that CNAs relied on the Kardex for care instructions, and that there was no order or care plan for a pressure-relief mattress. The facility used a contracted wound care and treatment company (WCTC) to manage the resident’s PIs. WCTC progress notes documented a right heel/foot Stage 4 PI that initially measured 15.75 cm² pre-debridement and 19.11 cm² post-debridement, with 100% necrotic tissue. Subsequent weekly assessments showed fluctuating but generally worsening wound characteristics, including increasing necrotic tissue, maceration, erythema, and a significant increase in wound size to 48 cm². WCTC notes over several visits identified peri-wound maceration and erythema and recommended multiple PI-related interventions, including aggressive offloading. However, review of the resident’s EHR, orders, care plans, and Kardex showed no documentation that any of the ten WCTC-recommended interventions were implemented. The resident completed an initial course of antibiotics shortly after admission, and no further antibiotics were ordered prior to hospital transfer, despite ongoing wound issues and later-confirmed osteomyelitis. Additional wounds were not identified or documented by facility staff prior to the resident’s transfer to the hospital. WCTC documentation showed a left 4th toe wound first described as a non-pressure chronic ulcer with 100% necrotic tissue and fragile peri-wound skin with mild erythema and maceration, later reclassified as an unstageable PI with persistent 100% necrotic tissue and progression to severe erythema and severe maceration. The facility’s EHR contained no documentation that this left 4th toe PI was present on admission or that it was identified or treated by the facility before transfer. Hospital records documented, at the time of admission, an unstageable right heel PI, a deep tissue PI to the left lateral ankle, and an unstageable sacral PI, all present on admission, yet the facility’s EHR contained no documentation that the left lateral ankle PI or sacral PI had been identified or treated. Hospital podiatry and provider notes later confirmed right calcaneal osteomyelitis with a non-salvageable right lower extremity and concern for osteomyelitis in the left calcaneus. Facility nursing and management staff acknowledged that WCTC recommendations had not been entered as orders or care-planned and that direct care staff relied on the Kardex, which did not reflect these interventions. Provider follow-up notes from the facility documented the resident’s reports of stabbing pain in both feet, heels, and sometimes up to the knees, and a decrease in effectiveness of gabapentin, with discussion of increasing the dose. These notes did not include any documented physical examination of the resident’s feet or foot wounds. A nurse’s progress note later recorded the resident’s transfer to the hospital for a non-pressure injury/pain-related care need. At the hospital, wound nurse and podiatry consults documented multiple PIs, including those not previously documented by the facility, and confirmed severe infection and osteomyelitis. Throughout this period, the facility’s failure to implement WCTC recommendations, to provide documented offloading and pressure-relief measures, to identify and document new or worsening PIs (left 4th toe, left lateral ankle, sacral area), and to conduct and document appropriate wound assessments and follow-up contributed to the identified deficiency in providing pressure ulcer care and preventing new ulcers from developing.
Failure to Prevent Accidents, Elopement, and Falls Due to Inadequate Supervision and Care Plan Implementation
Penalty
Summary
The facility failed to ensure that residents were free from accident hazards and did not provide adequate supervision to prevent accidents, resulting in multiple incidents of harm. One resident with severe cognitive impairment and a history of wandering was able to elope from the facility without staff knowledge. The front desk staff observed the resident leaving but did not intervene or follow elopement protocols, and there was a delay in calling 911 due to confusion about staff responsibilities. The resident was later found by a member of the public after experiencing a fall. Another resident at risk for elopement did not consistently have a Wander Guard device in place, as required, with documentation showing multiple missed opportunities to ensure the device was present and functioning. The facility also failed to provide the required level of assistance during care, resulting in avoidable injuries. One resident, who was totally dependent on staff for repositioning and required two staff members for bed mobility, was assisted by only one staff member, leading to a fall and a laceration near the eye that required hospital treatment. Despite care plan requirements, staff continued to provide care with only one person. Another resident with recent hip surgery and specific hip precautions experienced a dislocation and severe pain during a transfer when staff failed to follow the required precautions. The care plan and provider orders for hip precautions were not properly implemented or communicated. Additionally, the facility did not consistently assess the effectiveness of interventions or revise care plans in a timely manner following falls. One resident experienced three falls within a short period, resulting in injuries including a head laceration and hematoma, but the care plan was not updated with new interventions after the first two falls. Another resident, at high risk for falls and with a history of impulsivity, was left unattended after expressing intent to get out of bed, leading to a fall. In several cases, required safety equipment such as reacher tools and call lights were not kept within reach, and staff did not remain with residents at risk until help arrived.
Failure to Timely Investigate and Address Falls and Injuries
Penalty
Summary
The facility failed to thoroughly and timely investigate falls and injuries, and did not implement interventions to prevent repeat falls for several residents. For one resident with dementia and multiple comorbidities, there were repeated falls over several months, with delayed or incomplete investigations and unclear or delayed care plan interventions. Incident reports for some falls were completed days after the events, and some investigations were not completed at all. Another resident, also with dementia and mobility issues, experienced multiple falls, including one resulting in a head laceration and another in an occipital hematoma. The facility did not update the care plan with new interventions after one of the falls, and the incident report was completed several days late. Staff interviews confirmed that care plans were not revised and interventions were not implemented in a timely manner following these incidents. Additional deficiencies included a resident who sustained a head injury requiring sutures after falling from bed during repositioning, with the incident not recorded in the facility's logs and the investigation completed late. Another resident suffered a hip dislocation during a transfer, with no documentation of the incident in facility logs and no investigation completed. Staff interviews confirmed that these incidents were not reported or investigated as required.
