Port Washington Post Acute
Inspection history, citations, penalties and survey trends for this long-term care facility in Bremerton, Washington.
- Location
- 140 South Marion Avenue, Bremerton, Washington 98312
- CMS Provider Number
- 505240
- Inspections on file
- 48
- Latest survey
- April 6, 2026
- Citations (last 12 mo.)
- 62
Citation history
Health deficiencies cited at Port Washington Post Acute during CMS and state inspections, most recent first.
The facility reduced CNA staffing on all shifts, leaving as few as one aide to care for many residents, including two requiring 1:1 supervision. A resident with a Foley catheter reported their urine bag remained full most of the time and that they rarely saw aides. Another resident described a recent drop in aides and nurses, needing to leave their room to find help when call lights were unanswered. A paraplegic resident who needed a Hoyer lift and had a colostomy reported not being gotten out of bed as care planned and having to empty their own colostomy bag and throw it on the floor when no staff responded. CNAs confirmed they were responsible for up to 16 residents, could not complete showers or many required ADL tasks, and were unable to take breaks or lunch.
Surveyors found that the facility failed to ensure effective discharge planning for two residents, including coordination with community agencies and medication management. The discharge policy lacked guidance on pre-discharge needs such as medication ordering, medication teaching, arranging home care services, equipment, and follow-up appointments. One resident with diabetes and dementia was discharged home with family caregivers but without documented medication teaching or scheduled follow-up, and the community case manager was not notified, preventing caregiver scheduling and leaving the family without insulin administration training. Another resident with cognitive impairment and prior documented safety concerns at home was discharged without in-home care ordered, medication refills sent, or a follow-up physician appointment arranged, and the resident later returned after not receiving care and running out of medications. The SSD reported not handling medication re-ordering or teaching and typically not making follow-up appointments, while leadership staff acknowledged they were unaware of the lack of discharge coordination.
Surveyors found that meals were unappealing, poorly prepared, and not consistently served in a timely manner. A sample tray showed mixed and run-together vegetables, burnt bits in creamed corn, stringy green beans, bland unseasoned chicken, thin gray pudding with minimal flavor, and no butter for the roll. A resident with tracheal cancer and a pureed diet refused an untouched tray of unidentifiable pureed food, stating it looked unappealing and had no flavor. Another cognitively intact resident received a delayed lunch tray from a cart left in the hall and reported the food was cold and consistently terrible, citing past breakfasts of a glob of eggs, an unpalatable muffin, and dry cereal without milk. A third cognitively intact resident reported that food quality, consistency, and flavor had declined and that liquid eggs were used excessively, including at dinner, while the nutrition manager reported being unaware of these complaints and relying on meetings and floor staff to convey concerns.
The facility failed to provide ordered altered-consistency liquids and adequate hydration for two residents with post-stroke dysphagia. One cognitively intact resident was observed with an untouched meal tray lacking any fluids, had dry skin and chapped lips, and reported receiving unpalatable meals and dry cereal without milk, while staff were unclear about the "no drinks on the tray" diet slip and only later identified the need for Level 2 (nectar thick) liquids. Another cognitively intact resident with an order for Level 2 liquids received a tray with no liquid texture information and regular juices, and reported that CNAs bring regular juice on request despite disliking thickened fluids and recognizing inadequate fluid intake. The RD/Kitchen Manager acknowledged that residents should receive correct-consistency fluids, be monitored for hydration and compliance, and have their fluid consistency needs clearly communicated to floor staff.
A resident with encephalopathy related to glioblastoma and moderate cognitive impairment was started on Seroquel by the DON for anxiety and depression despite a psychiatry note stating there was no obvious need for psychotropic intervention and without documentation of behaviors to justify use. No psychopharmacologic informed consent was obtained, and the care plan misidentified Seroquel as an anxiolytic, lacking appropriate assessment, non-pharmacologic interventions, antipsychotic-specific monitoring, or a plan for gradual dose reduction. The DON later acknowledged not knowing why the medication had been started and that there was no documentation supporting the drug regimen.
The facility did not identify or address dementia-related behaviors for several residents, including one with severe cognitive impairment who exhibited wandering, yelling, and sexually inappropriate actions. Two residents reported repeated uninvited room entries and distressing incidents, while another resident's frequent yelling and aggression disrupted others. Staff documentation and care plans lacked interventions or guidance for managing these behaviors, and staff were unaware of or did not investigate reported incidents.
Two residents did not receive scheduled care and services as ordered, including timely weight monitoring and bathing, with care plans lacking directions for staff on refusals and specific care needs. Documentation was incomplete, and staff were unaware of equipment status and proper documentation practices.
A resident with a fractured femur, legal blindness, and moderate cognitive impairment did not receive the full number of occupational and physical therapy sessions as outlined in their care plan, receiving significantly fewer therapy visits than ordered before being discharged after insurance coverage ended.
A resident with a dehisced abdominal surgical wound and amputated toes was admitted with orders for wound vac therapy and dressing changes, but the facility failed to assess, monitor, or document care for the abdominal wound for over three weeks. The resident also developed a new lower extremity ulcer that was not identified until it required debridement. Staff were unaware of the abdominal wound, and necessary orders were not transcribed or implemented, resulting in the abdominal wound worsening in size before it was finally addressed.
The facility did not ensure timely and accurate receipt, dispensing, and administration of medications for all residents reviewed, resulting in multiple missed doses of critical medications such as anticoagulants, antibiotics, and cardiac drugs. These failures were due to inadequate staff training, lack of awareness of pharmacy procedures, and insufficient use of emergency medication access systems.
A resident who was cognitively intact reported that cash was stolen from their unsecured nightstand drawer after returning from a hospital stay. Despite requests for a lock and staff awareness of the cash, no secure storage was provided, and the incident was not properly investigated or reported to authorities.
The facility did not complete comprehensive skin assessments or proper documentation for three residents with wounds or skin conditions. For example, a resident with chronic wounds lacked ongoing wound measurements and documentation, another did not receive prescribed skin treatments as ordered and had undocumented wounds, and a third had wounds that were not properly assessed or described until seen by a wound management company. Staff interviews revealed confusion and inconsistent practices regarding skin assessment documentation.
A resident with a history of heart disease received multiple doses of 81mg aspirin for chest pain from an agency LPN without a provider's order, resulting in a total of 324mg administered in addition to the prescribed daily dose. The LPN acted based on agency training rather than facility protocol, and facility leadership confirmed that no protocol or physician order authorized this medication administration.
A resident with paraplegia who depended on staff for transfers was not provided with a standing frame needed to maintain or improve mobility, as the equipment had been loaned to another facility and was not returned promptly. Despite repeated requests and communication between nursing and therapy, the standing frame was not made available or set up for use, and the care plan lacked specific interventions or restorative services to address the resident's mobility needs.
The facility did not ensure that two residents who smoked were properly assessed and that required safety interventions were followed, resulting in residents smoking outside the designated area, not using required protective equipment, and cigarette smoke entering resident rooms. Staff and leadership were unaware that interventions were not being followed and that unsafe smoking practices were occurring.
A resident with a history of gastric ulcers, type 2 diabetes, and anemia was found to have multiple pills stored in a seasoning bottle at their bedside, despite facility policy requiring an assessment before allowing medications at bedside. The resident had refused all medications except for a weekly diabetes injection, and both the LPN and DON confirmed that no assessment had been completed to permit bedside storage.
Mechanical beds in several rooms were not maintained in safe, working order, resulting in one resident experiencing a bed collapse and others using beds with malfunctioning controls or components. Staff reported frequent breakdowns, lack of routine audits, and inconsistent reporting of maintenance issues, leading to unresolved equipment problems.
A resident with a peripheral IV device did not receive care in accordance with professional standards, as the device was used beyond the intended duration, lacked proper orders for flushing, was not routinely monitored, and was not removed prior to discharge. The resident experienced pain and a skin tear due to the delayed removal.
Three staff members did not follow CDC PPE protocols when caring for residents with confirmed COVID-19, including not wearing N95 respirators or eye protection as required, wearing surgical masks under N95s, and failing to remove PPE before leaving rooms. Staff interviews revealed confusion and lapses in understanding of proper PPE use, and the facility's Infection Preventionist confirmed these actions did not meet infection control expectations.
Two residents in a facility experienced inadequate assistance with ADLs, including incontinent care and positioning. One resident was left in a wet brief for over three hours, while another faced delays due to staff availability and lift equipment issues. The facility's failure to follow care instructions contributed to these deficiencies.
The facility failed to follow physician orders and monitor clinical conditions for two residents, leading to significant health complications. One resident did not receive a urinalysis for suspected bladder infection, resulting in a urinary tract infection and septic shock. Another resident with a chronic ulcer did not receive prescribed daily dressing changes, as confirmed by discrepancies in medical records and staff interviews.
A resident at risk for pressure ulcers due to immobility was not repositioned or provided with necessary care, leading to the development of a pressure ulcer on the right ankle and redness on the left heel. The facility's DNS was unaware of the wound, and the care plan was not updated with appropriate interventions. A hospice nurse and wound consultant confirmed the presence of a pressure ulcer and recommended interventions, which were not promptly implemented.
