Regency Wenatchee Rehabiliation & Nursing Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Wenatchee, Washington.
- Location
- 1326 Red Apple Rd, Wenatchee, Washington 98801
- CMS Provider Number
- 505382
- Inspections on file
- 32
- Latest survey
- March 13, 2026
- Citations (last 12 mo.)
- 3
Citation history
Health deficiencies cited at Regency Wenatchee Rehabiliation & Nursing Center during CMS and state inspections, most recent first.
Health information was left visible above the beds of several residents, including diet instructions and diagnoses such as dysphagia, stroke, Parkinson’s disease, heart failure, and diabetes. One resident with severe cognitive impairment and total care needs also had a swallowing-strategy sign posted above the bed, and an NA was observed calling the resident “baby” during meal assistance. The Interim DON acknowledged the posted signs and stated the resident could not consent to the sign above the bed.
The facility failed to notify the LTC Ombudsman of two resident discharges. One resident admitted with sepsis had intact cognition at discharge, and another admitted with influenza A had moderately impaired cognition at discharge; both were discharged home, but no Ombudsman notification was documented. The Admissions Manager stated notifications were only made for hospital transfers, while the Administer in Training stated every discharge should have been reported.
The facility failed to identify and address accident hazards for two residents, resulting in one resident sustaining a third-degree burn from hot soup and another experiencing multiple falls without thorough investigation or consistent intervention. Staff did not assess the ability to handle hot liquids or adequately investigate the causes of repeated falls, leading to increased risk of injury and compromised resident safety.
The facility did not provide required bed hold notifications to residents or their representatives during hospital transfers and failed to notify the LTC Ombudsman of resident discharges. Staff interviews revealed that residents and their representatives were not informed about bed hold options, and the medical records staff was unaware of the obligation to notify the Ombudsman, resulting in lapses in communication and documentation for several residents.
The facility did not complete or properly document baseline care plans within 48 hours of admission for several residents with complex medical needs, resulting in missing or incomplete information such as care goals, physician and dietary orders, and treatment plans. Staff interviews indicated that recent staffing changes and lapses in following procedures led to these deficiencies.
The facility did not designate a specific IDT member to coordinate hospice care or maintain required documentation, including hospice election forms and physician certifications, for two residents receiving hospice services. Both residents' records lacked evidence of a responsible staff member and necessary hospice care plans, and staff interviews confirmed a lack of awareness and adherence to required processes for hospice coordination.
A resident with multiple mental health diagnoses, including dementia, delirium, hallucinations, anxiety, and depressive disorder, was admitted without an accurate PASARR Level I screening. The form failed to identify serious mental illness indicators and did not trigger a required Level II evaluation, despite the resident's documented conditions. Both the Social Services Director and Administrator acknowledged the oversight in the review process.
The facility did not follow CDC and internal policy for monitoring the temperature of a refrigerator storing influenza and pneumococcal vaccines, recording temperatures only once daily instead of the required twice daily. The issue was attributed to the use of an incorrect temperature log, as confirmed by the Regional Clinical Director.
A resident who was cognitively intact and required an additional pneumococcal vaccine dose was not offered the vaccine, nor was there documentation of consent, refusal, or education on risks and benefits. Staff interviews confirmed that the required process for offering and documenting the pneumococcal vaccine, including education, was not followed.
A resident with impaired cognition and recent admission reported missing cash, of which only a portion was recovered by staff. The facility did not document the grievance, failed to investigate the full amount reported missing, and did not provide the resident with updates or a written resolution, contrary to facility policy.
A nursing assistant witnessed a registered nurse verbally and physically abuse a resident with moderate cognitive impairment and other medical conditions, but did not report the incident to the State Agency within the required two-hour timeframe. The delay in reporting was confirmed by the DON, resulting in non-compliance with mandated abuse reporting policies.
Two residents were not adequately protected or thoroughly investigated following allegations of abuse and multiple falls. In one case, a resident with cognitive impairment and a recent amputation experienced alleged physical and verbal abuse by an RN, but the incident was not promptly reported or fully investigated, and the resident was not immediately protected. In another case, a resident with dementia and joint disease had multiple unobserved falls, but the facility did not complete thorough investigations or consistently update care interventions. Leadership acknowledged these deficiencies in both protection and investigative processes.
