Parkside Care
Inspection history, citations, penalties and survey trends for this long-term care facility in Union Gap, Washington.
- Location
- 308 West Emma, Union Gap, Washington 98903
- CMS Provider Number
- 505401
- Inspections on file
- 33
- Latest survey
- March 23, 2026
- Citations (last 12 mo.)
- 35
Citation history
Health deficiencies cited at Parkside Care during CMS and state inspections, most recent first.
Failure to supervise a resident with severe cognitive impairment and a high fall risk led to repeated unwitnessed falls, including falls during toileting and while attempting to self-transfer from a w/c. Staff documented inconsistent monitoring, no scheduled toileting program, and no consistent 1:1 support despite the resident’s impulsive behavior and repeated falls. Two falls required hospital intervention for head injuries, including a scalp laceration requiring staples and another fall with brief LOC and hip pain.
Unsafe Food Handling and Unsanitary Kitchen Conditions: Staff failed to maintain a sanitary kitchen and did not follow proper food handling practices. The kitchen had heavy grime, dust, food buildup, peeling paint, and a broken ice machine, while the resident refrigerator stored facility-prepared foods past expiration alongside foods brought in from outside sources. During meal prep and service, an FF handled food, thermometers, and ice with poor hand hygiene and bare hands, then used contaminated melting ice on resident drinks and ice cream that were served in the dining room.
Meal service was not provided in a dignified manner for four residents who required assistance at lunch. Residents in the dining room waited about an hour while trays were served to room-bound residents first, and staff stated there was not enough time to fully assist residents who needed cueing or feeding. One resident with MS and dementia, one with tremors and swallowing problems, one with dementia and diabetes, and one with dementia and hearing loss were observed struggling to eat, spilling food, touching food with fingers, or unable to use utensils while staff moved between tables or were not present.
The facility failed to provide scheduled showers and bathing assistance for multiple residents who depended on staff for ADLs. Residents with conditions including MS, dementia, diabetes, kidney disease, dyskinesia, and arthritis reported missed showers, and records showed repeated gaps in bathing schedules because NAs were pulled from shower duties to cover the floor, staff called out, and replacement coverage was unavailable. Staff acknowledged that bathing was not consistent and that residents were not always bathed on their scheduled days.
Failure to monitor and address nutritional needs led to weight loss and poor meal intake for four residents. One resident with ESRD on dialysis, DM2, malnutrition, and swallowing complaints refused a sugary supplement and lost significant weight; another resident with dementia and malnutrition could not manage utensils and lost weight; a resident with dementia and hearing loss struggled to eat because staff did not assist promptly and also lost weight; and a fourth resident on a restorative eating plan was moved between tables, had delayed meal support, and ate only a few bites. The nutrition-at-risk record lacked recent notes for these residents, and staff interviews showed gaps in awareness of the weight loss and food preference details.
The facility did not have enough competent nursing staff to meet resident needs for ADLs and accident prevention. A resident with repeated falls had unwitnessed incidents and injuries, and staff said one-on-one supervision was needed but could not be provided because of staffing shortages. Several residents also reported missed or inconsistent showers, and staff confirmed the bath team had been reduced, shower aides were unavailable, and the facility needed to hire additional NAs.
A resident with intact cognition reported missing cash and coins from the room, but the grievance was closed without documented follow-up with the resident. Staff contacted the RR about the money, yet the resident was not re-interviewed after the investigation, and staff stated they believed the resident was satisfied or that follow-up was not their responsibility.
A resident with osteomyelitis, MS, and anxiety was subjected to repeated verbal interactions by the BOM that the resident described as confusing, overwhelming, and scary. The BOM discussed Medicaid, payment obligations, and limits on time away from the facility, and the resident felt targeted and afraid to speak with the BOM again. The DON stated the abuse allegation process included suspending the identified staff member while the matter was investigated.
A facility failed to follow its abuse prevention policy when a resident reported feeling bullied, targeted, and scared after interactions with the BOM. The resident, who had osteomyelitis, MS, and anxiety, said the BOM was abrupt and unkind and told them they could not be away from the facility for more than four hours or they would lose coverage. Staff were informed of the resident’s concerns, but the allegations were not initially handled as verbal abuse.
Failure to develop a patient-centered discharge plan. A resident with severe cognitive impairment, dementia, a history of falls, and extensive ADL needs was told by facility staff that they needed to find another placement because the facility did not provide 1:1 care. The resident’s representative reported receiving limited help with placement, conflicting information about Medicaid coverage, and a short deadline to remove the resident or pay privately, while staff gave inconsistent accounts of the discharge plan and the resident’s payer status.
The facility failed to provide a written bed-hold notice for one resident and failed to send transfer/discharge notices to the LTC Ombudsman for two residents. One resident with MS and diabetes was hospitalized for a UTI, and another resident with respiratory and heart failure discharged home AMA; records did not show the required notices were completed.
PASRR screening was not updated for two residents after a 30-day EHD. One resident had schizophrenia, malnutrition, and HF, and another had Alzheimer's, bipolar disorder, MDD, and anxiety with severe cognitive impairment. The PASRR records showed 30-day EHD admissions, but no timely updated PASRR was completed, and staff stated they were unsure of the 30-EHD requirements.
A resident with MS and a cognitively intact admission assessment signed a binding arbitration agreement, but staff did not explain the document in a form and manner the resident could understand. The BOM emailed the admission packet for review on a cellphone screen, did not personally review the arbitration terms page by page, and did not assess understanding; the resident later stated they did not know what arbitration was, believed signing was required for admission, and would have revoked the agreement after understanding it.
The facility failed to enforce its compliance and ethics program when an Administrator allowed a Dietary Manager to work with vulnerable residents before a background check was completed. Although policy required criminal screening before hire and before unsupervised resident contact, the staff member was working while the BGI remained pending. The HRD stated this was not the normal process, and the DON and DCO said staff should not work with vulnerable residents until screening was complete.
Laundry room WM1 was observed leaking water onto the floor, with a wet back plate, a puddle beneath the machine, and white soap-like buildup caked around rusted bolts and the base. Staff stated the leak had been present for over a week and that the residue should not be there. The deep channel drainage trough also contained stagnant water with gray sludge and a foul odor, and staff stated it was not sanitary and was not working properly.
A resident at risk for pressure injuries developed an open wound on the coccyx that progressed from Stage 1 to an unstageable PI due to lack of thorough skin assessments, delayed provider notification, and failure to implement pressure offloading and nutritional interventions. Staff interviews confirmed missing documentation, absence of pressure-relieving equipment, and no protein supplementation, resulting in the resident's wound worsening and requiring hospital evaluation.
A resident with significant mobility limitations and a history of pathological fractures was manually transferred by two nursing assistants without the use of a mechanical lift, contrary to the care plan directives. This failure to follow the established transfer guidelines placed the resident at risk for injury and unmet care needs.
The facility failed to maintain proper sanitization and food handling practices in the kitchen, risking foodborne illnesses. Observations showed unsanitary conditions, including dirty equipment and improper hand hygiene by staff. Personal drinks were found in the kitchen, and staff did not adhere to cleanliness expectations, contributing to the deficiency.
The facility did not submit required PBJ data for the 4th Quarter of 2024, leading to inaccurate CMS staffing data. The Administrator was unaware of this omission and planned to investigate.
The facility failed to ensure management staff attended Resident Council meetings only when invited, causing discomfort among residents. Two residents expressed feeling unable to voice concerns due to the presence of the Administrator and Resident Care Manager, who regularly attended meetings. Staff interviews revealed a misunderstanding about the necessity of management's presence, leading to residents' fear of reprisal.
The facility failed to accurately assess two residents' life expectancy, leading to discrepancies in their MDS assessments. One resident with multiple severe diagnoses was not informed of their prognosis, and another resident's representative was unaware of the life expectancy assessment. The MDS Coordinator relied on incomplete records without verifying physician documentation, contrary to RAI guidelines.
The facility failed to ensure PASARRs were accurately completed and updated for residents with SMI or ID/DD. Four residents were affected, with diagnoses such as dementia, depression, PTSD, and anxiety not properly reflected in their PASARRs. The Social Service Director did not review or update PASARRs as required, and staff interviews revealed a lack of training on new PASARR regulations.
The facility failed to ensure proper documentation and communication for residents requiring EOL care and those diagnosed with PTSD. Residents were placed on EOL care without prior discussion or significant health changes documented, and PTSD diagnoses were added without proper assessments. Staff actions lacked transparency and involvement of residents and their families, placing them at risk for unmet care needs.
The facility failed to implement proper infection control measures during wound care and medication administration. A treatment nurse did not perform hand hygiene or use barriers during wound care for two residents, and an LPN did not sanitize a glucometer between uses. Another LPN failed to wear appropriate eye protection in a precaution room. These lapses increased the risk of cross-contamination and disease transmission.
A resident's care plan contained inaccurate information labeling them negatively, affecting their dignity and quality of life. The resident, who is deaf, was misunderstood by staff, leading to misinterpretations of their communication as aggressive or inappropriate. Staff interviews and observations contradicted the care plan's documentation of negative behaviors.