Inaccurate Resident Assessments in Dental, Respiratory, and Restraint Care
Penalty
Summary
The facility failed to ensure accurate assessments for several residents in key areas, including dental conditions, respiratory care, and the use of restraints. For two residents with dental issues, staff observations and interviews revealed missing, broken, and discolored teeth, yet the Minimum Data Set (MDS) assessments did not accurately reflect these conditions. In one case, a resident with quadriplegia and malnutrition had multiple missing and stained teeth, which were noted in progress notes and the initial nursing evaluation, but the MDS incorrectly indicated no dental issues. Another resident with broken and discolored teeth was also inaccurately assessed in the MDS, which failed to document their dental problems. A resident receiving oxygen therapy for chronic obstructive pulmonary disease (COPD) was not properly coded for oxygen use in the modified quarterly MDS, despite having a provider order and being observed on oxygen during multiple visits. Staff interviews confirmed that the resident was receiving oxygen therapy and that the MDS should have indicated this, but it was marked incorrectly. Additionally, a resident was incorrectly documented as using a partial trunk restraint in the quarterly MDS, although staff later confirmed this was an error and the resident did not use such restraints. These inaccuracies in resident assessments were confirmed through interviews with staff, including the MDS nurse and the Director of Nursing Services, who acknowledged the errors and stated that the MDS should have accurately reflected the residents' conditions. The failures in assessment were identified through a combination of record review, direct observation, and staff interviews, and were not known to some staff members responsible for coordinating care, such as the social worker.
Failure to Follow Physician Orders for Oxygen Therapy
Penalty
Summary
The facility failed to provide respiratory care consistent with physician orders for oxygen therapy for two residents. For one resident with heart failure, COPD, and asthma, observations showed oxygen was administered at five and six liters per minute via nasal cannula, while the provider order specified three liters per minute continuously. Documentation in the treatment administration record indicated the order was being followed, but interviews with staff confirmed the resident was receiving a higher oxygen flow than ordered, and there was no documentation of a provider order change or notification. For another resident with encephalopathy, diabetes, and dementia, observations on multiple occasions showed oxygen was set at three liters per minute via nasal cannula, while the care plan required one liter continuously. Staff interviews confirmed the oxygen was set higher than ordered, and the expectation was that staff follow provider orders and monitor oxygen settings every shift. These failures resulted in oxygen being administered at rates inconsistent with physician orders for both residents.
Improper Storage of Medications and Expired Supplies in Medication Room
Penalty
Summary
Surveyors observed that medication and medical supplies were not stored according to accepted professional standards in the East medication room. Specifically, a large plastic bag labeled with a resident's name containing an IV solution of liquid nutrition, two vials of infuvite, and an infusion kit was found stored in the resident's food refrigerator instead of the designated medication refrigerator. Additionally, multiple expired medical supplies and equipment were found in cabinets, including universal viral transport kits, ECOLAB peroxide test strips, cleansing towelettes, and a gel/wound vac therapy system package, with expiration dates ranging from November 2022 to March 2025. During interviews, both an LPN and the Director of Nursing Services confirmed that medications should not be stored in the food refrigerator and that expired supplies should not be kept in the medication room. Both staff members acknowledged that these practices did not meet facility expectations. The findings were based on direct observation, staff interviews, and record review, and were cited as not being in compliance with regulations regarding the proper storage and labeling of drugs and biologicals.
Failure to Honor Resident Food Preferences and Grievance Resolution
Penalty
Summary
The facility failed to provide food services that met the stated preferences of five out of eight sampled residents. Multiple residents reported that their menu selections and food preferences, such as specific meal choices and requests for double portions, were not honored. For example, one resident did not receive their ordered cheeseburger and had to request it directly from the kitchen, while another reported not receiving their requested hamburger, juice, and tea for lunch. Several residents filed grievances regarding not receiving double portions or specific meal items, but continued to experience the same issues despite the grievances being marked as resolved in the facility's log. Observations and record reviews confirmed that residents did not consistently receive the foods or portions indicated on their meal cards, such as double portions, condiments, or additional beverages. Interviews with dietary staff and the registered dietician revealed a lack of communication regarding residents' grievances and food preference changes, with the dietician unaware of several residents' requests for double portions. The administrator acknowledged that food preferences should be honored and that the ongoing issues did not meet facility expectations.
Failure to Report Covid-19 Outbreak and Inadequate Infection Surveillance
Penalty
Summary
The facility failed to report a Covid-19 outbreak to the local health department as required by its own policy. After one resident was diagnosed with Covid-19 at the hospital, testing was conducted for all residents and staff on the affected hall, resulting in a second resident, who was the roommate of the first, also testing positive. Despite this, the local health department was not notified of the outbreak. Interviews with facility staff, including the Infection Preventionist and Director of Nursing Services, confirmed that the required notification did not occur. Additionally, the facility did not maintain adequate infection surveillance and tracking for two of three months reviewed. There was no infection control data available for one month, and incomplete tracking and lack of a monthly summary for another. In one case, a resident with an open abdominal wound and chronic kidney disease had multiple provider orders for urine testing to check for infection, but the tests were not completed in a timely manner. When the test was eventually performed, an infection was found and treated, but this infection was not included in the facility's infection control line list or tracked on the infection map. Staff interviews confirmed these lapses in infection tracking and timely testing.
Failure to Provide Required Abuse and Dementia Training for CNAs
Penalty
Summary
The facility failed to ensure that each staff member received required training related to resident abuse prevention, dementia management, and annual continuing competencies for certified nurse aides. Review of training records revealed that one CNA had a blank training record, and another CNA had only one in-service training completed within the past year. During an interview, the Administrator confirmed that these staff members did not have the necessary training and that this did not meet the facility's expectations for staff education and competencies prior to working with residents.
Failure to Honor Resident Bathing Preferences
Penalty
Summary
The facility failed to honor and facilitate a resident's choice regarding their bathing schedule. A resident with cerebral palsy, urinary tract infection, and muscle weakness, who was able to communicate their needs, reported that they could not set their own shower time and that showers were only scheduled twice a week at specific times, which were not consistently followed. Observations and interviews revealed that showers were assigned based on room and bed location, and although the resident was scheduled for a shower on certain days, the showers were not provided as planned. Documentation review confirmed that showers were not given on the scheduled days. Staff interviews indicated that while the expectation was to ask for and honor resident preferences, this did not occur for the resident in question. The deficiency was identified through observation, resident and staff interviews, and review of shower documentation, showing a failure to support resident self-determination and choice as required.