Nursing staff failed to follow professional standards for central line management by not documenting required measurements, moving a PICC line during a dressing change, and continuing IV infusions after line migration without provider notification. Additionally, staff did not process or implement physician orders for wound care for a resident with a necrotic toe, resulting in missed dressing changes and lack of prescribed interventions.
A facility failed to maintain a safe environment by placing a 1500-watt oil-filled space heater in a resident's room after the thermostat malfunctioned. The heater was hot to the touch, posing a risk of injury. The Maintenance Director placed the heater without notifying the Administrator, who stated that the correct procedure was to relocate the resident until the issue was fixed.
The facility failed to document and incorporate Advanced Directives (ADs) into the care plans for three residents, placing them at risk of not having their end-of-life care preferences followed. Interviews revealed that the Social Services Director did not have a process for follow-up if an AD was refused, and the facility administrator expected ADs to be addressed on admission and during quarterly care conferences, which was not consistently done.
The facility failed to conduct proper IDT care conferences for two residents, with one not having a care conference for over a year and another not since 2022. Additionally, required IDT members were not present at care conferences for two other residents. Staff interviews revealed inconsistencies in the understanding and execution of IDT care conferences.
The facility failed to ensure restorative therapy services, including the consistent use of braces and splints, were implemented for four residents. One resident with Parkinson's disease and contractures did not receive consistent exercises or adjustments to their new wheelchair, leading to immobility. Another resident with a stroke and hand contracture did not have a documented restorative program or wearing schedule for their hand brace. A third resident with dementia had not been assessed for therapy or placed on a restorative program since admission. Lastly, a resident requiring an ankle-foot brace did not have it consistently applied as per physician's orders.
The facility failed to ensure proper administration and documentation of enteral feedings and fluid intake via g-tube for a resident with difficulty swallowing and malnutrition. Staff did not check residuals or ask about symptoms, and documentation showed discrepancies in the amount of formula and free water administered, putting the resident at risk for dehydration and fluid imbalance.
The facility failed to maintain a medication error rate of less than five percent, resulting in an error rate of 28.57%. Errors included not priming insulin pens before administration for two residents with diabetes and administering medications three hours late for another resident. Staff admitted to not following proper procedures, and the Regional Director of Nursing Services acknowledged the need for correct insulin administration and adherence to medication schedules.
The facility failed to verify licensure for a NAR who worked with an expired license and did not provide documented annual abuse and neglect training for five staff members. This lack of oversight and training placed residents at risk for unrecognized abuse and unmet care needs.
The facility failed to complete a self-administration of medications assessment for a resident with Alzheimer's and dementia, leading to medications being left unattended in the resident's room. Staff admitted to leaving medications, which the resident sometimes destroyed, resulting in potential missed doses. An assessment was only completed after surveyor intervention, deeming the resident unsafe for self-administration.
The facility failed to provide a comfortable and appropriate length bed for a resident with lower spine degeneration and left foot drop. Despite multiple observations of the resident's feet pressing against the footboard and causing skin issues, no immediate solution was provided, as the only available bed extender was in use by another resident.
The facility failed to provide a Skilled Nursing Facility (SNF) Advance Beneficiary Notice (ABN) to a resident when their Medicare Part A skilled nursing and rehabilitation services ended. The resident, who required limited assistance for activities of daily living and had intact cognition, remained in the facility beyond the last covered day without receiving the required ABN, preventing them from making informed financial and care decisions.
The facility failed to maintain a homelike environment, with multiple rooms showing significant physical damage and improper storage of nutritional supplies. Additionally, two residents reported excessively noisy beds that disturbed their sleep, an issue acknowledged by staff but without a current plan for resolution.
A resident with dementia had a missing hearing aid, and the facility failed to follow its grievance procedure to resolve the issue. The resident's representative reported the missing item, but the Activities Director and Administrator did not document or track the grievance, leading to no resolution.