A facility failed to inform a resident's representative about hospice options when the resident was placed on end-of-life care. The RR was not given the opportunity to consider hospice services, as staff indicated that comfort measures could be provided in-house. Interviews revealed that the RR was not educated on hospice services, and the contracted medical provider was unsure of what hospice offered, highlighting a communication gap.
Two residents faced challenges due to inadequate room space, impacting their independence and safety. One resident with Parkinson's Disease struggled to maneuver their wheelchair, while another with COPD had limited access to their closet and sink. The room's layout did not meet space requirements, and staff were unaware of these deficiencies.
The facility failed to maintain separate accounting for pooled resident funds, affecting three residents with various medical conditions. Their personal funds were deposited into a single interest-bearing account, and monthly care fees were deducted without separate documentation. The Business Office Manager confirmed the lack of separate accounting for each resident's funds.
A facility failed to maintain a homelike environment due to inadequate maintenance of adaptive equipment and heating issues. Residents experienced discomfort from broken equipment, such as padded mobility rails and alternating air overlay mattresses, and cold room temperatures. Staff interviews revealed a lack of proactive assessment and maintenance, with delays in addressing heating issues due to reliance on external companies.
A facility failed to conduct required care conferences for a resident with spastic quadriplegic cerebral palsy and dementia. Despite policy requirements for regular care conferences, none were documented from January 2024 to February 2025. The resident's representative confirmed the lack of meetings, and facility staff acknowledged the issue, citing systemic problems with the process.
A resident with diabetes and low back pain did not consistently receive restorative therapy services due to staffing shortages, leading to concerns about their declining strength and ability to discharge home. Staff responsible for therapy were often reassigned to nursing duties, prioritizing daily care over restorative programs.
A facility failed to ensure proper dialysis care for a resident with ESRD by not maintaining effective communication with the offsite dialysis center. The facility's policy required coordination and documentation of pre/post dialysis weights and vital signs, but these were not consistently recorded. The DON admitted that communication forms were not used, and nursing staff did not consistently monitor the resident's condition, resulting in a deficiency in care.
A resident with PTSD, deafness, diabetes, and end-stage kidney disease did not receive trauma-informed care as per their care plan. The resident's PTSD, triggered by a history of sexual assault, required a private room, but the facility failed to provide one, leading to episodes of anger and anxiety. Staff acknowledged the need but cited a lack of available private rooms in the long-term care unit.
The facility failed to ensure residents were free of unnecessary psychotropic medications, as evidenced by two residents receiving such medications without specific monitoring for adverse side effects or documented necessity. Staff inconsistencies and a transition to a new electronic health record system contributed to the deficiency.
The facility failed to discard expired medications and wound supplies in both the medication and treatment storage rooms. Expired glucagon pens, albuterol sulfate doses, and wound dressings were found, along with medications lacking proper labeling. The DON stated that the day charge nurse was responsible for weekly checks, but due to low staffing, these checks were missed, placing residents at risk.
The facility failed to implement key components of their pneumococcal vaccination program, resulting in inadequate screening and documentation for two residents. One resident with diabetes had no verification of their vaccination status despite having received the vaccine outside the facility. Another resident with dementia had no documentation of risks and benefits provided or a signed declination, despite being offered the vaccine. The Infection Preventionist admitted to not verifying previous vaccinations beyond discharge records.
The facility failed to maintain safe and sanitary conditions in two storage rooms, posing risks to residents. One room had exposed electrical wires and was cluttered, with the door propped open due to overheating concerns. The Hoyer storage room had missing linoleum, exposed concrete, and broken tiles, which were not logged for repair, raising infection control concerns.
The Governing Body failed to ensure financial systems were in place, leading to staff using personal funds to pay vendors for essential supplies and services. This placed residents at risk of not receiving necessary care and services. Interviews revealed that the facility relied on a limited debit card and personal funds from staff, with several vendors placing the facility on credit hold due to non-payment. The Administrator had not received financial updates since April 2023, and utility bills were overdue, threatening service shut-offs.
The facility administration failed to manage resources effectively, leading staff to use personal funds for necessary supplies and services. The Administrator and DON, along with other staff, covered costs for resident care and facility maintenance due to insufficient funds. The lack of a budget and support from the owner contributed to this issue, placing residents at risk for disruptions in care.
The facility's FA was not properly updated to reflect changes in vendor services and lacked input from key stakeholders, including the governing body and medical director. The FA inaccurately listed compliance and ethics training as current, despite the absence of such a program. Interviews revealed a lack of training and involvement in the FA process, placing residents at risk of unmet care needs.
The facility's QAPI Committee failed to identify and address systemic deficiencies, including financial instability and lack of a Compliance and Ethics program. The Administrator used personal finances for resident needs due to inadequate support from the Governing Body. The QAPI meetings did not discuss these issues, and the Facility Assessment was outdated.
The facility failed to implement an effective compliance and ethics program, as evidenced by incorrect hotline information and lack of staff training. Interviews revealed staff were unaware of proper reporting channels for ethical concerns, and the Administrator acknowledged the absence of a formal program.
The facility failed to return the balance of funds to the Office of Financial Recovery (OFR) for four deceased residents, as required by state law. The policy mandates that upon a resident's death, any personal funds held in a trust account should be conveyed to the OFR. Interviews revealed that staff were unaware of this requirement, leading to non-compliance and potential risk for the state department.
A resident with bipolar disorder, anxiety, and depression did not receive necessary behavioral health services after the facility discontinued telehealth services. Despite the resident's expressed need for psychological support, the facility did not explore alternative options or utilize their existing telehealth contract, leaving the resident without access to mental health care.
A resident sustained a skin tear and subsequent infection due to a failure to follow their care plan, which required a two-person assist for transfers. A Nursing Aide attempted the transfer alone, leading to the injury. The resident's condition declined following the incident, as confirmed by staff interviews.
The facility failed to implement effective infection control measures for bed bug infestations, affecting four residents. Staff relied on internet research for mitigation plans, and no formal training was provided. The pest control company could not perform extermination due to unpaid bills, delaying treatment and allowing the infestation to spread to adjacent rooms.
Failure to Supervise a High Fall-Risk Resident
Penalty
Summary
The facility failed to identify hazards and risks and failed to provide adequate supervision for a resident with severely impaired cognition, a history of falls, and a high fall risk score. The resident required substantial to maximum assistance for activities of daily living, used a wheelchair, and had repeated falls after admission. The resident’s fall risk score increased from 55 to 105, and the record showed 14 falls between 01/29/2026 and 02/22/2026, with the most recent fall occurring on 02/22/2026. The resident experienced multiple unwitnessed falls despite several interventions being documented at different times, including keeping the resident in the hall next to the nurse, keeping the resident within visual sight, and calling in one-on-one staff for part of a night shift. The record also showed the resident had no toileting program and no scheduled toileting assistance, even though several falls occurred when the resident needed to use the bathroom or was in the bathroom. Staff interviews showed the resident was impulsive, not sleeping well, and was not consistently being watched or sat with one-on-one because staff said they did not have the staffing capability to provide that level of supervision. Two falls resulted in injuries that required hospital intervention. One hospital visit followed a fall with a brief loss of consciousness and a large scalp laceration that required five staples, along with complaints of back, hip, and neck pain. Another hospital visit followed a fall with head injury, a large scalp laceration, and left hip and thigh contusion, and the resident could not lift the left leg due to pain. The record also showed the resident had signs and symptoms of a urine infection during the fall period, and staff stated the resident had been treated for a urine infection. Staff and the resident representative stated the resident needed one-on-one assistance to stay safe, but the facility did not provide consistent one-on-one supervision.
Unsafe Food Handling and Unsanitary Kitchen Conditions
Penalty
Summary
The facility failed to ensure food was prepared, distributed, and served in accordance with professional standards of practice and that the kitchen environment was sanitary. During the kitchen observation, the entrance area had old dried splashes of food/liquid on the walls, a current wet puddle on the floor, and an ice machine that was broken and off. The resident refrigerator in the kitchen contained more than 30 facility-prepared pudding and applesauce cups that were labeled with expiration dates of 03/12/2026, 03/15/2026, and 03/16/2026, and staff stated those items should have been discarded before the expiration date and should not have been stored with resident foods brought in from outside sources. The kitchen also had multiple sanitation concerns. The juice machine dispenser nozzle had masking tape over some buttons that was soiled, discolored, and worn, and staff stated they did not know when it had last been cleaned. The dishwasher area had a thick layer of dust and food particles on top, black caked buildup around the pipes and on the floor and walls below it, a hole in the wall where piping came through, and peeling paint behind the dishwasher. The stove top burners had heavy grime and food buildup, the backsplash had splashes and food particles, and the grease traps had multiple layers of buildup. Shelves above the food preparation tables were dusty with grease, and under the food prep counters there was dust, grime, food particles, trash, and an upside-down mouse box with an imprint in the dust. Staff M and Staff T stated the area below the dishwasher was not sanitary, and staff could not produce records showing routine or deep cleaning was being completed as expected. During food preparation and service, Staff FF handled food and equipment without proper hand hygiene or glove changes. Staff FF removed gloves, opened a refrigerator, went to the dry storage area, then flipped a hamburger patty and handled a roast beef thermometer without washing hands or donning new gloves. Staff FF also handled a thermometer probe and a Tator Tot with bare hands, then washed hands and placed the same soiled Tator Tot back on the baking sheet. Staff FF later used ungloved hands to break up melting ice from the broken ice machine and placed that ice on resident drinks and ice cream. The same ice was observed melting on top of resident juice and milk lids and on ice cream cups, and those items were served to residents in the dining room. Staff M and Staff DD stated the ice machine had been turned off and was not to be used, but no sign had been placed on it at the time of the observation.