Failure to Complete Baseline AIM Assessment for Resident on Antipsychotic Medication
Penalty
Summary
The facility failed to conduct or document an initial or baseline abnormal involuntary movement (AIM) assessment for a resident who was prescribed an antipsychotic medication. The resident, who had diagnoses including dementia with psychotic disturbance and cognitive and communication deficits, was readmitted to the facility and received both antidepressant and antipsychotic medications on a routine basis. Despite the medication administration record indicating the need to monitor for extrapyramidal symptoms such as tardive dyskinesia, tremors, gait issues, and involuntary movements, there was no evidence in the electronic health record of a completed AIM assessment at admission or readmission. Observations showed the resident exhibiting various movements, such as moving legs and feet, and manipulating their gown, but staff were unable to locate any AIM assessment documentation. Interviews with both an LPN and the Director of Nursing confirmed that an AIM scale assessment should have been completed and documented for residents on antipsychotic medications, but this was not done for this resident. Both staff members acknowledged that this failure did not meet facility expectations.
Failure to Complete Required PASARR Assessments for Residents with Mental Health Diagnoses
Penalty
Summary
The facility failed to ensure that Pre-admission Screening and Resident Review (PASARR) assessments were accurately completed for two residents. For one resident with diagnoses including dementia, depression, and impaired memory, the record showed the resident was unable to make their needs known and was prescribed and administered multiple antidepressant medications. Despite indications for serious mental illness on the Level I PASARR, no Level II referral was completed. Staff interviews confirmed that the PASARR process was missed for this resident, and the lack of a Level II referral did not meet facility expectations. For another resident with multiple health conditions, including anxiety, depression, and PTSD, the Level I PASARR was marked as an exempted hospital discharge, allowing admission without a Level II review. However, the resident remained in the facility longer than 30 days, which should have triggered a correction of the PASARR and a Level II referral. Staff interviews confirmed that this step was not taken. The facility's policy required that all admissions have the appropriate PASARR completed and that state-specific guidelines be followed, but these procedures were not adhered to in these cases.
Failure to Individualize Care Plans for Oxygen Therapy and Oral/Dental Needs
Penalty
Summary
The facility failed to develop and implement individualized, comprehensive care plans for three residents regarding oxygen therapy and oral/dental status. For one resident with chronic obstructive pulmonary disease (COPD) and an order for supplemental oxygen, observations confirmed the resident was receiving oxygen therapy, but there was no corresponding care plan addressing this intervention. Both a Licensed Practical Nurse and the Director of Nursing Services acknowledged the absence of a care plan for oxygen use, despite the resident's ongoing therapy and provider orders. Another resident with cerebral palsy and multiple broken, discolored upper front teeth reported significant dental problems, but the care plan only included general oral care instructions and did not address the broken teeth or potential for oral pain. A third resident, dependent on artificial feeding and with a history of malnutrition and gastrointestinal hemorrhage, stated a need for lower dentures, but the care plan did not include any information or instructions regarding missing lower teeth. The Director of Nursing Services confirmed that care plans should have included details about broken or missing teeth.
Failure to Follow Provider Orders and Professional Standards of Care
Penalty
Summary
The facility failed to ensure that services provided to three residents met professional standards of quality. For one resident with diabetes, stiff joints, muscle weakness, and heart failure, there was a provider order for protective boots to be placed on both heels every shift. However, the resident was observed in a wheelchair without the boots, and both the resident and staff confirmed the boots were only worn in bed. There was no documentation of the resident's refusal to wear the boots while up, and staff did not notify the provider or clarify the order as required. Another resident with dementia, COPD, hypotension, and depression had a provider order for midodrine to be held if systolic blood pressure exceeded 120. Despite this, the medication was administered on two occasions when the resident's blood pressure was above the specified parameter. Additionally, a third resident dependent on artificial feeding via a central line had no provider order in place for the care of the central line, including monitoring for infection or dressing changes. Staff confirmed that care for the central line was not provided as expected.
Failure to Develop and Implement Individualized Activity Plan for Resident
Penalty
Summary
The facility failed to develop and implement an individualized activity plan for a resident who was admitted with diagnoses including encephalopathy, diabetes, and dementia. Observations over several days showed the resident sitting in a wheelchair near the nurse's station, and review of the electronic health record revealed that no activities assessment was completed upon admission and the care plan lacked an activities focus area. During interviews, the Recreation Director stated that no recreation assessment or activity care plan was completed because the resident was on isolation precautions at admission and was unaware of the resident's current isolation status. The Administrator confirmed that activity care plans are expected to be completed within 72 hours of admission and that residents on isolation should be offered one-on-one or in-room activities.
Failure to Document and Care Plan for Skin Injuries and Hospice Services
Penalty
Summary
The facility failed to provide necessary care and services for non-pressure skin injuries for two residents. One resident had a provider order for wound care to the left buttock, but the type of wound was not documented in the electronic health record (EHR), and the care plan did not specify the wound or include weekly assessments as required. Staff interviews confirmed the absence of documentation regarding the wound type and status, and the care plan lacked details about the wound and related pain management interventions. Another resident developed a skin tear and hematoma on the right-hand middle finger, which was observed and reported by the resident and staff. Although the injury was cleaned and bandaged, there was no provider order for treatment, and the care plan did not reflect the actual skin impairment. Staff acknowledged that treatment orders and care plan updates were missing and that this did not meet expectations. Additionally, the facility failed to develop a comprehensive, collaborative care plan involving Hospice services for a resident receiving end-of-life care. The resident's care plan did not include any information about Hospice, despite documentation in the EHR and Minimum Data Set (MDS) assessments indicating Hospice care. Staff interviews confirmed the omission of Hospice care planning and recognized that the care plan should have been updated to reflect the resident's current needs.
Failure to Assist Resident in Obtaining New Glasses
Penalty
Summary
Resident 63, who was admitted with diagnoses including diabetes, obesity, and chronic pain, reported that their glasses were four years old and that they needed new glasses. Although the resident was able to communicate their needs and had been seen by an eye doctor previously, there was no follow-up to obtain new glasses. The annual minimum data set assessment indicated the resident's vision was adequate with glasses. Staff interviews revealed that residents with vision needs were supposed to be seen yearly for eye exams, but Resident 63 was not seen during the most recent visit by the eye doctor, and staff acknowledged that this did not meet expectations.