The facility failed to provide a written bed hold notice to a resident at the time of transfer to the hospital, as required by their policy. The resident, who had chronic kidney disease and required extensive assistance, was transferred without receiving the necessary documentation. Interviews confirmed that the facility's process was not being followed correctly.
The facility failed to ensure the PASARR was accurately completed for a resident admitted with depression and insomnia, placing the resident at risk of inappropriate placement and unmet care needs. Staff interviews indicated that the Social Services Director was responsible for reviewing PASARRs, but this was not done correctly.
A resident with contractures and Parkinson's disease struggled to eat independently due to the facility's policy requiring meal assistance only in the dining room. Despite the resident's preference to eat in their room, staff did not provide the necessary help, leading to frustration and difficulty during meals.
The facility failed to follow physician orders for bowel and pain management for a resident with constipation and fractures. The resident experienced multiple shifts without a bowel movement, and pain medication was inconsistently administered, leading to unmet care needs and potential negative health outcomes.
The facility failed to ensure pre/post dialysis communication forms and vital signs were completed for a resident requiring dialysis. The medical record showed inconsistent documentation, and staff interviews confirmed that vital signs were not consistently monitored after dialysis, and communication forms were often not completed or returned.
The facility failed to provide trauma-informed care for a resident with a history of trauma and loss. Despite the resident's disclosure of past trauma and the need for a care plan, no interventions were implemented. Staff changes and training issues contributed to this oversight, putting the resident at risk for re-traumatization and a decline in psychosocial well-being.
The facility failed to serve bedtime snacks to three residents, including those with diabetes, leading to inconsistent snack offerings and potential nutritional risks. Staff interviews and records revealed that snacks were available but not routinely offered, and meal service times created a long gap between dinner and breakfast.
The facility failed to ensure proper disposal of trash, as observed over several days with the dumpster lids left open and unsecured trash bags, including a mattress. Interviews revealed that staff were unaware of the requirement to keep the dumpster lids closed, leading to unsanitary conditions.
Resident health information left visible and staff used disrespectful address
Penalty
Summary
The facility failed to protect the privacy of health information for four residents and also failed to ensure one resident was addressed respectfully by staff. The report states that the facility’s Resident Rights policy required residents to be treated with dignity and respect and to have their rights honored. Surveyors found that health information was posted in residents’ rooms where it was visible to anyone entering the room, and staff also used a pet name when speaking to one resident instead of addressing the resident by name. Resident 5 had diagnoses including dementia, Parkinson’s disease, and dysphagia, and the comprehensive assessment showed severe cognitive impairment with total assistance needed for dressing, grooming, toileting, mobility, and bathing. During observation, a handwritten sign titled “Swallow Strategies” was taped above the resident’s bed and displayed specific swallowing instructions. Staff U was observed assisting the resident with a meal and repeatedly referred to the resident as “baby.” On later observations, the same sign remained above the bed, and the Interim DON stated the resident was unable to give consent for the sign to be posted and that it was not appropriate for staff to call the resident “baby.” Resident 3, Resident 23, and Resident 41 also had signs posted above their beds that displayed diet information and diagnoses, including dysphagia and related diet instructions such as puree or thickened liquids. Resident 3 had diagnoses including stroke, cognitive communication deficit, dysphagia, and need for assistance with personal care, and was observed with a yellow sign hanging above the bed listing diet and diagnoses. Resident 23 had diagnoses including heart failure, dysphagia, and diabetes, and was observed with a yellow sign above the bed showing a puree diet and dysphagia diagnoses. Resident 41 had diagnoses including Parkinson’s disease, dysphagia, and dysphonia, and was observed with a sign above the bed stating thickened liquids were required. Staff interviewed about the signs stated they were unsure who placed them there and that several residents had similar signs posted.