Dignity and Meal Assistance Failures During Lunch Service
Penalty
Summary
Meal services were not provided in a dignified manner for four residents who were seated in the main dining room and required varying levels of assistance with eating. On 03/17/2026, residents in the dining room waited about an hour for lunch to be served, while trays were served to residents in rooms on the 100 hall first. The Regional Registered Dietician stated it was not dignified to make residents in the main dining room wait and that it would make sense to serve the dining room first because some residents required assistance. Resident 23 had diagnoses including progressive Multiple Sclerosis and dementia and was seated at the Progressive Self Feeding Program table with a care plan for memory loss, swallowing issues, and meal assistance with cues to slow down and take small bites. Staff Q, a restorative aide, stood and gave brief verbal cues but stated there was not enough time to sit with residents who needed assistance because other residents’ lunch trays had to be passed. Resident 31 had diagnoses including dyskinesia, kidney disease, and insulin-dependent diabetes, with tremors and swallowing problems that interfered with eating. Observations showed the resident shaking, spilling food, becoming embarrassed and tearful, asking to return to the room, and later coughing while staff moved between tables rather than fully assisting with meals. Resident 33 had dementia and diabetes and was observed without supervision, removing a clothing protector, touching food with fingers, and waiting with an uncovered tray for about 15 minutes before staff assisted. Resident 18 had dementia with behavioral disturbances and was hard of hearing, and was dependent on staff for all ADLs except meal set-up and clean-up. Observations showed the resident seated at a table that was too high, unable to pick up utensils, eating with fingers, and unable to cut food, while no staff came to assist. The DON stated there were issues at mealtimes in the dining room, that more people wanted to eat there, and that it was a lack of dignity and led to weight loss.
Missed showers and bathing assistance due to staffing shortages
Penalty
Summary
The facility failed to provide assistance with ADLs related to showers and bathing for five residents who were dependent on staff for this care. Resident 6, who had intact cognition and was dependent on staff for showering and bathing, reported that the facility only had one staff person assigned to showers and that when floor NAs did not report, shower staff were pulled to the floor and no one received showers. The resident stated they were scheduled for two showers a week but often received only one or none, and the task record showed six showers completed out of 14 scheduled during the review period. Resident 44, who had intact cognition and required substantial to maximum assistance with bathing and showers, reported going as long as two weeks without a shower and said they had reported the issue to the DON and Social Services Director. Records showed missed showers on the bathing schedule, including instances where floor NAs called in and shower NAs were pulled to work the floor. Staff B stated the facility had recently terminated a shower NA and another had been on family medical leave, and that staff available to complete showers were not always available on the resident’s scheduled days. Resident 24, admitted with left knee bacterial arthritis, malnutrition, and spondylolisthesis, required one to two staff for dependent/moderate assistance with ADLs and was scheduled for two showers per week, but the record showed only one shower completed and no documented refusals. Resident 31, who had dyskinesia, kidney disease, and insulin-dependent diabetes, depended on staff for transfers and bathing and reported missing showers because of staff call outs and no replacement staff; the resident’s hair was greasy and facial skin was flakey during observation. Resident 18, who had dementia with behavioral disturbances and was dependent on staff for all ADLs, was scheduled for two showers per week but received only five of ten scheduled baths/showers in the reviewed period. Staff stated the facility had not had consistent bathing/showers because NAs were pulled from bathing tasks to work on the floor due to staffing shortages, and that there were not enough staff assigned to resident care to complete baths/showers.
Failure to Monitor and Address Resident Nutritional Needs
Penalty
Summary
The facility failed to monitor and address nutritional needs for four residents who were reviewed for nutrition. The deficiency involved Resident 5, Resident 10, Resident 18, and Resident 33, all of whom had documented weight loss and meal intake concerns. The report states this failure placed the residents at risk for medical complications, nutritional weight loss, and a diminished quality of life. Resident 5 was readmitted with diagnoses including end stage kidney disease with dialysis, dental caries, missing teeth, diabetes type 2, malnutrition, and heart disease. The resident required setup only for meals, had some cognitive and hearing loss, and could make needs known. The resident reported difficulty swallowing foods and stated the puree diet was too sweet, signed a deviation from puree to regular soft foods, and identified preferred foods such as beans and rice, vegetables, wraps, soft tortillas, paella, and stuffed peppers. The resident also stated the supplement drink was too sugary and was refused. The record showed weight loss from 142.4 pounds to 123.1 pounds, a 13.55% loss, and low laboratory values. The regional dietician stated the prior RD did not confer with the dialysis dietician about the low lab results and that the resident could benefit from renal vitamin supplementation. Resident 10 was admitted with aftercare of bowel surgery, dementia, and malnutrition. The resident was confused but able to make needs known, required supervision and setup for meals, and had a regular texture diet with interventions including finger foods if needed and milk shake supplements. During observations, the resident picked at food, was unable to use utensils effectively, spilled food on their lap, and did not finish meals. The resident’s weight decreased from 148.6 pounds to 135.2 pounds, a 9.02% loss. Resident 18 had dementia with behavioral disturbances and hearing loss, was dependent on staff for meals with setup and cleanup only, and was observed struggling to eat because the dining table was too high and staff did not assist for some time. The resident ate with fingers, attempted to eat pudding with fingers, and could not cut chicken. The resident’s weight decreased from 112 pounds to 101.8 pounds, a 9.1% loss. Resident 33 had dementia and diabetes, needed staff assistance with meals, and was on a restorative eating plan with verbal cues and instructions to take liquids after two to three bites. During observations, the resident was moved between tables, had coffee with a lid and straw, removed the clothing protector, wheeled away from the table, and had a tray left uncovered for 15 minutes before staff readjusted the protector and gave a spoon. The resident took only a few bites and attempted to leave the table. The resident’s weight decreased from 162 pounds to 154.4 pounds, a 4.69% loss. The nutrition at risk book from December 2025 through March 2026 contained notes of meetings for residents with risk for weight loss and actual weight loss, but there were no recent notes for Residents 5, 10, 18, and 33. Staff interviews indicated the dietary manager should have had a detailed list of Resident 5’s food preferences, Staff T had not reviewed Resident 18 and was not aware of the weight loss, and Staff B stated there had been many staff changes and was not surprised there were residents with some weight loss. The deficiency was cited under WAC 388-97-1060(3)(h).
Insufficient Nursing Staffing Led to Missed ADLs and Inadequate Fall Supervision
Penalty
Summary
The facility failed to provide enough competent nursing staff to meet resident needs, including assistance with ADLs and supervision to prevent accidents. The facility assessment showed an average census of 48 residents and a staffing plan of eight NAs on day shift, seven on evening shift, and four on night shift, with staffing to be adjusted based on resident needs. However, the staffing pattern for 02/15/2026 through 03/17/2026 showed that 29 of 31 day shifts had only four NAs scheduled, and 21 of 31 evening shifts had only four NAs scheduled, with one evening shift showing three and a half NAs. The daily census sheets showed that on 29 of the 31 days reviewed, the census was over 50 residents. Resident 37 had 14 falls between 01/29/2026 and 02/22/2026, 12 of which were unwitnessed, and sustained injuries during six falls, with two requiring hospital intervention. Staff stated Resident 37 needed one-on-one supervision to stay safe from falling, but the facility did not have enough staff to provide that care. The facility also failed to provide routine bathing or shower care for residents who were scheduled for it. Resident 6 reported receiving only one shower a week, if any; Resident 24's representative said the resident had received only one shower since admission despite being scheduled for two weekly; Resident 31 said two of seven scheduled showers were missed because staff did not show up and there were no replacements; Resident 18 had brown substances under their fingernails and did not know when they last had a bath; and Resident 44 reported going 10 days to two weeks without a shower because there were not enough shower NAs or floor NAs did not report for work. Staff interviews confirmed shortages, including the need to hire five to six NAs, loss of bath team coverage, and inability to assign additional staff for Resident 37 or to provide showers consistently.
Incomplete grievance follow-up for missing resident money
Penalty
Summary
The facility failed to complete a thorough grievance process for one resident who reported missing money from the room. The resident, whose diagnoses included a right below-the-knee amputation, diabetes, and asthma, had intact cognition on comprehensive assessments. The resident stated that $40 in two $20 bills had been placed in an iPad case and later went missing, and also reported $8 in silver coins missing from a drawer. The resident said the facility did not replace the missing money and did not provide any follow-up after the report was made. The grievance record showed the resident claimed $40 missing from the room and documented that the resident last saw the money on 01/30/2026. The record also showed the resident representative was contacted and stated the resident did not have cash on them and that the representative had the wallet, while also noting that a family member had left money with the facility for the resident's trust account. The grievance was marked completed by the Administrator without any follow-up documented with the resident. During interviews, staff stated they did not follow up with the resident because they believed the resident was satisfied with the outcome or because they were not the person who completed the investigation, and the Grievance Officer stated they did not follow up with the resident and were not aware of the missing $8 in silver.