Failure to Provide Routine Dental Care for a Resident
Penalty
Summary
The facility failed to provide routine dental care for one resident who was admitted with diagnoses including cerebral palsy, urinary tract infection, and muscle weakness, and who was able to communicate their needs. Observation revealed that the resident had multiple broken and discolored upper front teeth and reported ongoing dental issues. Review of the electronic health record showed no evidence of dental consultation, plan, or treatment for this resident. The resident stated that staff informed them they could not see the dentist in the facility due to their temporary resident status. Social services staff confirmed they were responsible for scheduling routine dental appointments and referring emergent cases out of the facility but could not provide information regarding the resident's dental appointment status.
Failure to Provide and Follow Up on Dental Services for Two Residents
Penalty
Summary
The facility failed to provide assistance and follow-up for dental care services for two residents. One resident, who had quadriplegia, malnutrition, muscle weakness, and depression, was observed to have multiple missing lower teeth and remaining teeth that were deeply stained. This resident reported not having seen a dentist since admission, despite a provider's order for a dental consult and documentation of missing or broken teeth in both the progress note and initial nursing assessment. The initial MDS did not indicate obvious cavities or broken teeth, and staff interviews revealed that the process for scheduling dental appointments was not followed, as the resident had been re-approved for Medicaid and should have been seen for dental needs. Another resident, admitted with malnutrition, gastrointestinal hemorrhage, chronic pain, and dependence on artificial feeding, reported having upper dentures but needing lower dentures. The care plan did not address the missing lower teeth, and there was no evidence in the electronic health record of a dental consultation or plan for lower teeth. Staff interviews confirmed that routine dental appointments were scheduled by social services, and emergent needs should have been referred out, but this was not done for the resident.
Failure to Provide Consistent Bathing and ADL Care
Penalty
Summary
The facility failed to provide necessary activities of daily living (ADL) care and services, specifically bathing, for two of three sampled residents. One resident, who had no cognitive impairment and was dependent on staff for bathing and transfers, reported only receiving bed baths and stated that showers were missed, particularly on weekends when the designated shower aide was not present. Documentation confirmed that this resident received only sporadic bed baths and showers over a four-week period, with gaps in care and incomplete records. Staff interviews revealed that the shower aide worked only weekdays, and floor staff were expected to provide showers on weekends, but it was unclear if this occurred. Paper documentation of bathing was inconsistent and not always entered into the electronic record. Another resident, with moderate cognitive impairment and dependent on staff for bathing, also experienced missed showers, with records showing only one shower during a two-week period after admission. Staff were unable to consistently locate documentation of bathing for this resident, and additional records were only found after further searching. The facility's policy was for residents to receive one to two showers or baths per week according to their preference, but this was not consistently provided or documented for the residents reviewed.
Failure to Report and Investigate Allegations of Neglect
Penalty
Summary
The facility failed to identify, report, and investigate allegations of neglect for two residents, which placed them at risk for ongoing neglect and unmet needs. Resident 1, who was admitted after a leg amputation and had complications requiring rehospitalization, reported that a registered nurse delayed administering prescribed pain medication, oxycodone, by two to three hours after it was requested. Despite Resident 1 being alert and oriented, and able to make their needs known, the facility did not log or report this complaint as an allegation of neglect to the State Agency. Similarly, Resident 4, who was admitted with chronic pain and polyneuropathy, reported not receiving requested Tylenol on several occasions during the night shift. This resident also was alert and oriented, and able to communicate their needs. The facility did not log or report this complaint as an allegation of neglect either. Interviews with the Director of Nursing Services and the Administrator confirmed that these grievances should have been interpreted as allegations of neglect and reported to the State Agency, as per regulatory requirements.
Failure in Timely Pain Management for Residents
Penalty
Summary
The facility failed to manage pain effectively for two residents, leading to unmanaged and increased levels of pain. Resident 1, who had a history of leg amputation, fibromyalgia, depression, and anxiety, was prescribed oxycodone every six hours as needed for pain. On the day of observation, Resident 1 requested their pain medication at 10:55 AM but did not receive it until 12:20 PM, despite multiple reminders to the responsible nurse, Staff E, RN, by the resident and other staff members. This delay in administering the medication resulted in Resident 1 experiencing increased pain levels. Similarly, Resident 4, who suffered from chronic pain and polyneuropathy, reported not receiving their prescribed Tylenol and tramadol in a timely manner during the night shift. The resident expressed that they often had to wait until other scheduled medications were due, sometimes waiting three to four hours for their pain medication. The Director of Nursing Services confirmed that pain medication should be administered according to provider orders and as soon as possible after a resident's request, indicating a failure in adhering to these standards.
Failure to Provide Restorative Care Leads to Decline in Resident Mobility
Penalty
Summary
The facility failed to provide consistent restorative care to maintain or improve the range of motion (ROM) and mobility for three residents, leading to avoidable declines in their conditions. Resident 7, who had been admitted with diagnoses including right and left foot drop, experienced a decline in ROM due to the facility's failure to implement a restorative program. Despite being referred to physical therapy and showing some improvement, the resident's care plan was not followed, and the necessary splints were not applied, resulting in further contractures and potential skin breakdown. Resident 10, diagnosed with paraplegia and other conditions affecting mobility, was not placed on a restorative nursing program despite being referred for one. The resident expressed a desire to participate in such a program, but the facility did not provide the necessary passive ROM exercises. This oversight led to a significant decline in the resident's ROM, as evidenced by the comparison of measurements taken in 2020 and 2024, showing decreased flexibility in multiple joints. Resident 85, who was admitted with an absence of the right leg above the knee and muscle weakness, did not receive follow-up on referrals for a prosthetic leg and hand surgery. The facility failed to act on these referrals, leaving the resident without necessary interventions to address their mobility and contracture issues. This lack of action was attributed to the facility's failure to review hospital documentation and communicate the need for referrals, which did not meet the expected standards of care.