The facility failed to follow infection control standards for PPE use with two residents on transmission-based precautions. A resident with infectious gastroenteritis was not properly attended to by staff who ignored PPE requirements, while another resident with a skin infection was assisted without appropriate PPE due to staff misunderstanding of precautionary needs. The Director of Nursing confirmed the staff's actions did not meet facility policy.
A resident with hemiparesis and hemiplegia was unable to reach their call light, which was repeatedly found wedged in the bed frame, leading to unmet care needs and pain. Despite staff instructions to attach the call light to the resident's gown, this was not consistently done. Additionally, a medical provider's recommendation for a bed extender was not followed, despite the facility having them available.
The facility failed to develop and implement personalized discharge plans for two residents, leading to delayed discharges and unmet care needs. One resident, with kidney disease and diabetes, was unable to return home due to a lack of documented interventions and family opposition. Another resident, requiring wound care, was unable to transfer to an Adult Family Home due to the facility's failure to arrange necessary medical equipment and secure a primary care physician. Staff admitted to not having proper discharge plans, contributing to the delays.
The facility failed to follow prescribed diet textures for two residents at risk for aspiration, serving them regular textured foods instead of pureed diets. Additionally, the facility did not honor a resident's food preferences, leading to dissatisfaction and potential weight loss. The triple-check process for meal accuracy was ineffective due to staffing issues, and dietary staff did not use recipes for pureed diets.
The facility failed to provide dining services in a respectful manner, as some residents did not receive their meals while others at their tables had finished eating. Trays were distributed based on how they were loaded on the cart, leading to delays and residents questioning staff about the wait. Staff acknowledged that tables should have been served simultaneously to ensure a dignified dining experience.
The facility did not provide quarterly personal fund statements to residents with trust accounts, affecting four residents. During a resident council meeting, some residents reported never receiving statements, and one was unaware of having a trust account. The Business Office Manager admitted that the most recent documentation was from December 2023, indicating statements were likely not completed for subsequent months. The Administrator confirmed the expectation for consistent delivery of quarterly statements.
The facility failed to notify the state Ombudsman and provide written notices to residents and their representatives regarding hospital transfers, affecting six residents. Staff interviews revealed a lack of awareness and documentation of these required notifications.
The facility failed to provide written notification of its bed-hold policy to residents or their representatives during hospital transfers. This affected four residents, including one who was cognitively intact and another who was moderately impaired. Staff were unsure of the process, and there was no training on bed-hold procedures.
The facility did not ensure periodic reconciliation of controlled medications for two medication carts. Nurses failed to consistently count medications at shift changes or co-sign the ledger, as expected. This issue was noted on several dates, and the Regional Director of Operations confirmed the inconsistency.
The facility failed to monitor five residents for adverse side effects and target behaviors related to their prescribed psychotropic medications. Residents were prescribed medications such as trazadone, lorazepam, quetiapine, and Abilify without proper monitoring orders in their EHRs. The Director of Nursing Services confirmed the absence of necessary monitoring orders.
A facility failed to properly label and discard expired medications, as observed in a medication room and two medication carts. A registered nurse identified expired and undated medications, including insulin pens and intravenous ceftriaxone, which were not disposed of according to professional standards. Additionally, an unlabeled syringe with an unknown solution was found and discarded. These deficiencies posed a risk to residents' health.
The facility failed to maintain effective infection control practices, as staff did not perform hand hygiene between glove changes during wound care for three residents and did not adhere to PPE protocols for residents on transmission-based precautions. Additionally, staff did not use hand sanitizer during meal tray delivery, increasing the risk of infections.
The facility failed to ensure residents' mail was delivered unopened, violating their privacy rights. A Business Office Manager admitted to routinely opening mail, particularly social security checks, without residents' consent. This practice affected several residents, including one who was unaware their checks were being opened and deposited. The Administrator was unaware of this practice and stated that staff would be educated on proper mail handling procedures.
The facility failed to provide Advanced Directives (ADs) for two residents, risking their healthcare preferences not being honored. One resident, mildly cognitively impaired, and another, cognitively intact, both had signed documents indicating ADs, but no records were found in the Electronic Health Record (EHR). The Director of Nursing Services confirmed the absence of these documents in the EHR.
A resident reported a missing Motorola G turquoise blue phone, but the facility failed to properly file and address the grievance. Despite the resident's cognitive ability to recall the event, the grievance was not recorded in the facility's logs, and no follow-up was provided. Staff acknowledged the oversight, indicating a lapse in the grievance handling process, which risked diminishing the resident's quality of life.
A facility failed to complete a Significant Change MDS assessment for a resident admitted to hospice care, as required by the Resident Assessment Instrument manual. The resident, who was severely cognitively impaired, was admitted to hospice, necessitating an MDS assessment within 14 days. However, only an admission MDS was completed, with no further assessments found. The DON confirmed the oversight.
The facility failed to accurately document the health status of two residents in their MDS. One resident's terminal diagnosis was omitted despite hospice care, and another resident's major injury from a fall was incorrectly recorded. Staff acknowledged these inaccuracies.
A facility failed to ensure a PASRR assessment accurately reflected a resident's mental health diagnoses. The resident, who was cognitively intact, had anxiety and depressive disorders and was receiving related medications. However, the PASRR indicated no serious mental illness, despite active treatment for these conditions. The DON acknowledged the need to redo the PASRR.
A facility failed to create a comprehensive care plan for a resident with a femur fracture, omitting opioid-specific interventions despite the resident being on a pain medication regimen that included opioids. Staff acknowledged the care plan should have included opioid-specific monitoring, highlighting a deficiency in addressing the resident's opioid management needs.
The facility failed to conduct timely care conferences and update care plans for two residents. One resident, admitted with severe cognitive impairment and medical conditions, did not have a care conference documented. Another resident, with multiple diagnoses and referred to hospice, had an outdated care plan that did not reflect changes in their condition, such as the removal of a urinary catheter. The DON acknowledged that care plans were not updated as needed.
The facility failed to provide adequate pressure ulcer care for two residents, leading to deficiencies in treatment and monitoring. One resident with a stage 2 ulcer experienced inconsistent dressing changes and monitoring, while another with a stage 4 ulcer was found without a dressing. Staff acknowledged lapses in procedure, and the Director of Nursing confirmed expectations were not met.
A resident with a history of femur fracture surgery continued to receive scheduled pain medication despite reporting zero pain in most assessments. The facility failed to reassess the effectiveness of the medication and inconsistently documented non-pharmacological interventions. Staff interviews revealed a lack of communication and oversight in managing the resident's pain regimen, contributing to the deficiency.
A facility failed to maintain a medication error rate below five percent, resulting in an eight percent error rate. An LPN incorrectly administered eye drops to a resident, not following physician orders or manufacturer's guidelines, and admitted to being unaware of the required separation time between different eye drops.
A resident with a urinary catheter experienced delays in UTI diagnosis due to improper handling of urine samples, leading to frozen specimens and rejected lab results. Staff interviews revealed inadequate procedures for sample collection and storage, contributing to the deficiency.
A facility failed to notify a provider of abnormal lab results for a resident with a urinary catheter, leading to a delay in addressing a UTI. The resident's urinalysis and culture results were reported to the facility, but there was no documentation of provider notification. The facility's policy required prompt notification and documentation, which was not followed, resulting in the provider having to look up the results themselves.
The facility failed to ensure dietary staff were trained and competent in preparing pureed diets for two residents, resulting in them receiving incorrect diet textures. Staffing issues and lack of supervision contributed to the error, as a new cook was not adequately trained due to the absence of a dietary aide and the delayed arrival of a Certified Dietary Manager.
A resident with a known apple allergy and on a cardiac diet was repeatedly provided with apple juice, which was not documented in their electronic health record. The Dietary Manager was only informed of the allergy after multiple observations of the resident receiving apple juice. This oversight highlights a failure in accommodating the resident's dietary needs and preferences.
The facility failed to address the nutritional needs of two residents, leading to significant weight loss. One resident, with a history of bariatric surgery, experienced a 23.75% weight loss due to inconsistent weight monitoring and lack of physician notification. Another resident's weight loss was linked to unaddressed food dislikes and unimplemented RD recommendations. These deficiencies resulted in delayed nutritional interventions and unmet needs.