Resident subjected to verbal abuse during financial and discharge-related discussions
Penalty
Summary
The facility failed to protect a resident’s right to be free from verbal abuse when Staff K, the Business Office Manager, made repeated comments to Resident 64 about Medicaid eligibility, payment responsibilities, and time away from the facility. Resident 64 was admitted with diagnoses including right foot/ankle osteomyelitis, multiple sclerosis, and anxiety. During an interview, Resident 64 stated Staff K told them they would be required to apply for Medicaid after 21 days, would owe 20% of the bill, and asked whether they would be holding any money at the facility. Resident 64 described the interaction as confusing, overwhelming, off-putting, and lacking empathy or kindness. Resident 64 also reported a second interaction in which Staff K approached them by their ear as they were leaving the facility and stated they could only be gone four hours because the state would think they did not need to be at the facility if they were away longer. Resident 64 stated this scared them, made them not want to speak with Staff K again, and led them to feel targeted and as if they would be kicked out for visiting a friend. Staff K stated they provided a Medicaid application, discussed what residents would receive after Medicaid paid for the facility, and told Resident 64 they were only allowed four hours away from the facility because they were on Medicare. The Administrator stated Staff K was suspended after the allegation of verbal abuse was reported.
Failure to Recognize and Respond to Alleged Verbal Abuse
Penalty
Summary
The facility failed to implement its abuse and neglect prohibition policy for identifying verbal abuse for one resident reviewed for abuse. The policy stated residents had the right to be free from abuse and neglect, staff were prohibited from using verbal abuse, and the facility would provide immediate safety for a resident upon identification of potential abuse or neglect by staff and protect the resident from retaliation. Resident 64 was admitted with diagnoses including right foot/ankle osteomyelitis, multiple sclerosis, and anxiety. A nursing admission progress note stated the resident was independent with activities of daily living and able to make needs known. The facility investigation later identified opportunities for improvement related to customer service, timeliness of reporting, and recognizing and responding to alleged abuse allegations. Resident 64 reported feeling confused, overwhelmed, and off-put by interactions with Staff K, the Business Office Manager, and stated Staff K lacked empathy and was aggressive about the resident’s financial situation. The resident also reported being told they could not leave the facility for more than four hours or they would lose medical coverage, which made them feel scared, targeted, bullied, and concerned they would be kicked out of the facility. Staff Y reported the resident said they felt intimidated, talked down to, scared, and terrified, and Staff A initially spoke with other management and Staff K rather than directly addressing the resident’s allegations of verbal abuse.
Failure to Develop a Patient-Centered Discharge Plan
Penalty
Summary
The facility failed to develop a patient-centered discharge plan by the interdisciplinary team for one resident who was admitted with diagnoses including a surgical repair of the right ulna, a history of falling, and dementia. The resident’s comprehensive admission assessment showed severely impaired cognition, wheelchair use for mobility, and a need for substantial to maximum staff assistance with all activities of daily living. During interviews, the resident’s representative stated facility staff repeatedly told them the resident had to find another facility because the facility did not offer one-on-one care for a resident with dementia. The representative said they were given a phone number for another facility and a senior support service navigator, but no other assistance in finding placement. The representative also stated the resident liked to walk, but the facility did not want to walk the resident very often, and the resident became weak and started to fall. The representative reported being told they had only a few days to remove the resident and that the facility would begin charging a daily rate after the resident’s Medicare coverage ended, despite the representative stating the resident already had Medicaid and long-term coverage. Facility staff gave conflicting accounts about the discharge plan and the resident’s coverage. The unit manager and social services director stated they had contacted the representative about the resident needing a higher level of care and said the resident could not remain unless the family paid privately after Medicare ended. The business office manager stated the resident already had Medicaid with long-term coverage prior to admission and that the resident’s coverage would transition to Medicaid after the Medicare-covered days ended. The director of nursing stated the facility accepted residents with dementia and that the resident was expected to stay until family found caregivers or decided on long-term placement, and also noted confusion between business office and unit manager staff about the resident’s coverage.
Failure to Provide Bed-Hold and Ombudsman Discharge Notifications
Penalty
Summary
The facility failed to issue a written bed-hold notice for one resident and failed to provide written hospital transfer or discharge notices to the Office of the State Long-Term Care Ombudsman for two residents. Facility policy required a written bed-hold notice to be given to the resident or resident representative when the resident transferred to the hospital or took therapeutic leave, and the transfer/discharge policy required written notice to be given to the resident or resident representative before or at discharge and a copy to be sent to the LTC Ombudsman. One resident, who had diagnoses including MS and diabetes and whose comprehensive assessment showed intact cognition and dependence on staff for activities of daily living, was hospitalized for a urine infection and returned after several days; the record did not show a written bed-hold policy or a hospital transfer/discharge notice, and the LTC Ombudsman was not notified. A second resident, with diagnoses including respiratory and heart failure and intact cognition, discharged home against medical advice after being educated about the need to stay and receive care and signing the appropriate paperwork; the discharge record did not show that notification had been sent to the LTC Ombudsman. Staff later stated they rechecked the records and were unable to find that the bed hold or appropriate transfer/discharge notification had been completed for the first resident, and that Ombudsman notification had not been done for either resident.
PASRR Screening Not Updated After 30-Day EHD
Penalty
Summary
The facility failed to ensure that PASRR Level I screening was completed after a 30-day exempt hospital discharge for 2 of 5 residents reviewed for PASRR. The facility policy titled, PASRR Requirements, dated 04/2023, stated all PASRRs would be reviewed for accuracy and that a new PASRR Level I form would be completed immediately and the PASRR evaluators notified when needed. The policy also stated that when a resident was admitted on an EHD, the facility would notify the PASRR evaluators before the 30 days were exceeded. Resident 1 was admitted with diagnoses including schizophrenia, malnutrition, and heart failure. The comprehensive assessment showed the resident required substantial/set-up assistance with ADLs and was cognitively intact. The PASRR assessment showed the resident was admitted with a 30-day EHD, and the record indicated a Level II PASRR form must be completed when a scheduled discharge does not occur. Resident 10 was admitted with diagnoses including Alzheimer's, bipolar disorder, major depressive disorder, and anxiety. The comprehensive assessment showed the resident required substantial/set-up assistance of one to two staff for ADLs and had severe impaired cognition. The PASRR assessment also showed a 30-day EHD, but the record contained no updated PASRR. Staff D stated they were unsure of the requirements for 30-EHD PASRRs and had recently found Resident 10's PASRR while reviewing the chart because the resident had behaviors and a new PASRR was completed. Staff B stated that when a resident was admitted for a 30-day EHD, the facility was to submit a new PASRR for review prior to the end of the 30 days when discharge was not expected.
Arbitration Agreement Not Explained in Understandable Form
Penalty
Summary
The facility failed to ensure the nature and terms of a binding arbitration agreement were explained to a resident in a form and manner the resident could understand. Resident 64 was admitted with diagnoses including a right foot/ankle bone infection and MS, and the admission assessment showed the resident was cognitively intact and able to make needs known. The resident electronically signed the arbitration agreement, and the Business Office Manager signed as a witness before the resident’s signature. Staff K stated the facility’s process was to review and explain the arbitration agreement during admission, including that it was voluntary, not required for admission, and could be revoked within 30 days. During interview, Resident 64 stated they did not know what arbitration was, did not know they had signed a binding arbitration agreement, and said Staff K did not go over the document or explain that signing was voluntary or that it could be revoked. The resident stated the admission paperwork was emailed and was hard to read on a cellphone screen, and that they signed because they thought it was required to show receipt of the documents and to be admitted. Staff K later stated the arbitration form was emailed with the admission paperwork, offered to go over it if there were questions, and did not provide another format or personally assess whether the resident understood arbitration. The DON and Director of Clinical Operations stated staff were to go over the arbitration agreement page by page in a form and manner the resident could understand, and that emailing it for review on a small cellphone screen was not the correct process.
Failure to Enforce Background Check and Compliance Procedures
Penalty
Summary
The facility failed to implement, maintain, and enforce an effective compliance and ethics program with monitoring and auditing systems related to abuse screening and hiring practices. The report states that the facility’s policies required criminal background checks for all employees before hire and prohibited staff from working with vulnerable residents until screening was completed, but these procedures were not followed for a Dietary Manager who was hired while the background inquiry was still pending. Record review showed the Dietary Manager’s background inquiry was submitted before hire but had not been completed. During interviews, the Dietary Manager stated the Administrator knew the background check was still in process and approved them to work anyway. The Administrator confirmed the staff member was working in the facility without a current completed background check and stated they trusted the staff member and did not think supervision was necessary while the check was pending. The Human Resources Director stated the normal process was to complete the background check before a new staff member worked unsupervised with vulnerable residents, and that this was not the normal process in this case. The Human Resources Director also stated the Administrator made the decision to let the staff member work without the completed background check. The DON and Director of Clinical Operations stated new staff should not work with vulnerable residents until the background check was completed and were not aware the Administrator had approved the staff member to work unsupervised while the background inquiry remained pending.