Lack of Hospital Transfer Agreement
Penalty
Summary
The facility failed to maintain a written transfer agreement with at least one local hospital that is approved for participation in Medicare/Medicaid programs. This deficiency was identified during a review of facility documentation on September 9, 2024, which revealed no evidence of a transfer agreement or attempts to establish one. During an interview on the same day, the Administrator, referred to as Staff A, confirmed the absence of any documentation related to hospital transfer agreements. This lack of a formal agreement placed residents at risk for delayed transfers and timely admissions to the hospital when medically necessary.
Facility Lacks Qualified Social Worker
Penalty
Summary
The facility failed to employ a qualified social worker, which is a requirement for facilities with more than 120 beds. The facility had 145 available beds as per the daily census report. During interviews, both the Director of Social Services and the Administrator acknowledged the requirement and confirmed that the facility did not employ a qualified social worker. The Director of Social Services admitted to not holding a bachelor's degree, which is necessary for the position, and was aware of the requirement. The Administrator also confirmed the facility's non-compliance with the requirement, acknowledging that the lack of a qualified social worker did not meet expectations.
Deficiencies in Environmental Maintenance and Cleanliness
Penalty
Summary
The facility failed to maintain a safe and homelike environment in two of its halls, East B and [NAME] B, as observed between 08/23/2024 and 08/27/2024. Multiple resident rooms were found with broken or missing blind slats, compromising privacy, particularly for rooms facing public areas like parking lots. Resident 29 reported the issue weeks prior, and a family member had to improvise a privacy solution. The Maintenance Director acknowledged awareness of the issue but cited budget restrictions as a barrier to repairs. Additionally, several rooms had unsanitary conditions, with dried matter and stains on bedside tables, which residents and staff noted as not meeting expectations. Further deficiencies were noted in the cleanliness and maintenance of resident bathrooms. Resident 10's bathroom had brown stains in the tub, missing faucet handles, and a dead spider, with the Housekeeping/Laundry Manager admitting the situation was unacceptable and had been reported to maintenance months prior. Resident 60 also experienced broken blinds, and Suite 66's bathroom had a malfunctioning paper towel dispenser, with makeshift solutions that did not meet standards. Staff interviews confirmed awareness of these issues, but there was a lack of follow-up and resolution, as acknowledged by the facility's Administrator.
Inadequate Investigation of Incidents and Falls
Penalty
Summary
The facility failed to conduct thorough investigations into alleged incidents of abuse, neglect, and falls for three residents. For Resident 93, the facility did not interview staff present during a fall incident to determine the root cause, and interventions such as frequent checks and physical therapy were not documented or completed. This resident had a history of falls and was sent to the hospital after two additional falls, indicating a lack of effective intervention. Resident 83 experienced an unwitnessed fall resulting in a bruise on the forehead, but the incident was not investigated as required. The resident's care plan included monitoring for orthostatic blood pressure, but there was no documentation of this being done. The facility's incident investigation log did not include this fall, and staff were unaware of the incident until days later, showing a breakdown in communication and investigation processes. Resident 62 alleged verbal abuse by a staff member, but the investigation was incomplete, lacking a statement from the resident and comprehensive interviews with witnesses. The alleged staff member was not suspended during the investigation, and interviews with other residents and staff were delayed or insufficient. These deficiencies highlight the facility's failure to adhere to guidelines for investigating and addressing incidents of abuse and neglect.
Inaccurate MDS Assessments for Three Residents
Penalty
Summary
The facility failed to ensure the accuracy of the Minimum Data Set (MDS) assessments for three residents, leading to potential risks for unmet care needs and diminished quality of life. Resident 7, who was admitted with diagnoses including right and left foot drop, had an MDS assessment that inaccurately reflected no impairment in lower extremity range of motion, despite a physical therapy evaluation indicating chronic ankle contractures. Staff J, the MDS Nurse, believed their assessment was correct, but the Director of Nursing Services (DNS) expected accurate MDS coding. Resident 25's MDS assessment failed to document the use of antipsychotic medication, despite the resident receiving Seroquel daily for insomnia. Staff J acknowledged the incorrect coding, and the DNS reiterated the expectation for accurate MDS assessments. Resident 67's MDS assessment did not reflect dental issues or nutritional concerns, despite documentation of decayed teeth and dietary supplements for weight stability. The DNS noted that the MDS did not meet expectations for accuracy in these areas.
Inaccurate PASRR Assessments for Residents
Penalty
Summary
The facility failed to ensure that Pre-Admission Screening and Resident Review (PASRR) assessments were accurately completed for four residents, placing them at risk for unidentified mental health care needs. Resident 83's Level I PASRR was incomplete, lacking a signature, completion date, and documentation of mental health diagnoses, despite the resident having conditions such as anxiety, depression, and bipolar disorder. Staff H, the Social Work Designee, acknowledged the inaccuracies, and the Administrator expected corrections to be made promptly after readmission. For Resident 60, the Level I PASRR indicated serious mental illness (SMI) indicators for depressive and anxiety disorders, but a Level II evaluation was not initiated, contrary to new regulations. Similarly, Resident 93's PASRR showed SMI indicators for mood disorders, yet no Level II evaluation was conducted. Resident 20's PASRR, dated from 2019, was outdated and inaccurately reflected the resident's current mental health status, necessitating a Level II PASRR. Staff H confirmed the need for an updated assessment to meet current standards.