Insufficient CNA Staffing Leading to Unmet ADL and Supervision Needs
Penalty
Summary
The facility failed to provide sufficient nursing staff to meet residents’ Activities of Daily Living (ADL) needs and to adequately supervise care, as evidenced by resident and staff interviews and observations. One resident with an indwelling Foley catheter, cognitively intact and requiring partial to moderate assistance with ADLs per the quarterly MDS, was observed with a full urine bag hanging at the bedside and reported the bag was full most of the time. This resident stated they had not seen an aide all day except when lunch was delivered. Another cognitively intact resident, who required minimal assistance with ADLs, reported a noticeable decrease in the number of aides and nurses in recent weeks and said they often had to leave their room to find help because call lights were not answered, expressing concern for other residents needing more help. A third cognitively intact resident with paraplegia, substantial ADL assistance needs, and a colostomy reported that their care plan called for them to be out of bed by 9 AM, but they were often not out of bed until lunchtime. This resident stated that two aides were needed to use a Hoyer lift for transfers, but aides repeatedly told them another aide could not be found, and the resident emptied their own colostomy and frequently threw the feces-filled bag onto the floor because no one would come to collect it. CNAs reported being the only aide on a unit, caring for up to 16 residents, and stated that showers could not be completed, many required care tasks were not done, and they were unable to take breaks or lunch. The staffing coordinator reported that, about three weeks earlier, the interim Administrator had directed reductions in CNA staffing on all shifts and that two residents required 1:1 supervision on all shifts, with the expectation that floor aides would rotate this responsibility.
Failure to Coordinate Discharge Planning, Community Services, and Medication Management
Penalty
Summary
Surveyors identified a deficiency in the facility’s discharge planning process related to lack of coordination with community agencies and inadequate medication management for two residents. The facility’s Discharge Policy, revised 12/16/2026, did not address pre-discharge needs such as medication ordering, medication teaching, coordination of home care services, equipment needs, or ensuring follow-up appointments were made before discharge. For Resident 1, who had diabetes and dementia but was assessed as cognitively intact, the Discharge Plan of Care documented that assistance with bathing, toileting, and dressing would be provided by family and personal caregivers, but there was no documentation of medication teaching or follow-up appointments. The Home and Community Services case manager reported they were not notified of this resident’s discharge, so caregivers could not be scheduled, and the family later called with questions about sliding scale insulin administration because they had not received training from facility nurses before discharge. For Resident 2, who had unspecified cognitive impairment, adult failure to thrive, and needed assistance with personal care, the admission documentation included prior hospital case management concerns about safety at home and the family’s ability to provide care. The Discharge Plan of Care stated the resident was cognitively intact and would receive assistance with most ADLs from family, but in-home care was not ordered, medication refills were not sent to a pharmacy, and no follow-up appointment with the primary physician was made. The resident was later readmitted after not receiving care at home and running out of medications about a week after discharge. The Home and Community Services case manager stated they had not been notified of this resident’s discharge and indicated that, based on identified concerns, involvement would have been expected upon referral. The Social Services Director acknowledged not knowing about medication re-ordering or teaching for discharges and reported typically not making follow-up appointments, while leadership staff acknowledged lack of awareness of the coordination issues and that the discharges for these residents were not safe.
Failure to Provide Palatable, Attractive, and Properly Served Meals
Penalty
Summary
Surveyors observed that the facility failed to provide attractive, palatable, and flavorful food at safe and appetizing temperatures. A sample tray from the kitchen contained creamed corn and green beans running together on the plate, with the corn showing burnt bits and the green beans containing tough strings that had to be removed. The baked chicken breast was unseasoned and bland, the pudding was light gray, thin, and dripping off the spoon with only a faint chocolate taste, and there was no butter provided for the roll. The facility’s Registered Nutritionist/Kitchen Manager stated they were unaware of food complaints and relied on food council meetings and floor staff to communicate resident concerns. One resident with tracheal cancer, a voice box removal, moderate cognitive impairment, and a pureed diet had an untouched lunch tray consisting of a large pile of unidentifiable pureed food and reported the food looked unappealing, had no flavor, and they had no desire to eat it. Another cognitively intact resident did not receive their lunch tray when the cart was first passed; the tray remained on the cart in the hall until a CNA was prompted to deliver it, and the resident then reported the food was cold and terrible, describing prior breakfasts as a glob of eggs and an unpalatable muffin, and receiving two bowls of dry cereal without milk. A third cognitively intact resident reported that the food was terrible, that quality, consistency, and flavor had declined after a period of improvement, and that the facility used too many liquid eggs, including at dinner. The Administrator stated they believed food quality was improving and that managers would increase tasting and post-meal rounds to assess satisfaction.
Failure to Provide Ordered Thickened Liquids and Adequate Hydration
Penalty
Summary
The facility failed to ensure residents received liquids consistent with their ordered altered consistencies and hydration needs. One resident with post-stroke swallowing difficulties, cognitively intact per an admission MDS, was observed with an untouched lunch tray that had no fluids. The resident had chapped lips and dry facial skin and reported that meals had been cold and unpalatable since admission, describing breakfast as a glob of eggs and an unmanageable muffin, and receiving dry cereal without milk on two mornings. A CNA, upon checking the diet slip, noted it stated no drinks on the tray and did not know what that meant, indicating they would need to ask the nurse. An LPN then reviewed the orders and identified that the resident required Level 2 (nectar thick) liquids, retrieved a single carton of nectar thick juice from a locked nourishment room, and provided it, with no other Level 2 beverages observed in the refrigerator. The LPN stated that aides would need to ask the nurse to know what type of liquid to give a resident. Another resident, also admitted with post-stroke swallowing difficulties and cognitively intact per the admission MDS, had a dietary order for Level 2 liquids. During a meal observation, this resident’s tray diet slip contained no information about liquid textures, and the tray included two containers of normal-consistency juice. Later, the resident was observed in bed drinking normal-consistency cranberry juice and reported that aides bring juice containers upon request, expressing dislike for nectar thickened fluids, especially water, but acknowledging not getting enough fluids. The Registered Dietician/Kitchen Manager stated that all residents should receive sufficient fluids of the correct consistency, that residents with altered fluid consistency should be monitored for compliance and hydration, and that there should be a quick reference system to communicate residents’ fluid consistency needs to floor staff. The report states that these failures placed residents at risk for dehydration, aspiration, and decreased quality of life.
Antipsychotic Medication Initiated Without Assessment, Consent, or Proper Care Planning
Penalty
Summary
Surveyors found that the facility failed to ensure a resident’s drug regimen was free from unnecessary drugs when Seroquel, an antipsychotic medication, was initiated and continued without proper assessment, diagnosis, or monitoring. The resident was admitted with encephalopathy related to glioblastoma, was moderately cognitively impaired, and required extensive assistance with most activities of daily living. A psychiatry note documented that the resident was confused and minimally engaged, with an impression of unspecified cognitive disorders worsening due to recent medical events, and specifically stated there was no obvious need for psychotropic intervention. Despite this, the former Director of Nursing Services obtained an order for Seroquel 50 mg every morning and 150 mg at bedtime for anxiety and depression, without documentation of behaviors or other clinical justification explaining why the medication was started. There was no Psychopharmacologic Medication Informed Consent signed by the resident to show that risks, benefits, side effects, or the need for gradual dose reduction had been reviewed. The care plan later identified Seroquel incorrectly as an anxiolytic medication and, even when revised, did not include an appropriate assessment, non-pharmacologic interventions, or monitoring specific to an antipsychotic medication, nor did it address a plan for gradual dose reduction. When interviewed, the Director of Nursing Services stated they did not know why Seroquel had been started and acknowledged there was no documentation to support the drug regimen. The report states that this failure to complete a thorough evaluation before starting the medication and to provide necessary monitoring during therapy placed residents at risk for sedation, decreased quality of life, and death.
Failure to Address and Manage Dementia-Related Behaviors
Penalty
Summary
The facility failed to identify, address, and adjust care needs for five residents who exhibited dementia-related behaviors or were negatively impacted by such behaviors. One resident with a history of Neurocognitive Disorder with Lewy Bodies demonstrated severe cognitive impairment and exhibited behaviors such as yelling, wandering, and sexually inappropriate actions, as documented on behavior monitoring forms. Despite these documented behaviors, no interventions were added or recorded, and the resident's care plan and Kardex lacked any mention of these behaviors or guidance for staff on how to manage them. Other residents were directly affected by these deficiencies. Two cognitively intact residents reported that the resident with dementia repeatedly entered their room uninvited, with one incident involving urination on a bed and another involving an attempted sexual contact. Both residents expressed anger, frustration, and helplessness, and staff interviews revealed a lack of awareness or investigation into these incidents. Staff relied on the Kardex for intervention guidance, but it did not provide any relevant information for managing the behaviors. Another resident with dementia and behavioral disturbances was documented as frequently yelling, screaming, and exhibiting aggressive behaviors such as kicking, hitting, grabbing, and using abusive language. These behaviors were noted by staff and affected nearby residents, one of whom reported significant distress and sleep disruption. However, the care plan for this resident only addressed medication interventions and did not include strategies for managing the documented behaviors. Staff confirmed that the care plans and Kardexes did not provide adequate or person-centered interventions for these residents' behavioral needs.