Failure to Notify Ombudsman of Resident Discharges
Penalty
Summary
The facility failed to ensure that notice of resident transfers or discharges was provided to the representative of the Office of the State Long Term Care Ombudsman for 2 of 5 residents reviewed for discharge. Resident 52 was admitted with sepsis, had intact cognition on the discharge assessment, and was later discharged home, but the Ombudsman notification list for February and March 2026 showed no notification of the discharge. Resident 61 was admitted with influenza A, had moderately impaired cognition on the discharge assessment, and was later discharged home, but the Ombudsman notification list for February and March 2026 also showed no notification of the discharge. During interview, the Admissions Manager stated they were responsible for notifying the Ombudsman of discharges but only notified the Ombudsman if a resident was transferred to the hospital. The Admissions Manager stated they were not aware of the requirement to notify the Ombudsman of all facility discharges. The Administer in Training stated the correct process was for the Ombudsman to be notified of every resident discharge and stated the Admissions Manager did not follow the correct process.
Failure to Prevent Accidents and Investigate Falls
Penalty
Summary
The facility failed to identify and mitigate accident risks for two residents, resulting in harm and increased risk of injury. One resident, who was cognitively intact but required moderate to maximum assistance for activities of daily living following a recent pelvic fracture, suffered a third-degree burn to the left thigh when hot soup was served on an overbed table. The resident attempted to pull the tray closer, causing the soup to spill onto their lap. The soup had been held at a temperature of 187 degrees Fahrenheit in the kitchen, and there was no process in place to ensure the temperature was safe for direct consumption or handling by residents. The facility did not assess the resident's ability to safely handle hot liquids after the incident, nor did they have protocols to check the temperature of microwaved food before serving. Additionally, the facility failed to provide consistent supervision and thorough investigation following multiple falls experienced by another resident with dementia, degenerative joint disease, and moderately impaired cognition. This resident had nine falls over five months, with only two of the incidents resulting in updated interventions to reduce fall risk. For the seven unobserved falls, there were no witness statements or thorough investigations to determine the cause or to rule out abuse or neglect. The care plan for this resident identified multiple risk factors for falls, but interventions were not consistently updated after each incident. Interviews with facility staff, including the Administrator, Director of Nursing, and Regional Clinical Director, confirmed that no follow-up assessments or comprehensive investigations were conducted after the incidents. The lack of individualized assessment for handling hot liquids and insufficient investigation and intervention following repeated falls contributed to ongoing risks for the residents involved.
Failure to Provide Bed Hold Notices and Notify LTC Ombudsman During Transfers and Discharges
Penalty
Summary
The facility failed to provide required written notices of bed hold policies to residents or their representatives at the time of hospital transfers, and did not send notifications of transfers or discharges to the Office of the State LTC Ombudsman for four residents reviewed for the discharge process. Specifically, for two residents who were transferred to the hospital, there was no documentation that either the residents or their representatives received information about the bed hold policy, nor were they contacted during the hospital stay to discuss the option of holding the resident's bed. Interviews confirmed that neither the residents nor their representatives recalled receiving such notifications or being informed about the possibility of bed holds. Additionally, for two other residents who were discharged, there was no documentation that the LTC Ombudsman was notified of their discharge, as required. Staff interviews revealed that the facility's process for notifying the Ombudsman had lapsed, with the current medical records staff unaware of the requirement to send such notifications since taking their position. The administrator acknowledged that the facility had not been sending out these notifications as required. Facility staff also indicated a misunderstanding of the requirements, believing that providing a bed hold policy in the transfer packet or automatically holding beds for Medicaid residents was sufficient to meet regulatory obligations. However, there was no evidence of individualized follow-up or confirmation that residents or their representatives were informed of their rights or the specifics of the bed hold policy at the time of transfer or discharge.