Deficiencies in Care Plan Management and Timely Care Conferences
Penalty
Summary
The facility failed to ensure that care plans were reviewed and revised to accurately reflect the care needs of residents, leading to deficiencies in care for several residents. Resident 10, who was readmitted with paraplegia and other conditions, did not have a care plan for a restorative nursing program to maintain upper body strength and range of motion. The resident expressed interest in participating in such a program, but staff were unsure if any interventions were in place. The Director of Nursing Services acknowledged that the care plan was inadequate and did not meet expectations. Resident 78, who was readmitted with heart failure and diabetes, had a rash under the right breast that was being treated with a prescribed cream. However, the care plan inaccurately documented the rash's location and lacked measurable goals. Staff acknowledged the inaccuracies and the need for revision. Additionally, Resident 25 and Resident 68 did not have timely care conferences, with Resident 68 being overdue for a care conference since May, despite the expectation of holding them every three months. Resident 62, admitted with anxiety and depression, had incidents that were investigated but lacked a care plan addressing mental health needs. The care plan did not specify triggers or interventions for anxiety, leading to inadequate guidance for CNAs. Staff interviews revealed that the care plan and Kardex were not updated to include mental health needs, and the Director of Nursing Services confirmed that the care plan did not meet expectations by failing to include known triggers for anxiety.
Deficiencies in Care Coordination and Documentation
Penalty
Summary
The facility failed to ensure necessary interventions were in place for Resident 35, who was at risk for skin breakdown due to decreased mobility. Despite a provider's order for a low air loss (LAL) mattress to prevent further skin issues, the mattress was not provided, and staff inaccurately documented its use. This oversight was confirmed during interviews with staff, who acknowledged the absence of the LAL mattress and the improper documentation in the treatment administration record. For Residents 68 and 458, the facility did not adequately coordinate hospice care services. Resident 68, who was receiving hospice care for end-of-life needs, did not have a hospice care plan integrated into the facility's care plan, resulting in unmet personal care needs such as bathing and shaving. Similarly, Resident 458 experienced pain from a pressure wound, with no documentation or physician's orders related to the wound in their electronic health record. Despite communication from hospice staff about the wound, the facility failed to implement necessary treatments. The facility also neglected to monitor and document bowel movements for Residents 93, 358, and 25, failing to implement the bowel protocol as needed. Resident 93 experienced constipation without receiving appropriate medications, and Resident 358 had no documented bowel movements for several days. Resident 25 reported issues with constipation and diarrhea, yet the facility did not follow the bowel protocol. Additionally, Resident 108 experienced a significant change in condition with low blood pressure and unresponsiveness, but the facility did not notify the provider or resident representative in a timely manner, as required by their policy.
Deficiencies in Dialysis Care Documentation and Communication
Penalty
Summary
The facility failed to maintain a safe dialysis program for two residents, Resident 308 and Resident 60, who required dialysis services. For Resident 308, there was a lack of accurate documentation and communication regarding dialysis schedules and care. The resident's care plan and provider's orders were not updated to reflect the correct dialysis days and times, leading to discrepancies in the records. Additionally, the dialysis communication forms were incomplete, with missing information from both the facility staff and the dialysis provider. Resident 60's care was similarly compromised by inaccurate and incomplete documentation. The provider orders contained incorrect information regarding the resident's dialysis access type, as they specified an AV shunt when the resident had a perma cath. The care plan also had an incorrect pick-up time for dialysis, which did not match the provider's orders. Furthermore, the dialysis communication forms were often incomplete, and there was a lack of documentation for the administration of prescribed medications during dialysis sessions. Interviews with facility staff, including the Resident Care Manager and the Director of Nursing Services, revealed that the documentation and communication processes did not meet expectations. Staff acknowledged the discrepancies and incomplete records, indicating a failure to ensure accurate and consistent communication between the facility and the dialysis provider, which is essential for the safe and effective management of dialysis care for residents.
Failure to Provide Non-Pharmacological Interventions and Medication Management
Penalty
Summary
The facility failed to offer non-pharmacological interventions (NPI) before administering pain medications to four out of five sampled residents, which is a requirement to ensure that drug regimens are free from unnecessary medications. Resident 458, who was admitted with peripheral vascular disease and receiving hospice services, had an order for oxycodone every three hours as needed for pain. Despite the order for nurses to document NPI starting from a specific date, there were no documented attempts of NPI for Resident 458 during the review period. Staff interviews revealed that the expectation was to try two NPI before administering narcotics, but this was not consistently followed. Resident 83, who had a history of heart and lung disease, anxiety, depression, and bipolar disorder, was also not provided with NPI before receiving pain medications. The resident's care plan included interventions such as repositioning and the use of heat, but the medication administration record lacked documentation of these interventions throughout the month. Similarly, Resident 308, admitted with pneumonia and chronic pain, received PRN pain medications without any documented NPI, despite having an order for such interventions. Staff interviews confirmed that the orders for NPI were not properly linked to the PRN pain medication orders, leading to a lack of compliance with the facility's expectations. Resident 20, who had chronic kidney disease and chronic pain, also did not receive documented NPI before the administration of pain medications. Additionally, the facility failed to follow parameters for blood pressure medications, as Resident 20 received lisinopril despite having a heart rate below the specified threshold. Furthermore, orders for topical medications like lidocaine patches and diclofenac gel did not specify the application location, which was acknowledged as a requirement by the staff. These deficiencies placed residents at risk for adverse side effects and diminished quality of life.
Deficiencies in Psychotropic Medication Management
Penalty
Summary
The facility failed to ensure proper monitoring and justification for the use of psychotropic medications for two residents. Resident 460 was administered quetiapine, an antipsychotic medication, for dementia with agitation without a defined psychotic disorder. The pharmacist recommended a gradual dose reduction and cessation of the medication due to recent treatment for a urinary tract infection, but the provider did not act on this recommendation. Additionally, the facility did not monitor orthostatic blood pressures as ordered, which was necessary to assess potential side effects of the medication. Resident 25 was prescribed Seroquel for insomnia without proper documentation or evaluation of the cause of insomnia. The pharmacy consultation recommended a dose reduction and discontinuation, but the medication was continued without monitoring the resident's hours of sleep. Staff interviews confirmed that the necessary monitoring for effectiveness and gradual dose reduction was not conducted, leading to deficiencies in medication management for these residents.