Failure to Provide Scheduled Care and Services per Orders and Resident Preferences
Penalty
Summary
The facility failed to provide scheduled care and services according to physician orders and resident preferences for two residents reviewed for quality of care. One resident, admitted with a fractured femur and legal blindness, required extensive assistance with activities of daily living (ADLs) and was assessed as moderately cognitively impaired. Orders specified that weights should be obtained weekly for four weeks, but documentation showed that weights were not recorded until nearly two weeks after admission, with only one additional weight recorded before discharge, revealing a 10-pound loss. The resident's care plan, completed two days before discharge, did not address care needs such as bathing, obtaining weights, or instructions for staff regarding refusals of care, despite the resident being at nutritional risk due to multiple co-morbidities. No documentation was provided regarding showers or bathing during the resident's stay. Another resident, who was cognitively intact and required extensive assistance with ADLs, had a care plan indicating a bath should be provided twice weekly and as needed, with a sponge bath as an alternative if a full bath or shower could not be tolerated. The care plan lacked directions for staff on how to handle refusals. Documentation showed inconsistent bathing records, with some days marked as "not applicable" and others as "refused," and only one shower documented during the review period. Orders for weekly weights were not consistently followed, with only three weights documented and no further records. Staff interviews revealed a lack of awareness regarding the functionality of the wheelchair scale and uncertainty about documentation practices for showers and baths. The administrator confirmed that care plans should reflect personalized care needs, including interventions for refusals, but these were not present.
Failure to Provide Consistent Rehabilitative Services per Care Plan
Penalty
Summary
The facility failed to provide consistent specialized rehabilitative services as required by the care plan for a resident admitted with a fractured femur and legal blindness, who was moderately cognitively impaired and required extensive assistance with activities of daily living. According to the care plan and therapy orders, the resident was to receive occupational therapy (OT) and physical therapy (PT) five times per week for four weeks. During the certification period, the resident received only nine OT visits and fourteen PT visits, which was eleven OT visits and six PT visits fewer than planned. The resident was notified that insurance coverage would end and was discharged before the end of the planned therapy period. The administrator confirmed that all residents should receive specialized services according to their care plan.
Failure to Assess and Monitor Wounds Resulting in Wound Deterioration
Penalty
Summary
The facility failed to assess, monitor, and provide appropriate care for a resident with a non-pressure abdominal wound and a newly developed lower extremity (LE) ulcer. Upon admission, the resident had a dehisced surgical wound to the midline abdomen and amputated toes on the right foot, with diagnoses including peripheral vascular disease and diabetes. The admission assessment noted the presence of the abdominal wound and wound vac, but did not include wound measurements or detailed wound characteristics. Hospital transfer orders specified wound vac settings and dressing change frequency, but these were not transcribed into the facility's records, and no care plan interventions were developed to address the wound or minimize further breakdown. From admission, there was no documentation of wound care, assessment, or monitoring for the abdominal wound until 24 days later, nor for the right calf wound until 13 days after admission. The Treatment Administration Records (TARs) and electronic medical record (EMR) lacked any entries regarding the abdominal wound, wound vac, or required dressing changes during this period. The resident developed a new ulcer on the right posterior calf, which was not present on admission and was only identified after it had progressed to 75% slough and required mechanical debridement. Staff interviews confirmed that the abdominal wound was not assessed or treated because staff were unaware of its presence, and the necessary wound care orders were not implemented. When the abdominal wound was finally assessed 24 days after admission, it had increased in size, indicating a worsening condition. The wound care consult documented the wound's increased area and provided new treatment recommendations. The Director of Nursing acknowledged that the facility failed to identify and treat the wounds in a timely manner, and that the right LE ulcer should have been detected earlier, especially given the resident's need for maximal assistance with lower body dressing.
Failure to Ensure Timely Medication Administration Due to Inadequate Pharmacy Procedures
Penalty
Summary
The facility failed to develop and implement effective pharmacy procedures to ensure that medications were timely and accurately received, dispensed, and administered to meet the needs of all seven residents reviewed for admission medication reconciliation. The pharmacy delivery schedule required that medications ordered before 10:00 AM would be delivered in the evening, and those ordered after 10:00 AM but before 7:30 PM would be delivered overnight. If medications were needed before the next scheduled delivery and the cutoff time was missed, staff were expected to request STAT delivery and utilize emergency access systems such as Omnicell. However, there was no documentation that staff followed these procedures, resulting in multiple missed doses of critical medications for several residents. Residents admitted with time-sensitive and high-risk medication needs, such as anticoagulants, antibiotics, cardiac medications, and antipsychotics, experienced significant omissions. For example, one resident with a history of blood clots did not receive scheduled doses of rivaroxaban, despite the medication being available in the Omnicell system. Another resident with a C. difficile infection missed 12 out of 25 scheduled vancomycin doses due to failures in transcribing a formulary interchange and lack of staff follow-through. Additional residents failed to receive IV antibiotics, anticonvulsants, and other essential medications due to similar lapses in order entry, pharmacy communication, and emergency medication access. Interviews with staff revealed a lack of training and awareness regarding pharmacy ordering deadlines, STAT medication requests, and the use of emergency medication systems. Some nurses were unaware of the need to fax certain medication orders or the existence of pharmacy order cutoff times. The Director of Nursing confirmed that several staff members did not have access to the Omnicell system, further contributing to the delays and omissions. These systemic failures in medication management and staff competency led to repeated missed doses and inadequate medication administration for all residents reviewed.
Failure to Protect Resident's Property from Theft
Penalty
Summary
A cognitively intact resident was admitted to the facility and, according to the quarterly Minimum Data Set, was able to make independent decisions. The resident reported being unable to lock the top drawer of their nightstand and stated that they had made at least two requests for maintenance to install a lock, which were not fulfilled. The resident kept $376 in the top drawer, with another resident as a witness to the amount. After being hospitalized for several days, the resident returned to find only one dollar remaining in the drawer. The missing money was immediately reported to the Social Services Director. Facility staff interviews revealed that the Social Services Director received the complaint and reported it to their supervisor but did not notify law enforcement or initiate a formal investigation, only speaking to the witness who denied seeing the money. The Business Office Manager was aware the resident had cash in the room and encouraged the use of a facility trust account, but did not verify the security of the drawer. The Maintenance Director was unaware of any request for a lock and confirmed the drawer was not lockable. The administrator, newly in position, acknowledged the incident should have been investigated and reported. Documentation confirmed the resident's report of theft and the lack of a secure storage solution for their belongings.
Failure to Complete Comprehensive Skin Assessments and Documentation
Penalty
Summary
The facility failed to ensure comprehensive skin assessments were completed for three residents who required services meeting professional standards. For one resident with multiple chronic wounds on admission, there was no documentation of wound measurements or characteristics on weekly skin evaluations after the initial assessment, and no skin evaluations were completed following hospitalizations for cellulitis and skin tears. Staff interviews confirmed that nurses were expected to document wound location, measurements, characteristics, and notify providers of changes, but this was not consistently done. Another resident with skin conditions in the abdominal folds, groin, and under the breasts reported that prescribed treatments were not administered as ordered, and documentation lacked details about a coccyx wound and the characteristics of skin conditions. The DON was unaware of the coccyx wound and acknowledged possible incomplete documentation of care and treatment refusals. A third resident had a wound care order, but skin evaluations did not document the wound or its characteristics, and a new skin tear was not measured or described until the wound management company became involved. Staff interviews revealed confusion about proper documentation and incomplete use of skin evaluation forms.
Significant Medication Error Due to Unordered Aspirin Administration
Penalty
Summary
A facility failed to ensure that a resident was free from significant medication errors when an agency LPN administered multiple doses of 81mg chewable aspirin without a provider's order. The resident, who had a history of myocardial infarction and heart disease and was assessed as mildly cognitively impaired, began experiencing chest pain late in the evening. The LPN gave a total of 324mg of aspirin in 81mg increments every five minutes while simultaneously calling 911, despite the resident already having received their prescribed daily dose of 81mg aspirin that morning. There were no standing or emergency orders in place for additional aspirin administration for chest pain. The LPN stated that their agency training directed them to begin an aspirin protocol for chest pain, but acknowledged that no physician order was obtained prior to administering the medication. Facility leadership, including the Administrator and DON, confirmed that there was no facility protocol authorizing this action and that a physician should have been contacted before administering any additional medication. The incident was documented in the nursing progress notes and confirmed through staff interviews and record review.
Failure to Provide Required Equipment and Restorative Services for Mobility
Penalty
Summary
A resident with paraplegia, who was dependent on staff for transfers and required a Hoyer lift, was not provided with the necessary equipment to maintain or improve mobility. The resident had been requesting access to a standing frame for several months, but the device had been loaned to a sister facility and was not returned in a timely manner. Despite communication between nursing and therapy staff regarding the resident's need for the standing frame to assist with mobility, the equipment remained unavailable for an extended period. The resident expressed ongoing frustration about the lack of access to the standing frame, and observations confirmed that the device was not present or set up for use during multiple visits. Additionally, the resident's care plan did not include specific interventions, exercises, or therapy to maintain or improve mobility, nor did it reflect the resident's preference for a restorative program utilizing the standing frame. The lack of appropriate equipment and individualized care planning resulted in the resident not receiving restorative services necessary to maintain or improve range of motion and mobility.