Failure to Complete Baseline Care Plans Within 48 Hours of Admission
Penalty
Summary
The facility failed to develop baseline care plans (BCPs) within 48 hours of admission for six out of ten residents reviewed for new admissions. The BCPs were either incomplete or missing, lacking essential elements such as resident-specific goals, physician orders, dietary orders, treatment plans, and social service needs. This was contrary to the facility's own policy, which required a BCP to be developed within 48 hours of admission to include the minimum healthcare information necessary for resident care. For several residents, the BCPs that were completed did not include required information. For example, one resident admitted with palliative care needs, Alzheimer's disease, severe malnutrition, and hospice services had a BCP that omitted resident-specific goals and interventions for dietary, social services, and hospice care. Another resident with sepsis and a PICC line for antibiotic therapy had a BCP that lacked goals and interventions for dietary orders, physician orders, social services, and PICC line care. Additional residents with complex medical needs, such as stroke, surgical aftercare, and amputation, either had incomplete BCPs or no BCP documentation at all. Interviews with facility staff revealed that recent staffing changes contributed to gaps in the completion of BCPs. Staff acknowledged that the process for developing BCPs was not being followed as required, and some BCPs were simply missed. The facility's process was described as including a review of the BCP within 24 hours of admission, but this was not consistently implemented for the residents reviewed.
Failure to Designate Hospice Care Coordinator and Maintain Required Documentation
Penalty
Summary
The facility failed to designate a specific member of the interdisciplinary team (IDT) to coordinate care and communication with hospice providers for two residents receiving hospice services. Facility policy and a written agreement required the identification of a responsible party for this coordination, as well as the implementation of a collaborative care plan between the facility and hospice. However, record reviews for both residents revealed no documentation of a designated staff member responsible for coordinating hospice care, nor evidence of required hospice documentation such as the hospice election form, physician certification of terminal illness, or the most recent hospice care plan. For one resident with Alzheimer's disease, severe malnutrition, and significant cognitive impairment, the medical record lacked documentation of a designated coordinator, hospice election form, physician certification, and a current hospice care plan. The resident's care plan referenced hospice services but did not specify what those services were or include the hospice care plan. For the second resident, who had cancer, severe malnutrition, and was cognitively intact, similar documentation gaps were found, including the absence of a designated coordinator, hospice election form, and physician certification. Interviews with facility staff and hospice personnel confirmed that the process for coordinating hospice care was not followed. Staff were unaware of the required documentation and the need for a designated coordinator, and communication between the facility and hospice was inconsistent. The administrator acknowledged that there was no appointed staff member for hospice coordination and was not aware of the regulatory requirement to designate one in writing.
Failure to Ensure Accurate PASARR Screening for Resident with Mental Health Diagnoses
Penalty
Summary
The facility failed to ensure the accuracy of the Preadmission Screening and Resident Review (PASARR) process for a resident with multiple mental health diagnoses. According to facility policy, the admission coordinator or designee is required to request and review a PASARR Level I screening prior to admission, with Social Services responsible for verifying its accuracy. For one resident, the PASARR Level I form indicated no serious mental illness indicators and did not trigger a Level II evaluation, despite the resident having documented diagnoses of dementia, delirium, hallucinations, anxiety, and depressive disorder. The comprehensive assessment also showed the resident had severely impaired cognition, required substantial assistance with activities of daily living, and was receiving hospice services. During interviews, the Social Services Director acknowledged responsibility for reviewing the PASARR form and admitted the form was filled out incorrectly, stating it should have been referred for a Level II evaluation prior to admission. The Administrator confirmed that both the admissions coordinator and Social Services Director were responsible for reviewing the PASARR forms and was unsure how the error was missed. The deficiency was identified through observation, interview, and record review, and was cited under WAC 388-97-1915(1)(2)(a-c).
Failure to Monitor Vaccine Refrigerator Temperatures per CDC Guidelines
Penalty
Summary
The facility failed to adhere to CDC guidance and its own policy regarding the monitoring of vaccine storage temperatures. Specifically, the refrigerator used to store influenza and pneumococcal vaccines was only monitored for temperature once daily, as evidenced by the temperature log posted on the refrigerator for the months of March, April, and May. According to CDC guidance and the facility's policy, temperature monitoring should occur at least twice daily when a digital data logger is not used. During an observation, it was noted that the incorrect temperature log was posted for staff to complete, resulting in the failure to meet the required monitoring frequency. This deficiency was confirmed during an interview with the Regional Clinical Director, who acknowledged that the vaccines required twice daily monitoring and that the wrong log had been used.