Laundry Room Leak and Unsanitary Drainage Trough
Penalty
Summary
The laundry room was observed to have an unsafe, nonfunctional, and unsanitary environment involving washing machine WM1 and the drainage system. On 03/18/2026 at 5:11 PM, surveyors observed a one foot by one foot puddle of water underneath the back end of WM1 on the concrete floor, with water slowly dripping from a pipe supplying water to the machine and running down the back left side of the machine. The metal plate on the back left side was wet to the touch, and the floor beneath the machine had a white soap-like substance forming a dried ring that extended underneath the left side of WM1. The left-side nuts/bolts and black metal plate were caked with the white dried substance and showed dark reddish brown rust underneath, while the right-side bolts and plate were clean and shiny. The laundry room also had a concrete commercial-grade deep channel drainage trough with stagnant water, a thick layer of grayish sludge floating on top, and a strong foul odor. During interview, the Laundry Director stated they were not sure how long WM1 had been leaking and confirmed the white substance should not be there, the leak was coming from a hose supplying WM1, and the leak needed to be fixed. The Laundry Aide stated WM1 had a lot of white soap-like buildup around the base and had been leaking for over a week, and said they had never seen the drainage trough empty all the way in eight years. The Maintenance Director stated they were not aware of WM1 leaking, confirmed the residue needed to be cleaned, and stated the drainage trough was not sanitary and was not working properly.
Failure to Provide Timely Pressure Injury Assessment and Interventions
Penalty
Summary
A resident was admitted with multiple diagnoses, including rheumatoid arthritis, heart failure, and a urinary tract infection, and was identified as being at risk for pressure injuries (PIs) upon admission. Initial skin assessments documented blanchable redness on the coccyx, and a barrier cream was applied. The care plan included general interventions for skin integrity, such as keeping skin clean and dry, but did not include specific interventions for pressure offloading or enhanced monitoring. No additional interventions were added to the care plan prior to discharge, despite the resident's high risk for PIs and dependence on staff for repositioning and activities of daily living. Several days after admission, an open wound was observed on the resident's coccyx, but there was no documentation of wound measurements, description, or staging at that time. Progress notes and care conferences failed to identify or address the new wound, and the Nutrition at Risk meeting did not recognize any current skin issues, even though the wound had been present for three days. Physician orders for wound care were obtained, but there was no timely documentation of wound assessment, measurements, or staging. It was not until nine days after the wound was first documented that a wound care specialist assessed the wound, diagnosing it as a Stage 3 PI. The wound later progressed to an unstageable PI, requiring debridement and hospital evaluation. Throughout the resident's stay, there was a lack of documentation and implementation of essential interventions such as pressure-relieving surfaces, repositioning schedules, and nutritional support. Interviews with staff revealed that the resident did not receive an air mattress or protein supplements, and repositioning was not documented until 21 days after the wound opened. Staff also reported the absence of facility policies or guidelines for PI prevention and management. The resident's condition declined, leading to hospital transfer for suspected wound infection. The failure to provide thorough skin assessments, timely provider notification, and appropriate interventions contributed to the worsening of the resident's pressure injury.
Failure to Follow Care Plan for Safe Resident Transfers
Penalty
Summary
The facility failed to ensure that a comprehensive, person-centered care plan was followed regarding transfer guidelines for a resident with multiple complex medical conditions, including multiple sclerosis, epilepsy, osteoporosis, and multiple leg contractures. The resident was cognitively intact and required total staff assistance for all activities of daily living due to chronic weakness and inability to bear weight or stand. The care plan specifically directed staff to use a mechanical lift with two staff members for all transfers between surfaces, such as from bed to wheelchair. Despite these directives, two nursing assistants manually lifted the resident from bed to wheelchair without using the mechanical lift, as confirmed by both the resident and staff interviews. The incident was acknowledged by the Resident Care Manager and Director of Nursing, who confirmed that the care plan had been updated to require mechanical lift transfers due to the resident's fragility and history of pathological fractures. The failure to follow the established care plan placed the resident at risk for injury and unmet care needs.
Deficiency in Kitchen Sanitation and Food Handling Practices
Penalty
Summary
The facility failed to ensure proper sanitization and food handling practices in the kitchen, which placed residents at risk for foodborne illnesses. Observations revealed multiple areas of concern, including a ceiling fan with a thick dark substance above a resident refrigerator and ice machine, and a sink with crusty substances and food debris. The cabinet below the sink showed exposed concrete debris, rodent traps, and pipes covered in substances, indicating poor maintenance and cleanliness. The dishwashing station had dirty trays and dishes, while clean dishes were stored uncovered on a wire rack, leading to potential contamination. Staff members were observed not following proper hand hygiene protocols. A dietary cook washed their hands in a sink meant for dirty dishes, using dish soap instead of hand soap, and did not perform hand hygiene after removing soiled gloves. Another staff member, a dietary aide, did not perform hand hygiene after removing a glove and handling food. The registered dietician was observed stirring food near a sink where soapy water was splashing, and staff continued to handle food and utensils without proper hand hygiene. The facility's handwashing sink was not properly maintained, with a broken soap dispenser and no trash receptacle nearby. Staff were seen using the sink improperly, squeezing soap from a crushed bag, and disposing of wet paper towels inappropriately. Personal drinks were found in the kitchen area, and staff did not adhere to the facility's expectations for cleanliness and hygiene. These actions and inactions contributed to the deficiency in maintaining a clean and sanitary kitchen environment, as required by the facility's policies and standards of practice.
Failure to Submit PBJ Data for 4th Quarter 2024
Penalty
Summary
The facility failed to electronically submit direct care staffing information to the Centers for Medicare and Medicaid Services (CMS) for one of the three quarters of 2024 reviewed for Payroll Based Journal (PBJ) data submission. Specifically, the facility did not report PBJ data for the 4th Quarter, from July 1, 2024, to September 30, 2024. This omission resulted in CMS having inaccurate data related to nursing home staffing levels, which could potentially impact the care and services provided by direct care staff. During an interview, the Administrator, identified as Staff A, stated they were unaware of the failure to submit the required PBJ data and indicated they would investigate the issue.
Management Attendance at Resident Council Meetings Causes Resident Discomfort
Penalty
Summary
The facility failed to ensure that management staff attended Resident Council meetings only when specifically invited, leading to discomfort among residents. During a Resident Council meeting observed by surveyors, residents expressed that they felt uncomfortable voicing their concerns in the presence of management staff, specifically the Administrator and the Resident Care Manager, who regularly attended these meetings. Residents 11 and 35 reported feeling unable to speak freely due to the presence of these staff members, fearing they might say something wrong or face retaliation. Interviews with facility staff revealed a misunderstanding regarding the attendance of management at Resident Council meetings. The Activities Director, Staff EE, indicated that management had been invited in the past and continued to attend, assuming their presence was desired. However, it was not communicated that some residents felt uncomfortable with this arrangement. Staff A, the Administrator, also stated they were unaware of the residents' discomfort and believed their attendance was wanted to address concerns. This oversight placed residents at risk of discomfort and fear of reprisal when discussing issues during meetings.
Inaccurate Life Expectancy Assessments for Two Residents
Penalty
Summary
The facility failed to accurately assess two residents for Minimum Data Set (MDS) accuracy, specifically regarding their life expectancy of less than six months. Resident 1, who was admitted with multiple diagnoses including spastic quadriplegic cerebral palsy, dementia, major depressive disorder, and PTSD, had comprehensive assessments indicating a life expectancy of less than six months. However, there were no corresponding physician orders in the medical records for this diagnosis, and the resident's representative was not informed of this prognosis until much later, causing shock and surprise. Similarly, Resident 26, admitted with diabetes and depression, was assessed to have a life expectancy of less than six months in multiple comprehensive assessments. Despite this, the resident's representative was not informed, and staff expressed doubts about the accuracy of this prognosis. The MDS Coordinator admitted to completing assessments from home and relying on the diagnoses list in the medical record without consistently verifying with physician documentation, contrary to the guidelines in the Resident Assessment Instrument (RAI) manual.
Failure to Update PASARRs for Residents with Mental Health Diagnoses
Penalty
Summary
The facility failed to ensure that the Preadmission Screening and Resident Reviews (PASARR) for residents with serious mental illness (SMI) or intellectual/developmental disabilities (ID/DD) were accurately completed and updated. This deficiency was identified for four residents who were reviewed for PASARR compliance. The facility's policy required a Level I PASARR to be completed prior to admission and updated if a new SMI/ID/DD diagnosis was made. However, the Social Service Director (SSD) did not review or update the PASARRs as required, leading to residents not receiving the necessary Level II evaluations. Resident 12 was admitted with dementia, agitation, and depression, and was receiving anti-depressant and antipsychotic medications. Despite these conditions, the PASARR completed on 06/10/2024 indicated no SMI or dementia at admission. Resident 42, admitted with a stroke and depression, later received diagnoses of depression and PTSD, but no new PASARR or Level II referral was completed. Resident 14, admitted with major depressive disorder, PTSD, and anxiety, had a PASARR that did not reflect these diagnoses, and Resident 48, admitted with PTSD, had a PASARR that incorrectly marked all diagnoses as no. Interviews with staff revealed that the SSD was aware of the requirement to review PASARRs prior to admission but had not been doing so. The Director of Nursing Services (DNS) confirmed that the SSD was responsible for ensuring PASARRs were correct and updated with any new diagnoses. However, the SSD had not received training on the new PASARR regulations, contributing to the oversight. This failure placed residents at risk of not receiving appropriate mental health care and services.