Failure to Enforce Smoking Safety Policies and Interventions
Penalty
Summary
The facility failed to ensure that residents who smoked were properly assessed and that safety interventions were followed, as required by their own smoking policy. Two residents, both moderately cognitively impaired and with significant physical or cognitive limitations, were not managed according to their Smoking Evaluations. One resident, who required a smoking apron, was observed smoking without it, and another resident, who had been deemed not safe to smoke, was also observed smoking. Additionally, residents were not restricted to the designated smoking area, with several observed smoking along the sidewalks outside the designated structure. Observations revealed that residents were flicking ashes onto the ground and pocketing cigarette butts, and that cigarette smoke was drifting into rooms with open windows, affecting other residents. Staff interviews confirmed that required interventions based on Smoking Evaluations were not being followed, and that facility leadership was unaware of these lapses. The facility's policy required quarterly smoking evaluations and adherence to safety interventions, but these were not consistently implemented or monitored.
Failure to Secure Medications at Bedside Without Assessment
Penalty
Summary
A deficiency was identified when a resident, who was cognitively intact and had a history of gastric ulcers, type 2 diabetes, and anemia, was found to have a variety of pills stored in a garlic seasoning bottle inside a Kleenex box at their bedside. The resident stated they only wanted to take their weekly Mounjaro injection and did not want to take the other medications, which included omeprazole, a probiotic, a multivitamin, Vitamin D, and iron. The medication administration record confirmed these medications were prescribed, and the care plan documented the resident's refusal to take any medication other than Mounjaro. Despite the resident's refusal, there was no assessment found that allowed for medications to be left at the bedside, as required by facility policy and professional standards. Both the LPN Unit Manager and the DON confirmed that medications should not be left at the bedside unless an assessment had been completed. The lack of an assessment and the presence of unsecured medications at the resident's bedside constituted a failure to store medications appropriately, as required by regulation.
Failure to Maintain Mechanical Beds in Safe Working Condition
Penalty
Summary
The facility failed to maintain mechanical beds in a fully functional and safe condition for four out of four beds reviewed. One resident reported that their bed collapsed while they were sitting on the edge, resulting in a significant drop. Staff attempted to identify the issue at the time but were unable to resolve it, and the resident was moved to another bed. Maintenance was notified of the broken bed through the TELS system, and a part was ordered for repair. However, staff interviews revealed that other beds were also malfunctioning, including beds that would not raise or lower, beds with non-functioning remotes, and beds where the head section would not operate, requiring staff to physically support residents during transfers. Observations confirmed that several beds were not operating as intended, with issues such as motors making loud grinding noises and remotes being jammed. Staff reported that the bed frames were old and prone to frequent breakdowns, with two frames breaking in the previous week. Maintenance staff indicated that there was no routine audit of mechanical beds to ensure proper functioning, and communication about bed issues was inconsistent, with some staff using the TELS system and others only mentioning problems informally, leading to unresolved maintenance needs.
Failure to Follow Professional Standards for IV Device Management
Penalty
Summary
The facility failed to implement proper procedures for the care and management of a peripheral intravenous (IV) device for one resident. The resident was admitted with a peripheral IV device that was intended for use for less than six days, but records showed the device was used for more than six days. There were no documented orders for flushing the IV with saline after antibiotic infusions, and the IV was not routinely assessed or monitored for signs and symptoms of infection or other concerns, as required by facility policy and professional standards. The care plan and treatment administration record did not reflect appropriate monitoring or care of the IV device. Additionally, the IV was not removed prior to the resident's discharge from the facility. The resident reported not being aware that the IV was still in place until after leaving the facility and required removal at their primary doctor's office. The resident experienced pain and a skin tear due to the delayed removal of the IV dressing. The Director of Nursing confirmed that the IV should have had orders for flushing, should have been monitored, and should have been removed before discharge.
Failure to Adhere to CDC PPE Guidelines for COVID-19 Precautions
Penalty
Summary
Three of seven staff members failed to use personal protective equipment (PPE) in accordance with CDC guidelines when caring for residents with confirmed COVID-19 infections. Observations showed that staff entered rooms marked with aerosol precaution signs without wearing the required N95 respirator and eye protection, and sometimes only wore surgical masks, gowns, and gloves. In several instances, staff wore a surgical mask underneath the N95 respirator, which the Infection Preventionist later confirmed was not appropriate as it prevents a proper seal. Staff were also observed exiting resident rooms while still wearing PPE such as N95 respirators and surgical masks, and walking through hallways and to other units without removing or properly discarding the PPE as required. Staff interviews revealed a lack of understanding or adherence to PPE protocols, with some staff admitting they forgot to wear eye protection or believed that N95 respirators and eye protection were only necessary when providing direct care. The Infection Preventionist confirmed that the facility's expectation was for staff to wear a N95 respirator, eye protection, gown, and gloves when entering rooms of residents on aerosol precautions, and to remove all PPE upon exiting the room. The failure to follow these procedures was acknowledged as not being in line with the facility's infection control policies.
Inadequate ADL Assistance and Equipment Issues
Penalty
Summary
The facility failed to provide adequate assistance with Activities of Daily Living (ADL) for two residents, leading to issues with incontinent care, cleanliness, and positioning in bed. Resident 1, who was cognitively intact and required substantial assistance, was observed lying in bed for over three hours without receiving necessary incontinent care or repositioning. When staff eventually attended to Resident 1, they found the resident in a wet brief and lying on wet sheets, indicating a lack of timely care. The staff changed the sheets and the resident's brief but did not wash the resident's body before dressing them in a new nightgown. Resident 2, also cognitively intact and requiring substantial assistance, expressed dissatisfaction with the delays in receiving care, particularly in the mornings and afternoons. The resident reported having to wait for extended periods to be changed and transferred, often due to staff being occupied with other tasks or issues with lift equipment. On one occasion, the resident had been waiting since 3:00 PM for a brief change, but the lift's battery was not charged, causing further delays. Staff confirmed the ongoing issue with lift batteries and the discomfort caused by using a manual lift. The facility's failure to adhere to the care instructions outlined in the residents' Kardexes contributed to the deficiencies observed. Staff were expected to follow these instructions, which included scheduled checks and changes for incontinence, but were unable to do so consistently due to equipment issues and staffing constraints. This lack of adherence to care plans resulted in residents experiencing discomfort and potential risks to their skin integrity and dignity.
Failure to Follow Physician Orders and Monitor Clinical Conditions
Penalty
Summary
The facility failed to follow physician orders and monitor clinical conditions for two residents, leading to significant health complications. Resident 3, who was cognitively intact, expressed concerns about a possible bladder infection and had a physician order for a urinalysis on 11/22/2024, which was not completed by the nursing staff. Despite continued complaints of pain during urination, there was no documentation of nursing assessment or monitoring from 11/22/2024 to 12/06/2024. Resident 3 was eventually sent to the emergency department on 12/07/2024 and diagnosed with a urinary tract infection, leading to admission to the intensive care unit for septic shock. Resident 4, also cognitively intact, had a chronic ulcer on their right foot and was under orders for daily dressing changes from a wound clinic. However, the facility failed to implement these orders, as evidenced by the resident arriving at the wound clinic with the same dressing from a week prior. The facility's electronic medical records showed discrepancies in the documentation of dressing changes, and the resident's care was not adjusted according to the wound clinic's orders. This oversight was acknowledged by the Resident Care Manager, who noted that the orders should have been followed upon the resident's return from the clinic. The deficiencies in care for both residents were confirmed through interviews with facility staff and review of medical records. The Director of Nursing and other staff members acknowledged the lack of documentation and failure to follow through with physician orders, which contributed to the residents' deteriorating health conditions. These failures highlight significant lapses in the facility's adherence to care protocols and monitoring of residents' clinical conditions.
Failure to Prevent Pressure Ulcers in a Resident
Penalty
Summary
The facility failed to implement necessary interventions to prevent the development of pressure ulcers for a resident who was at risk due to immobility. The resident, who was cognitively intact and required substantial assistance with activities of daily living, was observed lying in bed for several hours without being repositioned or receiving incontinent care. This lack of care resulted in the resident developing redness and a black area on the right lateral ankle bone, as well as redness on the left heel. Despite the facility's policy to consider all residents at risk for skin impairment and to implement preventive measures, these interventions were not carried out effectively for this resident. The Director of Nursing (DNS) was unaware of the wound on the resident's ankle until it was pointed out during an observation. The care plan for the resident was not updated to reflect the new skin concerns, and no interventions such as floating the heels or applying skin prep were documented. A hospice nurse confirmed the presence of a pressure ulcer on the right ankle and noted that the resident's heels were not floated as expected. The wound consultant later recommended the use of cushioned boots and floating the ankles and heels off the mattress, but these recommendations were not implemented in a timely manner.