Failure to Follow Menu Leads to Nutritional Deficiency
Penalty
Summary
The facility failed to adhere to the posted menu during a lunch service, as observed during a tray line inspection. Specifically, the menu indicated that one cup of macaroni with ham should be served, but staff used a grey-handled scoop, which was only half a cup, resulting in residents receiving a half portion of the main course. This discrepancy was confirmed by the Dietary Manager, who acknowledged that the server should have provided two scoops to meet the menu requirements. Resident feedback further highlighted issues with the menu not being followed and sudden changes to the menu, as noted in the resident council minutes. One resident expressed concern about not receiving half of the items listed on the menu. The facility's Dietary Manager and Administrator both emphasized the importance of following the dietician-developed menus to ensure adequate nutritional intake for residents, acknowledging that the failure to do so did not meet the facility's expectations.
Deficiency in Food Quality and Temperature
Penalty
Summary
The facility failed to provide palatable food served at appetizing temperatures for several residents, as observed during a survey. Multiple residents reported that the food was often cold, bland, and unappetizing. Resident 68 mentioned that the food was usually cold, while Resident 7 stated that the food was bland and often arrived cold, leading them to rely on their daughter for meals. Resident 93 reported receiving lunch as late as 3:00 PM, and Resident 20 expressed dissatisfaction with the smell, taste, and texture of the food, opting to eat only sandwiches. Resident 10 described the food as bland and processed, and Resident 62 criticized the food quality, noting that issues raised in food council meetings had not been addressed for two years. Observations during meal service revealed several issues with food preparation and serving. On one occasion, the lunch meal consisted of macaroni with ham, spinach, and a roll, with alternate options of chicken breast or pork chop. The rolls were flat and unappealing, the spinach was flaccid and soggy, and the macaroni was congealed. The tray line ran out of spinach, and staff resorted to microwaving a bag of spinach, which also turned out soggy. The meal service was prolonged, with the last resident tray being served over an hour and a half after service began. A test tray showed that the food was lukewarm and unappetizing, with macaroni at 115°F, chicken breast at 115°F, and spinach at 110°F. The resident council minutes from June, July, and August 2024 indicated ongoing grievances about food quality, including overcooked food and watered-down juice. Despite monthly food council meetings and resident interviews, the facility did not resolve these concerns. Staff R, the Dietary Manager, acknowledged that improper storage and handling of food trays could affect food temperatures. Staff A, the Administrator, admitted that residents should not receive food two hours after preparation and that the resident council's concerns should have been addressed.
Food Safety and Storage Deficiencies
Penalty
Summary
The facility failed to ensure the safe preparation and storage of food, as observed during a kitchen inspection. Two cans of food, specifically butterscotch pudding and cut sweet potato, were found with dents, which could potentially lead to contamination. Additionally, during a meal service, staff ran out of spinach and resorted to microwaving a bag of spinach in water, which was not a standard practice. Furthermore, a dietary aide was observed performing hand hygiene incorrectly by turning off the faucet with bare hands after washing, which does not meet the expected hygiene standards. The facility also failed to properly monitor the temperatures of resident food refrigerators. The East Hall refrigerator consistently recorded temperatures above 40°F for 28 consecutive days, and the [NAME] Hall refrigerator exceeded 40°F on 5 days and had a freezer temperature above 0°F on 11 days. The temperature logs used were not appropriate for food storage, as food should be kept between 33°F and 40°F. Staff interviews revealed that the monitoring process did not meet expectations, and the facility's adherence to the Food Code was questioned.
Ineffective QAPI Program Leads to Repeated Deficiencies
Penalty
Summary
The facility failed to ensure that its Quality Assessment and Performance Improvement (QAPI) program effectively self-identified deficiencies and developed or implemented effective plans of action to sustain corrections for previously identified deficiencies. This failure resulted in repeated deficiencies, a pattern of deficiencies, widespread deficiencies, and a pattern of actual harm that placed residents at risk for unmet needs. During an interview, the facility's administrator acknowledged that the QAPI process was not currently effective and needed to be reevaluated for its effectiveness. The report lists several deficiencies that were either not identified, not addressed, or had ineffective plans of correction, leading to repeated issues. These deficiencies included maintaining a safe, clean, and comfortable environment, investigating and preventing alleged violations, ensuring the accuracy of assessments, and maintaining nutrition and hydration status, among others. The deficiencies were noted to have occurred repeatedly over several years, indicating a systemic issue with the facility's QAPI program in sustaining corrections and preventing recurrence.
Failure to Implement Transmission-Based Precautions and Sanitize Laundry Equipment
Penalty
Summary
The facility failed to implement transmission-based precautions for five residents, which increased their risk of infection. Resident 6, who had an indwelling catheter and an open area, did not have a sign for Enhanced Barrier Precautions (EBP) or an isolation cart with personal protective equipment (PPE) outside their door. Similarly, Resident 458, with multiple wounds, and Resident 358, with pressure injury wounds, also lacked proper signage and PPE availability. Resident 466, diagnosed with a urinary tract infection and requiring contact precautions, had a sign posted, but staff failed to adhere to the PPE requirements. Staff Y entered the room without wearing a gown and gloves, claiming ignorance of the contact precautions. Resident 93, also on contact precautions for a UTI with ESBL, had a sign posted, but Staff X entered the room without PPE, misunderstanding the requirements for contact precautions. Additionally, the facility did not ensure proper cleaning and disinfecting of washing machines used for soiled isolation gowns. Observations showed that the laundry aide, Staff W, did not sanitize the front of the machines or the rubber gaskets between loads, despite visible soil. Staff V, the LPN and infection preventionist, acknowledged the issue and stated that education had been provided to the laundry staff. The Director of Nursing Services, Staff B, confirmed the expectation for proper implementation of isolation precautions and machine sanitization according to guidelines.
Failure to Obtain Informed Consent for Psychotropic Medication
Penalty
Summary
The facility failed to obtain informed consent for the administration of an antianxiety medication for one of the residents reviewed for unnecessary medication use. The resident, who was diagnosed with anxiety disorder and depression, was readmitted to the facility and was able to communicate their needs. Despite this, the resident was administered hydroxyzine, a psychotropic medication, for three days before an informed consent was signed. This oversight placed the resident at risk of not being fully informed about their treatment options and the potential risks and benefits of the medication. The facility's policy on psychotropic medication use, dated July 2022, mandates that residents, families, or their representatives be involved in the medication management process, which includes obtaining informed consent prior to medication administration. The policy also emphasizes the right of residents or their representatives to decline treatment after being informed of the risks and alternatives. Interviews with facility staff confirmed that the informed consent process was not followed as expected, with the Director of Nursing Services acknowledging that the consent should have been obtained before the medication was administered.