Deficiencies in EOL and PTSD Care Documentation and Communication
Penalty
Summary
The facility failed to ensure that staff followed accepted standards of clinical practice for residents requiring end-of-life (EOL) care and those diagnosed with Post Traumatic Stress Disorder (PTSD). For residents identified for EOL care, the facility did not have supporting documentation or physician diagnoses in their medical records. Specifically, Residents 16, 26, and 34 were placed on EOL care without prior discussion with the residents or their responsible representatives (RRs), and without significant changes in their health conditions being documented. The Palliative Performance Scale (PPS) was used to determine EOL eligibility, but it was not documented in the residents' records, and the residents and their RRs were not informed or involved in the decision-making process. For residents diagnosed with PTSD, the facility also failed to provide supporting documentation or physician orders. Residents 12, 35, and 48 were given PTSD diagnoses without proper assessments or documentation of trauma screens by a physician. The diagnoses were added based on nursing staff's actions without appropriate medical evaluation or consultation with the residents or their RRs. The Social Services Director expressed concerns about the appropriateness of these diagnoses, indicating that they were nursing-driven and not necessary for receiving mental health services. Interviews with staff revealed that the Director of Nursing Services (DNS) and Resident Care Manager (RCM) were involved in instructing or carrying out these actions, often without proper documentation or communication with the residents and their RRs. The attending physician relied on nursing assessments for PTSD diagnoses and did not conduct thorough evaluations. The facility's practices placed residents at risk for unmet care needs and lacked transparency and involvement of residents and their families in critical care decisions.
Infection Control Lapses in Wound Care and Medication Administration
Penalty
Summary
The facility failed to implement proper infection prevention and control measures during wound care treatment and medication administration, as observed in the cases of two residents and two licensed nurses. During wound care for Resident 14, the treatment nurse did not perform hand hygiene before preparing wound dressings and failed to sanitize the bedside table or use a barrier before placing wound care supplies on it. The nurse also neglected to change gloves between dirty and clean tasks and did not perform hand hygiene when exiting the room. Similarly, for Resident 48, the treatment nurse placed wound supplies on the bedside table without a barrier, used the same gloves for dirty and clean tasks, and did not perform hand hygiene before exiting the room. In the case of medication administration, Staff BB, an LPN, did not sanitize the glucometer between uses for different residents, increasing the risk of cross-contamination. Staff BB was unaware of the need to sanitize the glucometer and allow for drying time between uses. Additionally, Staff CC, another LPN, failed to wear appropriate eye protection when entering a transmission-based precaution room, mistakenly believing that personal eyeglasses sufficed as protective equipment. The Director of Nursing Services confirmed that the facility's hand hygiene process should follow CDC guidelines, which include placing a barrier between clean supplies and dirty surfaces, changing gloves between dirty and clean tasks, and performing hand hygiene when entering and exiting rooms. These lapses in infection control practices placed residents at an increased risk of exposure to cross-contamination and transmission of infectious diseases.
Inaccurate Care Plan and Misunderstanding of Resident's Communication
Penalty
Summary
The facility failed to ensure that a resident, identified as Resident 17, was treated with respect and dignity, as required by resident rights. The care plan for Resident 17 contained inaccurate information that labeled the resident negatively, which could potentially affect their quality of life. The care plan inaccurately documented behaviors such as striking out, lack of energy, yelling, hallucinations, refusal of care, and inappropriate sexual contact, despite the resident being cognitively intact and having no identified negative behaviors during the assessment period. Interviews with staff members revealed that the resident's communication style, due to their deafness, was misunderstood and misinterpreted as aggressive or inappropriate. Staff interviews indicated that Resident 17's request for hugs was not intended to be sexual, but rather a form of communication and gratitude, which was misunderstood by some staff. The Social Services Director acknowledged that the resident's communication could be mistaken for aggression due to their deafness. The Resident Care Manager admitted to documenting generic behaviors on the care plan to establish a baseline, expecting other disciplines to update the care plan with accurate information. Observations showed the resident interacting pleasantly with staff and other residents using a communication board, contradicting the negative behaviors listed in the care plan.
Failure to Inform Resident Representative of Hospice Options
Penalty
Summary
The facility failed to fully inform the Resident Representative (RR) of the benefits, options, and treatment alternatives available for hospice services when a resident experienced a significant change in medical condition and was placed on end-of-life care. This deficiency was identified for one of six residents reviewed for resident rights. The facility's policy on providing end-of-life care, revised in October 2024, stated that care and services should be provided in accordance with the resident's preferences and goals. However, the RR was not given the option to consider hospice services, as the nursing staff indicated that comfort measures could be provided within the facility without involving an outside hospice provider. Interviews conducted during the investigation revealed that the RR had inquired about hospice services months prior but was not presented with any options or education regarding hospice services. The contracted medical provider confirmed that the process should involve educating the RR on both the facility's end-of-life care and hospice services to enable informed decision-making. However, the medical provider admitted to being unsure about the specific services offered by hospice, indicating a gap in communication and understanding of available care options for the resident and their family.
Inadequate Room Space for Residents
Penalty
Summary
The facility failed to accommodate the individualized needs of two residents, leading to frustration, lack of independence, and potential injury. Resident 32, who has Parkinson's Disease and uses a wheelchair, experienced difficulty maneuvering in their room due to inadequate space. Their bed was positioned far from the entryway, and the narrow space between the door and their roommate's bed caused the resident to scrape their hands and arms while self-propelling. Additionally, Resident 32's access to their closet was blocked by their roommate's belongings, preventing them from independently choosing their clothes. Resident 12, who has chronic obstructive pulmonary disease and malnutrition, also faced challenges due to the room's layout. Their bed was positioned in a way that limited access to their closet and the shared sink, which was blocked by Resident 32's recliner. The room's configuration did not allow enough space for visitors, and Resident 12 expressed a desire to use the sink, which was inaccessible. Measurements taken by the Maintenance Director confirmed that the room did not meet the required usable space for a multi-bedroom. Interviews with staff revealed a lack of awareness regarding room requirements for usable space. The Director of Nursing Services acknowledged the issue but stated there were no other rooms available to accommodate the residents' needs. Despite the presence of empty rooms in the facility, the current room arrangement did not allow for adequate space for the residents to move around or access their personal belongings independently.
Improper Management of Resident Personal Funds
Penalty
Summary
The facility failed to ensure proper management and separate accounting of pooled resident funds for three residents, identified as Resident 12, 40, and 43. Each resident's personal funds were deposited into a secure interest-bearing account, but the facility did not maintain separate accounting or statements for each resident's share. Instead, monthly care fees were deducted directly from the residents' personal trust accounts without separate documentation of these transactions. This lack of separate accounting placed residents at risk of not having an accurate record of their personal funds held in trust. Resident 12, who has chronic obstructive pulmonary disease and moderately impaired cognition, had their funds managed in this manner. Similarly, Resident 40, with dementia and severely impaired cognition, and Resident 43, with end-stage renal disease and intact cognition, experienced the same issue. During an interview, the Business Office Manager confirmed that the facility managed the residents' trust funds in a single account and directly deducted participation fees without separate accounting or statements for each resident's personal funds.
Deficiencies in Equipment Maintenance and Heating in LTC Facility
Penalty
Summary
The facility failed to maintain a warm, comfortable, and homelike environment for several residents, as evidenced by observations of inadequate maintenance of adaptive equipment and heating issues. Resident 35, who has diabetes and chronic pain, was observed with padded mobility rails on their bed that had missing outer material, exposing an uncleanable surface. Resident 42, with severe cognitive impairment and a history of falls, had a fall mat with peeling outer covering, exposing the inner foam material. Additionally, Residents 16, 13, 31, and 41, all using alternating air overlay mattresses, had machines with broken C-shaped clamps, causing the machines and tubing to sit on the floor, which is not ideal for maintaining a homelike environment. Heating issues were also prevalent, particularly affecting Residents 35 and 42. Resident 35 reported their bathroom was very cold, and observations confirmed no warm air was coming from the heater vent. Despite reporting the issue to staff and maintenance, the problem persisted, with the maintenance director acknowledging the issue but failing to resolve it promptly. Resident 42, sharing the same room, also reported feeling cold, and observations confirmed the room's temperature was lower than expected, with makeshift solutions like taping vents being used. Interviews with staff revealed a lack of proactive assessment and maintenance of equipment and environmental conditions. The Infection Control Preventionist admitted to not reassessing adaptive equipment for functionality, relying on floor staff to report issues. The Maintenance Director also admitted to not assessing resident equipment for functional use and acknowledged delays in addressing heating issues due to reliance on external companies. The facility's administrator and director of nursing services were aware of the heating issue but expressed limitations in resolving it due to external dependencies.