Infection Control Deficiency Due to Improper PPE Use
Penalty
Summary
The facility failed to adhere to infection control standards concerning the use of personal protective equipment (PPE) for residents on transmission-based precautions (TBP). Resident 1, diagnosed with infectious gastroenteritis and colitis, was on contact precautions. However, on two separate occasions, staff members entered Resident 1's room without donning the required PPE or washing their hands, despite clear signage indicating the need for such precautions. Staff A, a Certified Nursing Assistant (CNA), entered and exited the room without washing hands or wearing a gown and gloves, claiming not to have noticed the sign. Similarly, Staff D entered the room, turned off the call light, and handled the food tray without PPE or hand hygiene, also stating they did not notice the sign until after exiting. Resident 2, with a diagnosis of a skin infection, was on enhanced barrier precautions (EBP) due to a wound. Staff B, a Resident Care Manager (RCM), and Staff C, a CNA, entered Resident 2's room without donning the required PPE while assisting with a manual lift. Both staff members incorrectly believed that only Resident 2's roommate was on EBP, not Resident 2. Upon review, Staff B acknowledged that Resident 2 was indeed on EBP and that they should have worn gowns and gloves during the transfer. The Director of Nursing confirmed that the staff did not follow the facility's policy, which required PPE for close contact tasks such as transferring and changing briefs.
Failure to Provide Accessible Call Light and Bed Extender
Penalty
Summary
The facility failed to provide a call light within reach and a bed extender for a resident with hemiparesis and hemiplegia on the left side due to a stroke. The resident, who was cognitively intact and required extensive assistance for most activities of daily living, was unable to reach the call light, which was observed multiple times wedged in the bed frame and dangling towards the floor. The resident expressed that this inability to reach the call light led to periods of laying in soiled briefs and experiencing pain due to feet pressing against the footboard. Staff were instructed to attach the call light to the front of the resident's gown, but this was not consistently done. Additionally, a medical provider noted that the resident complained of right foot pain from hitting the end of the bed and recommended an extended bed and regular repositioning to prevent pressure injuries. Despite the facility having bed extenders available, the resident did not receive one. Staff, including a housekeeper, expressed frustration with the situation, and a grievance was filed. The Director of Nursing Services acknowledged that the resident should have had access to the call light and that staff should have followed the medical provider's recommendations.
Failure in Discharge Planning for Two Residents
Penalty
Summary
The facility failed to develop and implement personalized discharge plans for two residents, leading to delayed discharges and unmet care needs. Resident 1, who was admitted with kidney disease and diabetes, expressed a desire to return home once well. Despite this, the facility did not document any interventions in the discharge care plan beyond the initial admission date. The resident repeatedly expressed frustration about not being able to go home, even contacting emergency services. Staff acknowledged the lack of a discharge care plan and noted that the resident's spouse did not want them to return home, contributing to the resident feeling trapped. Resident 2, who was cognitively intact and required wound care and a pressure-reducing device, had secured a spot at an Adult Family Home (AFH) but was unable to transfer due to the facility's failure to arrange necessary medical equipment and secure a primary care physician. Despite the resident's eagerness to transfer, the facility did not follow through with the arrangements, and the discharge care plan lacked further interventions. Staff admitted to not having a discharge plan and retained information mentally, which contributed to the delay. The Social Service Director acknowledged the oversight in discharge planning, citing being busy with other tasks as a reason for the delay. The facility's administrator recognized that the discharge planning did not meet expectations and indicated a need for staff education on identifying barriers to discharge and care planning.
Failure to Follow Diet Textures and Honor Food Preferences
Penalty
Summary
The facility failed to ensure that menus were followed and that modified diet textures were prepared according to established guidelines and physicians' orders for two residents at risk for aspiration, pneumonia, and choking. Resident 35, who had severe cognitive impairment and was on a mechanically altered diet, experienced episodes of choking and coughing during meals. Despite being on a pureed diet, Resident 35 was served regular textured scrambled eggs and chopped sausage, which were not in accordance with the prescribed diet. Similarly, Resident 125, who also had severe cognitive impairment and required an altered texture diet, was served regular textured scrambled eggs and chopped sausage instead of the prescribed pureed diet. The facility's system for ensuring the correct food texture was not effective, as evidenced by the failure of the triple-check process intended to verify the accuracy of meal trays. Staff D, the Head Cook/Dietary Manager in Training, explained that the triple-check process involved the cook, dietary aide, and direct care staff verifying the diet type and texture. However, due to staffing issues and lack of oversight, the new cook was not adequately supervised, leading to errors in diet texture for Residents 35 and 125. Additionally, dietary staff did not have access to or utilize recipes when preparing pureed diets, contributing to the inconsistency in meal preparation. Furthermore, the facility failed to honor food preferences for Resident 61, who was cognitively intact and had significant weight loss. Despite multiple communications and a completed food preference form indicating a dislike for pasta and vegetables, the resident continued to receive meals that did not align with their preferences. The dietary staff did not input the resident's food preferences into the dietary computer, resulting in continued dissatisfaction with meals and potential risk for further weight loss.
Failure to Provide Dignified Dining Services
Penalty
Summary
The facility failed to provide dining services in a respectful and dignified manner for five of the fourteen residents eating in the dining room. During the observation, it was noted that trays were passed out according to how they were loaded on the cart, rather than ensuring all residents at a table were served simultaneously. As a result, Residents 54, 33, 15, 60, and 22 did not receive their trays while others at their tables had already finished eating. This led to residents questioning staff about the delay, and staff responded that they were looking for the food. The facility's policy stated that residents have the right to be treated with respect, and staff acknowledged that each table should have been served at the same time to ensure the best dining experience.
Failure to Provide Quarterly Personal Fund Statements
Penalty
Summary
The facility failed to provide quarterly personal fund statements to residents with personal fund accounts, affecting four sampled residents. During a resident council meeting, three residents reported never receiving a quarterly statement for their trust account balance, while another resident was unaware of having a trust account. A review of the facility's document titled 'Trial Balance' showed that three residents had a balance in their trust fund, while one had a balance of zero dollars. The Business Office Manager admitted that the most recent documentation available was from December 2023 and acknowledged that if documentation was missing, the statements were likely not completed for those months. The Administrator confirmed that the expectation was for residents or their representatives to receive quarterly statements consistently.
Failure to Notify Ombudsman of Resident Transfers
Penalty
Summary
The facility failed to provide timely written notifications to residents, their representatives, and the state Ombudsman regarding hospital transfers, as required by regulations. This deficiency was identified for six residents who were hospitalized during the review period. The lack of documentation in the Electronic Health Records (EHR) indicated that the facility did not notify the Ombudsman for any of these transfers, which is a regulatory requirement. Interviews with staff, including the Director of Nursing Services and the Social Services Director, confirmed the absence of such notifications and revealed a lack of awareness about the requirement to notify the Ombudsman. Specific cases highlighted include Resident 18, who was cognitively intact and hospitalized due to a fall, and Resident 19, who was moderately cognitively impaired and hospitalized three times without Ombudsman notification. Other residents, such as Resident 67, Resident 30, Resident 16, and Resident 73, also experienced hospital transfers without the required notifications. Staff interviews further confirmed the absence of documentation and awareness, with the Social Services Director admitting to not knowing about the requirement and the Director of Nursing Services acknowledging the issue.
Failure to Provide Bed-Hold Policy Notification
Penalty
Summary
The facility failed to provide written notification of its bed-hold policy to residents or their representatives at the time of transfer to a hospital for four residents. Resident 18, who was cognitively intact, was hospitalized due to a fall, but the bed-hold notice was filled out after the resident had already left the facility, and there was no documented notification to the resident or their representative. Resident 19, who was moderately cognitively impaired, was hospitalized three times, but no bed-hold forms were present for the first two hospitalizations, and the forms for the third hospitalization lacked signatures from the resident or their representative. Staff involved were unsure of the process and did not review the bed-hold with the patient before their departure. Resident 30, who was cognitively intact, was hospitalized, but no documentation of a transfer notice was found. Staff acknowledged the absence of notices. Similarly, Resident 73 was transferred to an acute care hospital, but there was no documentation that a written notice of the bed-hold policy was provided at the time of transfer. The facility's failure to provide these notifications was confirmed by staff, including the Director of Nursing Services and the Regional Director of Operations, who admitted there was no current process for training staff on bed-hold procedures.
Failure to Reconcile Controlled Medications
Penalty
Summary
The facility failed to implement a system ensuring periodic reconciliation and accounting for all controlled medications, affecting two medication carts (C cart & A cart). Facility nurses did not consistently reconcile controlled medications at shift change or co-sign the ledger to confirm the accuracy of the controlled medication count. This failure was observed on multiple dates in May and June 2024 for the C-cart and in June 2024 for the A-cart. The Regional Director of Operations acknowledged that it was expected for both nurses to perform a controlled medication count and co-sign the ledger, but confirmed that this was not consistently occurring.