Failure to Offer and Document Pneumococcal Vaccine and Education
Penalty
Summary
The facility failed to ensure that a resident was offered the pneumococcal vaccine, nor was there documentation of the resident's refusal or acceptance of the vaccine, or education on the risks and benefits. The facility's policy required that residents be offered the pneumococcal vaccine, with consent obtained and education provided, unless medically contraindicated. However, review of the resident's medical record showed that although the resident was assessed as cognitively intact and able to make their needs known, there was no evidence that the vaccine was offered or that education was provided. The resident had a history of receiving one pneumococcal vaccine, but according to the PneumoRecs VaxAdvisor tool, an additional dose was required to be up-to-date, and this was not addressed by the facility. Interviews with the resident, the DON, and the Regional Clinical Director confirmed that the correct process was not followed. The resident stated they had not been offered or educated about the pneumococcal vaccine and was unaware of the risks and benefits. Both the DON and the Regional Clinical Director acknowledged that the resident needed another dose and that the required process for offering and documenting the pneumococcal vaccine, including education, was not followed.
Failure to Promptly Resolve and Document Resident Grievance Regarding Missing Money
Penalty
Summary
The facility failed to ensure that grievances voiced by a resident were promptly resolved and that the resident was appropriately updated on the progress and conclusion of the grievance. Specifically, a resident who was admitted with multiple medical conditions, including pneumonia, insomnia, sepsis with septic shock, and delirium, reported that $193 in cash went missing shortly after admission. Although $93 was found by staff in the laundry and turned over to the Administrator, the resident stated that an additional $100 was still missing. The resident reported discussing the missing money with the Administrator, who indicated that an investigation would be conducted, but the resident did not receive any further updates or the missing funds. Interviews with staff revealed that the process for handling found money involved filling out a grievance form and submitting the money to the Administrator. However, there was no documentation in the facility's grievance log regarding the missing money, and the Administrator acknowledged that a grievance form was not completed and that there was no documentation of investigative steps or resolution. The facility's policy required prompt efforts to resolve grievances, keep residents informed, and provide written decisions, but these procedures were not followed in this case.
Failure to Timely Report Witnessed Abuse Incident
Penalty
Summary
Nursing staff failed to immediately report a witnessed incident of verbal and physical abuse involving a resident with moderate cognitive impairment, right below the knee amputation, anxiety, long-term pain, and peripheral vascular disease. The incident occurred when a registered nurse, while providing care, grabbed the resident's arm, shoved them, and used profane language after the resident did not turn quickly enough during incontinent care. The abuse was witnessed by a nursing assistant, who did not report the incident to other staff or the State Agency until several hours later, outside the required two-hour reporting window outlined in facility policy. The Director of Nursing Services confirmed that the report to the State Agency was not made until after they were informed of the incident, which was not in accordance with the facility's policy requiring immediate reporting of abuse allegations. The failure to promptly report the witnessed abuse resulted in non-compliance with mandated reporting requirements and placed the resident at risk for unidentified and potentially ongoing abuse.
Failure to Protect Residents and Conduct Thorough Abuse/Neglect Investigations
Penalty
Summary
The facility failed to immediately implement effective protective measures and conduct thorough investigations in response to allegations of abuse and neglect for two residents. In the case of one resident with a right below-knee amputation, moderate cognitive impairment, and chronic pain, a nursing assistant reported witnessing a registered nurse physically and verbally abuse the resident during medication administration. The nursing assistant delayed reporting the incident due to fear of the nurse, and did not take steps to protect the resident from further harm. The alleged perpetrator was not immediately removed from access to the resident, and the resident’s representative was not promptly or thoroughly interviewed as part of the investigation. The investigation was incomplete, with staff interviews failing to corroborate the initial allegation, and the process for resident protection and data collection was not fully followed according to facility policy. For another resident with dementia and degenerative joint disease, the facility failed to thoroughly investigate a series of nine falls, seven of which were unobserved, over a five-month period. The incident reports for these falls lacked witness statements and did not document that abuse or neglect had been thoroughly ruled out as potential causes. The resident’s care plan, which identified a high risk for falls due to multiple medical and cognitive factors, was only updated with additional interventions after two of the nine falls, indicating a lack of comprehensive follow-up and prevention efforts after each incident. Interviews with facility leadership confirmed that investigations into the causes of the falls were not thorough and that limited interventions were implemented to prevent future incidents. The facility’s actions did not align with its own policy, which requires immediate protection of residents and comprehensive investigation of all alleged abuse, neglect, or unexplained injuries. These failures resulted in residents being at risk for unidentified abuse, unmet care needs, and potential continued exposure to abuse or neglect.