Failure to Conduct Required Care Conferences
Penalty
Summary
The facility failed to conduct care conferences for a resident with spastic quadriplegic cerebral palsy and dementia, as required by their policy. The policy mandates that the Interdisciplinary Team (IDT) hold face-to-face care conferences 72 hours after admission, 14 days after admission, quarterly, and with any significant changes in condition. However, a review of the resident's medical record revealed no documentation of care conferences from January 2024 to February 2025. This lack of care conferences was confirmed by the resident's representative, who stated they had never been scheduled for a meeting to discuss the resident's care, only receiving phone calls for changes like the flu. Interviews with facility staff, including the Social Service Director and the Director of Nursing Services, confirmed the deficiency. Both staff members acknowledged the requirement for care conferences on admission, quarterly, and as needed, involving the IDT, residents, and their representatives. Despite this, they admitted that no care conferences had been scheduled or conducted for the resident in question. The Director of Nursing Services further acknowledged that completing care conferences was a known issue within the facility, indicating a systemic problem with the process.
Inconsistent Restorative Therapy Implementation Due to Staffing Issues
Penalty
Summary
The facility failed to consistently implement restorative therapy services for a resident, identified as Resident 35, who was at risk for loss of range of motion (ROM) and deconditioning. Resident 35, who had been admitted with diagnoses including diabetes and low back pain, had intact cognition and required supervision for mobility and transfers. Despite being discharged from physical therapy in January 2025 and referred to a restorative therapy program, the resident did not consistently receive the prescribed therapy, which included active ROM exercises and an ambulation program. The resident expressed concerns about feeling weaker and the impact on their ability to discharge home. Interviews with staff revealed that the restorative therapy programs were not consistently completed due to staffing issues. Staff responsible for restorative therapy were frequently reassigned to work as nursing assistants due to staff shortages, leaving the restorative programs incomplete. The Restorative Director acknowledged the staffing challenges and the prioritization of daily care needs over restorative therapy. The Director of Nursing Services also confirmed the staffing issues and the decision to prioritize personal care over restorative needs, noting the absence of a staffing coordinator and the lack of agency staffing to fill gaps.
Lack of Communication and Monitoring for Dialysis Care
Penalty
Summary
The facility failed to ensure that dialysis services met professional standards of care for a resident requiring such services. Specifically, there was no effective or coordinated communication process between the facility and the offsite dialysis center, which is essential for continuity of care. The facility's policy required that the care plan reflect coordination between the facility and the dialysis provider, including documenting and monitoring pre/post dialysis weights and vital signs, and providing a report to the dialysis provider regarding the resident's condition for each dialysis treatment. However, the review of Resident 17's medical record showed no communication with the offsite dialysis center before or after dialysis treatments, and no consistent documentation of vital signs or assessments of the resident's condition upon return to the facility. Resident 17, who was cognitively intact, was readmitted to the facility with diagnoses including end-stage renal disease (ESRD) requiring dialysis and diabetes. The resident received dialysis three times weekly at an offsite center. During an interview, the Director of Nursing (DON) acknowledged that pre/post dialysis communication forms were no longer used because they were not returned, and stated that communication between the facility's Registered Dietician (RD) and the dialysis center RD was considered adequate. However, the DON also indicated that nursing staff should be monitoring and documenting the resident's condition pre/post dialysis, which was not being done consistently, leading to a deficiency in care for Resident 17.
Failure to Provide Trauma-Informed Care for Resident with PTSD
Penalty
Summary
The facility failed to provide culturally competent and trauma-informed care for a resident diagnosed with PTSD, deafness, diabetes, and end-stage kidney disease. The resident, who had a history of sexual assault during childhood, had specific care plan interventions to minimize PTSD triggers, such as leaving their room door open at night, being around trusted individuals, and not sharing a room with strangers. Despite these interventions, the facility did not accommodate the resident's need for a private room, which was a significant trigger for their PTSD, leading to episodes of anger and anxiety. Staff interviews revealed that the facility was aware of the resident's PTSD triggers and the need for a private room. However, the facility did not provide a private room due to the unavailability of such rooms in the long-term care unit, as the only available private rooms were reserved for short-term residents on the Medicare unit. This lack of accommodation resulted in the resident experiencing triggered behaviors, including yelling at their roommate, which staff struggled to manage. The facility's inability to implement the care plan interventions placed the resident at risk of re-experiencing past trauma.
Failure to Monitor and Document Psychotropic Medication Use
Penalty
Summary
The facility failed to ensure residents were free of unnecessary psychotropic medications, as evidenced by the cases of two residents. Resident 12, who was admitted with depression and dementia with agitation, was observed to be difficult to arouse and inactive in conversation, with their oxygen machine turned off. The resident was receiving Remeron for malnutrition and Seroquel, an antipsychotic medication, without specific monitoring for adverse side effects or an AIMS assessment for abnormal involuntary movements. Resident 42, admitted with a stroke and severe cognitive impairment, was receiving Celexa for depression despite scoring zero on the depression scale. The resident's medical records showed no documented adverse side effects or changes in behavior before or after the medication was started. The facility's staff placed general behavior monitoring on all residents upon admission, but failed to update the monitoring and interventions to be resident-specific, especially after a change in the electronic health record system. Interviews with facility staff revealed inconsistencies in documenting behaviors and interventions, as well as a lack of ongoing monitoring for adverse side effects of psychotropic medications. The Director of Nursing Services acknowledged the loss of documentation during the transition to a new electronic health record system, which contributed to the deficiency in monitoring and documenting the necessity of psychotropic medications for residents.
Expired Medications and Supplies Found in Storage Rooms
Penalty
Summary
The facility failed to ensure that medications and wound supplies were properly discarded when expired and labeled correctly, as observed in both the medication storage room and the treatment storage room. During an inspection, it was found that the medication storage room contained expired glucagon injection pens, lactulose with a torn-off resident name, expired albuterol sulfate doses, and ipratroprium bromide doses with blacked-out resident names. Additionally, an expired vial of cefazolin was found. These findings indicate a lack of adherence to the facility's policy on medication storage, which requires routine inspections for outdated or improperly labeled medications. In the treatment storage room, expired wound dressings, hydrogel sheets, chlorhexidine gluconate cloths, and suction catheter kits were discovered. The Director of Nursing Services acknowledged that it was the responsibility of the day charge nurse to check for expired and unlabeled medications and supplies weekly. However, due to low staffing, the day charge nurse was reassigned to work on the floor, leading to a lapse in these checks. This oversight placed residents at risk of receiving expired medications and treatments.
Failure to Implement Pneumococcal Vaccination Protocols
Penalty
Summary
The facility failed to implement essential components of their immunization program for the pneumococcal vaccine, as evidenced by the lack of thorough screening for vaccination status upon admission and failure to administer the vaccine according to CDC and Advisory Committee on Immunization Practices guidelines. This deficiency was identified in two residents reviewed for immunizations. Resident 2, who had intact cognition and a history of diabetes, had previously received the pneumococcal vaccine outside the facility. However, there was no verification of the vaccination status, including which vaccine was received, when it was administered, or if the resident still required the vaccine. Similarly, Resident 21, who had severely impaired cognition due to dementia, was noted to have an up-to-date pneumococcal vaccine status, but there was no documentation of risks and benefits being provided or a signed declination for the vaccine. The facility's process for verifying previous vaccinations was inadequate, as highlighted by the interview with Staff J, the Infection Preventionist/Restorative Director. Staff J admitted that they did not attempt to access previous immunization records beyond reviewing discharge records and relied on residents' verbal confirmation of their vaccination status. This oversight resulted in a failure to ensure proper documentation and verification of vaccination status for residents who had received vaccines outside the facility, as demonstrated in the cases of Residents 2 and 21.
Unsafe and Unsanitary Conditions in Facility Storage Rooms
Penalty
Summary
The facility failed to maintain a safe and sanitary environment in two storage rooms, which posed a risk of injury and potential illness to residents. In the first storage room, observations revealed an ajar and unlocked door, with exposed electrical wires and a computer network system on the floor. The room was cluttered with spools of wire, a whiteboard, an easel, and overflowing shelves of activity supplies and decorations. The door was consistently found propped open with cones, which was acknowledged by the Administrator and Director of Nursing Services as a potential fire and safety hazard due to overheating concerns when the door was closed. In the Hoyer storage room, two lift devices were stored on a floor with missing linoleum, exposing concrete with discoloration and debris. The room also had broken and missing tiles on the walls, and uncapped plumbing pipes were observed. The Maintenance Director was unaware of these conditions and stated that repairs were not logged as needed. The Director of Nursing Services identified the condition of the Hoyer room as an infection control concern due to the broken flooring and walls.