Privacy Violations During Medication Administration and Personal Calls
Penalty
Summary
The facility failed to ensure resident privacy during the administration of topical medications for two residents and did not provide a private location for personal phone calls and conversations for another resident. Resident 25, who was admitted with diagnoses including urine retention, depression, and heart failure, expressed concerns about the lack of privacy in their room due to a roommate's frequent yelling. Despite raising these concerns, staff reportedly laughed about the situation, and the roommate's yelling was observed during an interview. Resident 465, admitted with chronic respiratory failure, malnutrition, and anemia, was observed receiving topical medication with the door and privacy curtain open while the roommate had a visitor. The LPN applied patches to the resident's shoulder and back, exposing the resident's body without ensuring privacy. Similarly, Resident 62, with diagnoses of depression, anxiety, and adult failure to thrive, was observed applying a pain patch with the blinds open and lights on, exposing their body without any attempt to provide privacy. The DNS acknowledged that this was not acceptable practice.
Failure to Address Resident Grievances
Penalty
Summary
The facility failed to properly initiate and process grievances for two residents, leading to unmet needs and unresolved issues. Resident 7, who required extensive assistance with activities of daily living, reported sleep disturbances due to a noisy roommate. Despite multiple complaints to staff, including a CNA and an LPN, no formal grievance was initiated, and the issue was not addressed until social services were informed days later. The facility's policy required grievances to be investigated and resolved within 72 hours, but this was not adhered to in Resident 7's case. Resident 67, who was cognitively intact, reported a missing pair of black pants and filed a grievance that remained unresolved for several months. The grievance log confirmed the unresolved status, and interviews with staff, including the Social Services Director and Laundry Services, revealed a lack of follow-up and communication. The Administrator acknowledged that the grievance, filed months earlier, was not resolved until the day of the interview, which did not meet the facility's expectations.
Failure to Provide Transfer Notification
Penalty
Summary
The facility failed to provide written notification of the reason for transfer to the hospital to Resident 358 or their responsible party. This deficiency was identified during a review of the electronic health record (EHR) and interviews with facility staff. Resident 358, who was admitted to the facility with diagnoses including multiple sclerosis, heart failure, and diabetes, experienced a hospitalization and subsequent readmission. However, there was no documentation of a transfer notice in the EHR. Interviews with the Resident Care Manager/Licensed Practical Nurse and the Director of Nursing Services confirmed the absence of the required transfer notification documentation.
Failure to Provide Bed Hold Notice for Hospitalized Resident
Penalty
Summary
The facility failed to provide a written bed hold notice at the time of transfer to the hospital for one of the two sampled residents reviewed for hospitalization. This deficiency involved Resident 358, who was admitted to the facility with diagnoses including multiple sclerosis, heart failure, and diabetes, and was capable of making their needs known. The electronic health record (EHR) indicated that Resident 358 was hospitalized and subsequently readmitted to the facility, but there was no documentation of a bed hold notice. During interviews, both the Resident Care Manager/Licensed Practical Nurse and the Director of Nursing Services confirmed the absence of the required bed hold documentation, which was expected to be documented and scanned into the EHR.
Failure to Develop Baseline Care Plans for New Admissions
Penalty
Summary
The facility failed to develop a baseline care plan within 48 hours of admission for two residents, Resident 460 and Resident 68, which is a requirement to ensure that immediate needs are met. Resident 460 was admitted with multiple diagnoses, including heart disease, diabetes, Alzheimer's, and dementia, and had moderately impaired cognitive skills. Despite having provider orders for dementia treatment, including monitoring agitation and administering Seroquel, the facility did not create a focus area for dementia in the care plan. Interviews with staff revealed that the baseline care plan was a group effort, but there was a delay in generating it for Resident 460. Resident 68 was admitted with diagnoses of dementia and adult failure to thrive and was receiving hospice care for end-of-life services. However, no care plan for hospice services was found in the medical record. The Director of Nursing Services acknowledged that it was expected for the facility to collaborate and initiate a care plan for hospice services upon admission, which did not occur for Resident 68. This oversight placed the residents at risk for unmet needs and a diminished quality of life.
Unprofessional Documentation in Resident Records
Penalty
Summary
The facility failed to maintain professional standards of quality in documentation for one of the residents, identified as Resident 67. The resident was admitted with several diagnoses, including reduced mobility, chronic obstructive pulmonary disease, cognitive communication deficit, chronic pain, and anxiety, and was able to communicate needs. A review of the electronic health record revealed that a registered nurse, Staff F, documented subjective and unprofessional comments about Resident 67, describing them as 'annoying' and 'difficult' in progress notes. Interviews with Staff F, the Resident Care Manager, and the Director of Nursing Services confirmed that such subjective documentation was not professional and should not have been included in the resident's records.
Deficiencies in Pressure Ulcer Care for Two Residents
Penalty
Summary
The facility failed to provide necessary treatment and services for pressure ulcers for two residents, leading to deficiencies in care. Resident 458, who was at high risk for pressure injuries due to congestive heart failure, had a pressure ulcer on the tailbone documented in the care plan but lacked documentation and treatment orders for a painful wound on the ischium. Despite the hospice nurse identifying and communicating the new wound to facility staff, no incident investigation or treatment orders were initiated, as confirmed by the Director of Nursing Services. Resident 358, diagnosed with multiple sclerosis, heart failure, and diabetes, experienced multiple pressure injuries, including sores on the sacrum, left heel, right buttock, and a new open area on the left buttock. The care plan did not reflect the actual skin condition, and observations showed the resident was not repositioned as required, with heels touching the mattress due to improper placement of a wedge cushion. The Certified Nursing Assistant confirmed the incorrect positioning, and the Director of Nursing Services acknowledged the failure to follow the care plan and skin prevention plan.
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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