Failure to Monitor Psychotropic Medication Effects
Penalty
Summary
The facility failed to monitor five residents for adverse side effects and target behaviors related to their prescribed psychotropic medications. Resident 10, who was severely cognitively impaired, was prescribed trazadone for insomnia and lorazepam and diazepam for anxiety, but there were no orders for monitoring target behaviors or side effects in the Electronic Health Record (EHR). Similarly, Resident 68, moderately cognitively impaired, was prescribed quetiapine for dementia and psychosis without any monitoring orders for target behaviors or side effects. Resident 38, also moderately cognitively impaired, was prescribed lorazepam for anxiety and citalopram for major depressive disorder, but the EHR lacked documentation for monitoring target behaviors or side effects. Resident 62, cognitively intact, was prescribed mirtazapine for depression and appetite increase, yet there were no monitoring orders in the EHR. Lastly, Resident 18, cognitively intact with frequent mood disturbances, was prescribed Abilify for psychosis and sertraline for depression, but there were no monitoring orders for adverse side effects or target behaviors. The Director of Nursing Services confirmed the absence of necessary monitoring orders for these residents.
Expired and Undated Medications Found in Facility
Penalty
Summary
The facility failed to ensure that drugs and biologicals were labeled and dated according to accepted professional standards, and expired medications were not discarded. During an observation of the medication room, a registered nurse identified several expired and undated medications. These included an opened Byetta pen for a resident that should have been discarded 30 days after opening, an opened vial of Humulin R insulin for another resident that was opened more than 28 days prior, and five bags of intravenous ceftriaxone that were brown and discolored. The nurse confirmed that these medications needed to be disposed of. Further observations of two medication carts revealed additional issues. On one cart, an opened and undated Lispro insulin pen and an opened Aspart insulin pen dated beyond the recommended discard date were found. On the second cart, a syringe containing an unidentified red syrup-like solution was found without any labeling or indication of when it was prepared. The nurse was unable to identify the medication or its preparation date and subsequently discarded the syringe. These deficiencies placed residents at risk of receiving expired medications and potential negative health outcomes.
Infection Control Deficiencies in Wound Care and PPE Use
Penalty
Summary
The facility failed to establish and maintain effective infection prevention and control practices, as evidenced by multiple observations of staff not adhering to established protocols. During wound care for three residents, staff did not perform hand hygiene between glove changes, which is a critical step in preventing the spread of infections. Specifically, Staff P was observed changing gloves multiple times without using hand sanitizer or washing hands between changes while providing wound care to Residents 62, 40, and 69. Additionally, Staff P was seen using the same box of gloves across different resident rooms, which further compromised infection control measures. In addition to the issues with wound care, staff also failed to adhere to transmission-based precautions. For instance, Staff JJ, a Physical Therapy Assistant, did not wear gloves or a gown while working with Resident 324, who was on contact precautions. Similarly, Staff II and Staff AA did not wear the required personal protective equipment, such as gowns and gloves, while providing high-contact care to Residents 53 and 10, respectively, who were under enhanced barrier precautions. These lapses in following PPE protocols increased the risk of spreading infections among residents. Furthermore, the facility's staff did not consistently perform hand hygiene during meal tray delivery. Staff AA was observed delivering meal trays to multiple rooms without using hand sanitizer before entering or after exiting the rooms. This failure to perform hand hygiene as per the facility's policy further contributed to the risk of healthcare-associated infections. The facility's policies on hand hygiene and enhanced barrier precautions were not effectively implemented, as evidenced by the staff's non-compliance with these critical infection control practices.
Violation of Resident Mail Privacy
Penalty
Summary
The facility failed to ensure that residents' mail was delivered unopened, violating their right to privacy. This deficiency was identified for four out of seven residents reviewed for resident rights. The facility's policy, dated August 2022, mandates compliance with federal law 42 U.S.C 483.10, which includes respecting residents' privacy in their communications. However, during a resident council interview, it was revealed that the Business Office Manager, Staff F, routinely opened mail, particularly social security checks, without the residents' consent. Resident 43 reported that the office manager opened envelopes that appeared to contain checks, and Resident 46 confirmed receiving opened mail that did not contain a check. Staff F admitted to opening some residents' mail, specifically social security checks for Residents 30 and 25, and did not perceive this as an issue. Resident 30 expressed dissatisfaction upon learning that their social security check was being opened and deposited without their knowledge. The Administrator, Staff A, was unaware of this practice and stated that staff would be educated on the expectation that mail should be opened at the bedside with the resident's permission. This practice of opening mail without consent placed residents at risk for a lack of privacy and a diminished quality of life.
Failure to Provide Advanced Directives for Residents
Penalty
Summary
The facility failed to provide an Advanced Directive (AD) for two residents, Residents 59 and 62, which placed them at risk of not having their healthcare preferences honored. Resident 59, who was mildly cognitively impaired, was admitted to the facility and had signed a document indicating the presence of an AD, but no record of the AD was found in the Electronic Health Record (EHR). Despite multiple requests for the AD, the Director of Nursing Services (DNS) confirmed the absence of the documentation in the EHR. Similarly, Resident 62, who was cognitively intact, had also signed a document indicating the presence of an AD, but no record was found in the EHR. The DNS acknowledged the absence of the AD in the EHR and expressed the expectation to follow up with the resident and their family to obtain the document. This deficiency was identified during a review of the facility's compliance with resident rights regarding advanced directives.
Failure to Address Resident Grievance on Missing Property
Penalty
Summary
The facility failed to properly address a grievance filed by Resident 18 regarding a missing personal item, specifically a Motorola G turquoise blue phone. Resident 18, who was admitted with diagnoses including depression and psychosis, was cognitively intact and able to recall events. The resident reported the missing phone to the activity person, but there was no follow-up or information provided about the grievance, leaving the resident upset and flabbergasted. Despite the resident's clear recollection of filing a grievance, the facility's Grievance Log and Incident Log did not reflect any record of the grievance or incident related to the missing property. Staff G, the Activities Director, confirmed that a Missing Property Report was filed, but it did not address the second phone that Resident 18 reported missing. Staff H, the Social Services Director, acknowledged that if the resident perceived the loss as theft, it should have been filed as a grievance. Staff A, the Administrator, stated that grievances should be resolved within two days, indicating a failure in the facility's grievance handling process. This oversight placed residents at risk for a diminished quality of life, as their grievances were not promptly or adequately addressed.
Failure to Complete Significant Change MDS for Hospice Resident
Penalty
Summary
The facility failed to complete a Significant Change Minimum Data Set (MDS) assessment for a resident who was reviewed for hospice and end-of-life care. According to the Resident Assessment Instrument manual, a Significant Change in Status Assessment (SCSA) is required when a terminally ill resident enrolls in a hospice program and remains at the nursing home. Resident 10, who was severely cognitively impaired, was admitted to hospice on May 11, 2024, necessitating a Significant Change MDS assessment within 14 days. However, the Electronic Health Record (EHR) showed that only an admission MDS was completed on April 24, 2024, with no further MDS assessments found. The Director of Nursing Services confirmed that an MDS assessment should have been completed within the required timeframe.
Inaccurate MDS Documentation for Residents
Penalty
Summary
The facility failed to ensure the accuracy of Minimum Data Sets (MDS) for two residents, which are crucial for reflecting residents' health status and care needs. For Resident 73, the MDS inaccurately documented the resident's health status by omitting a terminal diagnosis, despite the resident receiving hospice services and having a prognosis of six months or less to live. This discrepancy was acknowledged by the MDS Nurse, who confirmed that the MDS should have reflected the resident's terminal condition. For Resident 18, the MDS inaccurately recorded the severity of a fall-related injury. The resident had been hospitalized for a fall that resulted in a right femoral fracture, a major injury requiring surgical intervention. However, the MDS incorrectly coded the fall as resulting in no major injury. The Director of Nursing Services confirmed that the MDS should not have indicated zero major injuries, highlighting a failure to accurately document the resident's condition.
Inaccurate PASRR Assessment for Resident's Mental Health
Penalty
Summary
The facility failed to ensure that a Pre-Admission Screening and Resident Review (PASRR) assessment accurately reflected the mental health diagnoses of a resident. The resident, who was cognitively intact, had diagnoses of anxiety and depressive disorders and was receiving antidepressant, antianxiety, and antipsychotic medications. However, the Level I PASRR assessment indicated no indicators of serious mental illness, including depressive and anxiety disorders, despite the resident being actively treated for these conditions. This discrepancy was acknowledged by the Director of Nursing, who stated that the PASRR needed to be redone.
Deficiency in Opioid Management Care Plan
Penalty
Summary
The facility failed to develop and implement a comprehensive and individualized care plan for Resident 18, who was admitted with a fall and fracture of the right femur, requiring surgical intervention. The resident was cognitively intact and on a scheduled pain medication regimen, including opioids, as well as non-medication interventions for pain. However, the care plan reviewed did not specify or include opioid-specific interventions or monitoring for signs and symptoms related to opioid use. Staff members, including an LPN and an Advanced Registered Nurse Practitioner, acknowledged that the care plan should have included a specific section on opioids, indicating a deficiency in addressing the resident's needs related to opioid management.