Governing Body Fails to Ensure Financial Systems for Vendor Payments
Penalty
Summary
The Governing Body of the facility failed to ensure that financial systems were in place to pay vendors who supplied essential care, services, and necessary supplies for the residents. This deficiency was identified when it was found that facility staff had to use their own funds to pay vendors, as the facility's financial system was unreliable. This situation placed residents at risk of not receiving necessary supplies, care, and services, and caused potential psychological harm and distress due to the fear of displacement if the facility could not meet their basic needs. Interviews and record reviews revealed that the facility was using a debit card with a weekly limit to purchase essential items, and staff members were using personal funds to cover expenses when the debit card was insufficient. The Business Office Manager reported that the facility had been without petty cash for over a week and had no contact person for accounts payable. Several vendors, including those providing oxygen, medical supplies, and food, had placed the facility on credit hold due to non-payment, and utility bills were overdue, threatening service shut-offs. The Administrator and other staff members expressed concerns about the lack of financial oversight and communication from the Governing Body, which was identified as the owner. The Administrator had not received financial statements or a budget since April 2023 and was using personal credit cards to ensure residents' needs were met. Despite claims from the Governing Body that the facility was financially solid, numerous vendors reported past due accounts, and some had ceased providing services due to non-payment.
Facility Mismanagement Leads to Staff Using Personal Funds
Penalty
Summary
The facility administration failed to manage its resources effectively and efficiently, leading to staff members using personal funds to purchase necessary supplies and services for the facility. The Administrator and Director of Nursing Services, along with other staff, used their own money to cover costs for resident care supplies, food, and facility maintenance due to insufficient funds on the facility's prepaid debit card. This situation arose because the Administrator was not provided with a budget or information on accounts payable, and there was a lack of support from the facility owner. Staff members expressed concerns about the financial management process and the need to ensure continued services for residents. Interviews revealed that the Business Office Manager and other staff members routinely used personal funds when the facility's resources were depleted. The Administrator and Director of Nursing Services felt compelled to cover expenses to prevent disruptions in resident care, despite not being reimbursed. The facility owner acknowledged the Administrator's use of personal funds but did not perceive it as a financial issue. The Administrator and staff did not report these financial concerns to the State Agency, as they did not initially recognize the severity of the situation. This mismanagement placed residents at risk for disruptions in care and services.
Inadequate Facility Assessment and Lack of Stakeholder Input
Penalty
Summary
The facility failed to adequately review and update its Facility Assessment (FA), which is crucial for determining the resources necessary to meet residents' care and service needs. The FA was not updated to reflect substantial modifications in vendor services and lacked input from key stakeholders, including a member of the governing body, the medical director, and residents or their representatives. This oversight resulted in an inaccurate FA, particularly concerning compliance and ethics training, which was listed as current despite the facility not having such a program. Interviews revealed that the governing body representative had not reviewed the FA, and the Director of Nursing (Staff B) had no training on completing the FA. Staff B also noted that the FA included vendors not used by the facility and was unaware of the compliance and ethics training requirement. The Administrator (Staff A) admitted to creating the FA without input from the governing body or the medical director and acknowledged the absence of a compliance and ethics program. These deficiencies placed residents at risk of unidentified and unmet care and service needs.
Ineffective QAPI Committee and Financial Instability
Penalty
Summary
The facility failed to maintain an effective Quality Assurance/Performance Improvement (QAPI) Committee, which resulted in widespread systemic deficiencies. The QAPI Committee did not self-identify deficient practices related to administration, governing body, compliance and ethics, facility assessment, and financial instability. The facility's QAPI procedures were not utilized to sustain compliance with regulations, placing residents at risk for unsafe conditions, delays in necessary care and services, and a diminished quality of life. The QAPI meeting minutes from several months in 2024 showed no discussion of these critical issues. The Administrator and Director of Nursing Services admitted that financial issues were not discussed in QAPI meetings, as they believed it was on a need-to-know basis. The Governing Body was not involved in the QAPI plan or program development and only wanted to be informed of major issues. The Administrator supplemented personal finances to purchase goods and services for residents, indicating a lack of financial support from the Governing Body. Additionally, the facility had not developed a Compliance and Ethics program, and the Facility Assessment was outdated and lacked input from required members.
Lack of Effective Compliance and Ethics Program
Penalty
Summary
The facility failed to design, implement, maintain, and enforce a compliance and ethics program aimed at preventing and identifying violations of the Social Security Act S 1819, which is essential for ensuring quality care in skilled nursing facilities. The review of the facility's policies revealed that while there were documents outlining a compliance hotline and a reporting system, these were not effectively operational. The compliance hotline number posted in the facility was found to be incorrect, leading to a rewards and redemption center instead of a compliance hotline. Additionally, the facility's policies were not dated, and there was no evidence of a designated compliance and ethics contact person. Interviews with staff members, including the Human Resources Director, Nursing Assistant, and Laundry Aide, indicated a lack of awareness and training regarding the compliance and ethics program. Staff members reported not receiving any compliance and ethics training and were unsure of the proper channels to report ethical concerns. The Administrator acknowledged the absence of a formal compliance program and training, and there was confusion about the hotline's purpose. The Administrator also realized the need for a separate compliance and ethics hotline for anonymous reporting of ethical violations.
Failure to Return Resident Funds to OFR
Penalty
Summary
The facility failed to return the balance of funds to the Office of Financial Recovery (OFR) for four residents who had expired, as required by state law. The policy titled 'Resident Personal Funds' mandates that upon discharge, eviction, or death, any personal funds held by the facility in a trust account should be conveyed within 30 days to the resident or, in the case of death, to the individual or probate district administering the resident's estate. However, the facility did not comply with this policy for Residents 1, 2, 3, and 4, whose trust account balances were not returned to the OFR. Interviews with facility staff revealed a lack of awareness regarding the requirement to return Medicaid funds to the OFR. Staff C, the Business Office Manager, stated that their process involved allowing the family to decide where the trust account balance should go and was unaware of the OFR requirement. Similarly, Staff A, the Administrator, was also unaware of the need to send Medicaid funds to the OFR upon a resident's expiration, believing that any remaining funds should be returned to the family. This lack of knowledge and adherence to the policy placed the state department at risk for loss of funds and interest accumulated.
Failure to Provide Behavioral Health Services
Penalty
Summary
The facility failed to provide necessary behavioral health services to Resident 5, who was diagnosed with bipolar disorder, anxiety, depression, and had a history of substance abuse. The comprehensive assessment indicated that Resident 5 experienced feelings of depression and hopelessness nearly every day. Despite these needs, the facility did not offer any behavioral health services, as confirmed by the Director of Nursing Services and the Social Services Director. The facility had previously provided telehealth services for behavioral health, but these services were discontinued months prior, leaving Resident 5 without access to necessary mental health care. Interviews revealed that Resident 5 expressed dissatisfaction with the lack of mental health support, stating a desire to see a psychologist and feeling that their mental state was deteriorating. The facility had a working contract with a telehealth provider, but had not utilized their services since February 2024, despite the provider's attempts to re-establish contact. Staff members acknowledged the absence of behavioral health services and the need for Resident 5 to see a mental health professional, but no actions were taken to explore alternative options or discuss the issue with the facility's administration.
Failure to Follow Care Plan Results in Resident Injury
Penalty
Summary
The facility failed to prevent an avoidable accident by not adhering to the care plan for a resident who required a two-person assist for transfers. The resident, who was cognitively intact and had a history of making false accusations, was injured during a transfer when only one staff member, a Nursing Aide, attempted to move them from a wheelchair to a bed. This resulted in a large skin tear on the resident's lower left extremity, which required emergency room evaluation and later developed an infection necessitating antibiotic treatment. The incident occurred because the Nursing Aide relied on verbal reports from other staff rather than consulting the electronic care plan, which clearly stated the need for two-person assistance. The Nursing Aide admitted to being aware of the requirement but was unable to find additional staff to assist. The failure to follow the care plan led to the resident's injury and subsequent decline in condition, as confirmed by interviews with various staff members, including the Resident Care Manager, Registered Nurse, and the facility Administrator.
Failure to Implement Effective Bed Bug Control Measures
Penalty
Summary
The facility failed to effectively implement infection control interventions to mitigate and contain bed bug infestations for four residents. The incident log showed bed bugs were identified on two occasions, and the facility's investigation revealed that residents were moved to isolation rooms, and their belongings were treated. However, the pest control company could not perform extermination due to an outstanding balance, delaying the treatment and potentially allowing the infestation to spread to adjacent rooms. Staff interviews revealed that the Maintenance Director and Infection Preventionist relied on internet research to develop a mitigation plan, as there was no specific policy for bed bugs. The staff did not receive formal training on identifying or managing bed bugs, and the pest control company confirmed the infestation but could not proceed with extermination due to unpaid bills. The delay in extermination likely contributed to the spread of bed bugs to adjacent rooms. Observations showed that the infested rooms were sealed with tape, but staff were not adequately trained to monitor for bed bugs. The Director of Nursing acknowledged that staff should be monitoring for signs of bed bugs, but no training had been provided. The Administrator was aware of the billing issue and eventually paid the outstanding balance personally to facilitate pest control services. The deficiency highlights a lack of effective infection control measures and staff training, leading to the spread of bed bugs within the facility.
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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