Failure to Conduct Timely Care Conferences and Update Care Plans
Penalty
Summary
The facility failed to conduct timely care conferences for two residents, leading to deficiencies in care planning and potential risks to resident well-being. Resident 10, who was admitted with severe cognitive impairment and medical conditions including Crohn's disease and cellulitis, did not have a care conference documented after admission. Staff responsible for arranging and documenting care conferences acknowledged that an initial care conference was not conducted within 48 hours of admission, as required. Resident 38, who was admitted with major depressive disorder, muscle weakness, pressure ulcers, and severe protein-calorie malnutrition, also experienced deficiencies in care planning. Despite being referred to hospice care and having changes in their medical condition, such as the removal of a urinary catheter, the facility's care plan was not updated to reflect these changes. Observations confirmed the absence of a catheter, contradicting the care plan. The Director of Nursing Services admitted that care plans were not updated as care needs changed, indicating a lack of timely revisions to care plans.
Deficient Pressure Ulcer Care and Monitoring
Penalty
Summary
The facility failed to provide adequate pressure ulcer care for two residents, leading to deficiencies in treatment and monitoring. Resident 69, who was admitted with a stage 2 pressure ulcer and other health issues, reported that their dressing was not consistently changed or monitored. Despite orders for regular dressing changes and monitoring, the resident experienced periods without a dressing, and staff failed to document or perform as-needed dressing changes. The resident expressed that the ulcer was painful and that staff assistance with turning was only provided upon request. Observations confirmed that the dressing was often not in place, and staff acknowledged that proper procedures were not followed. Similarly, Resident 40, who had a stage 4 pressure ulcer, was found without a dressing during a wound care observation. The resident was unaware of when the dressing had fallen off, and staff admitted that nursing assistants did not report missing dressings. The care plan for Resident 40 required monitoring of the dressing to ensure it was intact, but this was not adhered to. The Director of Nursing Services confirmed that the expectation was for nursing staff to ensure dressings were in place, highlighting a failure in communication and adherence to care protocols.
Inadequate Pain Management for a Resident
Penalty
Summary
The facility failed to provide adequate pain management for a resident who required such services, leading to a deficiency in care. The resident, who was admitted with a fall and fracture of the right femur requiring surgical intervention, was on a scheduled pain medication regimen. Despite reporting zero pain in 34 out of 45 assessments, the resident continued to receive scheduled pain medication without reassessment of its effectiveness. The resident expressed feeling overly tired and attributed this to the pain medication, indicating a potential need to taper the medication. Additionally, non-pharmacological interventions were inconsistently documented, with several days lacking any recorded interventions. Staff interviews revealed gaps in the facility's pain management practices. A Licensed Practical Nurse (LPN) acknowledged that the pain regimen should have been reassessed daily and that opioids should have been withheld if the resident appeared overly sedated. However, the LPN did not notify the provider about the resident's lack of pain despite receiving scheduled opioids. Furthermore, an Advanced Registered Nurse Practitioner was unaware of any symptoms of oversedation or the absence of as-needed opioid doses since a specific date. These oversights contributed to the deficiency in providing safe and appropriate pain management for the resident.
Medication Error Rate Exceeds Acceptable Threshold
Penalty
Summary
The facility failed to maintain a medication error rate of less than five percent, resulting in an error rate of eight percent. This deficiency was observed when Staff P, an LPN, incorrectly administered medications to Resident 39 during a medication pass. Specifically, Staff P administered three drops of cyclosporine ophthalmic emulsion into the resident's left eye and two drops into the right eye, contrary to the physician's order of one drop in each eye. Additionally, Staff P administered two drops of Refresh ophthalmic solution into the right eye and four drops into the left eye, instead of the prescribed one drop in each eye. Furthermore, Staff P did not adhere to the manufacturer's guidelines, which required a 15-minute interval between administering cyclosporine and any lubricating eye drops, and a 5-minute interval for Refresh eye drops. Staff P admitted to not knowing about the required separation time between the eye drops, which contributed to the medication errors. These actions placed residents at risk for ineffective treatment and potential adverse side effects.
Deficiency in Laboratory Services for UTI Diagnosis
Penalty
Summary
The facility failed to ensure the quality and timeliness of laboratory services for a resident with a urinary catheter, leading to delays in diagnosing a urinary tract infection (UTI). The resident, who was cognitively moderately impaired, had an elevated white blood cell count (WBC) reported on multiple occasions, indicating a potential infection. However, there were significant delays and issues with urine sample collection and processing. On several occasions, urine samples were either not successfully completed, not sent to the lab, or were rejected by the lab due to being frozen. These issues resulted in a delay in obtaining a proper diagnosis and starting appropriate treatment for the resident's UTI. Staff interviews revealed a lack of proper procedures for handling urine samples, contributing to the deficiencies. A Licensed Practical Nurse (LPN) admitted to placing urine samples on ice, which led to them being frozen and subsequently rejected by the laboratory. The Director of Nursing Services (DNS) acknowledged awareness of the issue and mentioned a recent change in laboratory procedures, but was unable to demonstrate proper storage conditions for urine samples. Additionally, an Advanced Registered Nurse Practitioner (ARNP) noted a lack of follow-up on missing lab results, indicating a breakdown in communication and persistence in obtaining necessary diagnostic information.
Failure to Notify Provider of Abnormal Lab Results
Penalty
Summary
The facility failed to promptly notify the provider of laboratory results that were outside of normal ranges for a resident who was reviewed for urinary catheter or Urinary Tract Infection (UTI). The resident, who was cognitively moderately impaired and had an indwelling urinary catheter, was admitted to the facility and had a urinalysis and culture ordered. The sample was collected and received by the lab, and the results were reported to the facility. However, there was no documentation of provider notification from the date the facility received the results to the date the provider first documented the positive UTI. The facility's policy required nurses to document the receipt of lab results, provider notification, and any new orders received. For non-critical abnormal labs, the provider should be called with the results, and for critical values, repeat calls should occur if there is no response. In this case, the Advanced Registered Nurse Practitioner had to look up the results themselves, as there was no notification from the staff. The Director of Nursing Services could not provide documentation of provider notification by staff, only a provider progress note showing the provider discussed the urinalysis results with the patient.
Dietary Staff Training Deficiency
Penalty
Summary
The facility failed to ensure that sufficient dietary staff were trained and competent in preparing and providing pureed diets for two residents who required such diets. This deficiency was identified through observation, interview, and record review. Both residents were admitted with orders for regular, pureed diets with thin liquids. However, during a breakfast meal observation, they were served regular texture scrambled eggs and chopped sausage, along with pureed pancakes, which did not comply with their dietary requirements. The error occurred due to staffing issues and lack of proper training. The Head Cook/Dietary Manager in Training, Staff D, explained that the facility had a process for triple-checking meal trays for accuracy, but this process failed. A new cook, who was supposed to be trained on reading resident tray cards, was not supervised adequately because the dietary aide called off, and Staff D had to assume additional duties. Furthermore, the Certified Dietary Manager from another facility, who was training Staff D, had not arrived, leading to insufficient oversight and resulting in the diet texture errors.
Failure to Accommodate Resident's Dietary Needs and Allergies
Penalty
Summary
The facility failed to ensure that Resident 67, who was cognitively intact and had a known allergy to apples, received meals that accommodated their dietary needs and preferences. Despite being on a cardiac diet and having an allergy to apples, Resident 67 was repeatedly observed with unopened containers of apple juice on their bedside table and breakfast tray over several days. A Life Enrichment Evaluation documented the apple allergy, but this information was not reflected in the electronic health record. During an interview, the Dietary Manager/Cook and the Regional Registered Dietitian acknowledged that they were informed of resident preferences and allergies upon admission, but the Dietary Manager had only been made aware of Resident 67's apple allergy on the morning of the interview.
Failure to Address Nutritional Needs and Weight Loss
Penalty
Summary
The facility failed to timely identify, assess, and address the nutritional needs of two residents, leading to significant weight loss. Resident 69, who had a history of bariatric surgery and severe protein-calorie malnutrition, experienced a 23.75% weight loss after admission. The facility did not consistently obtain weekly weights as ordered, and there was a lack of follow-up on the significant weight discrepancy between the hospital and facility records. Staff failed to notify the physician or document any interventions, despite alerts indicating weight loss concerns. Resident 61 also experienced unaddressed weight loss due to the facility's failure to honor dietary preferences. Despite multiple reports of food dislikes and a documented weight loss of 6.5% over 90 days, the facility did not implement the Registered Dietician's recommendations for increased protein and milk intake. The resident's food preferences were not recorded in the dietary system, leading to continued provision of meals that the resident disliked, contributing to poor meal intake and further weight loss. The facility's inaction in both cases resulted in delayed nutritional interventions and unmet nutritional needs. Staff failed to follow established protocols for monitoring and addressing weight loss, and there was a lack of communication and documentation regarding the residents' nutritional status and preferences. These deficiencies placed the residents at risk for continued and unidentified weight loss.
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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