Failure to Follow Professional Standards for Central Line and Wound Care Management
Penalty
Summary
The facility failed to ensure that services provided met professional standards of practice in two key areas: management of a central vascular access device (CVAD) for one resident and processing and following physician orders for wound care for another resident. For the resident with a peripherally inserted central catheter (PICC) line, the facility's own guidance required documentation of external catheter length and upper arm circumference upon admission and during dressing changes, as well as the use of a securement device to prevent migration. However, the admission assessment did not include these measurements, and during a dressing change, the nurse moved and rotated the PICC line multiple times without a securement device in place. The external catheter length was found to have increased from six to nine centimeters, indicating migration, but IV medication continued to be infused through the line despite this finding and without provider notification, contrary to facility policy and professional standards. For the second resident, who was readmitted with a right below-the-knee amputation and a necrotic fourth toe on the left foot, the hospital transfer orders specified a dressing change every other day with betadine application and placement of gauze between the affected toes. Upon review, these orders were not processed or initiated by nursing staff, and the resident did not have a dressing or gauze in place for the necrotic toe. Nursing staff were only monitoring the toe daily and had not reviewed or implemented the wound care orders from the hospital. The omission was confirmed by both the nurse responsible for the admission assessment and the regional clinical director, who acknowledged that the transfer orders were missed and not followed. These failures resulted in residents not receiving care in accordance with professional standards and physician orders. The lack of proper documentation, assessment, and adherence to protocols for central line management and wound care placed residents at risk for improper medication delivery and delays in treatment, as evidenced by the continued use of a migrated PICC line and the absence of prescribed wound care interventions.
Improper Use of Space Heater in Resident Room
Penalty
Summary
The facility failed to ensure a resident environment free from accident hazards due to the placement of a 1500-watt oil-filled indoor electric space heater in a resident's room. During an observation, the space heater was found on the right side of the sink, turned on medium heat, and was hot to the touch, posing a risk of avoidable accidents or injury. Staff B, the Maintenance Director, admitted to placing the heater in the room after the thermostat stopped working and was unaware of any policy regarding space heaters. Staff B did not inform the Administrator about the heater placement. The Administrator stated that the correct procedure was to move the resident to another room until the heating issue was resolved, which Staff B failed to follow.
Failure to Address and Document Advanced Directives
Penalty
Summary
The facility failed to address required documentation for Advanced Directives (ADs) and incorporate them into the care planning process for three residents. Resident 6 had a Durable Power of Attorney for Healthcare (DPOA) but no preferences for end-of-life care documented in their care plan. Resident 15, who had severe cognitive impairment and required significant assistance with activities of daily living, did not have an AD in place, and their representative stated that the facility had not discussed formulating an AD or end-of-life preferences. Resident 16, who had moderate cognitive impairment and physical deficits due to a stroke, also did not have an AD, and there was no documentation showing that the facility offered assistance in formulating one or included their end-of-life care wishes in the care plan. Interviews with staff revealed that the Social Services Director (SSD) was responsible for addressing ADs upon admission but did not have a process for following up if an AD was refused. The SSD also stated they were not aware of the specifics regarding the ADs for Residents 6, 15, and 16 because they were not employed at the time those ADs were completed. The facility administrator expected ADs to be addressed on admission and followed up during quarterly care conferences, but this was not consistently done. These failures placed the residents at risk of not having their end-of-life care preferences and decisions followed.
Failure to Conduct Proper IDT Care Conferences
Penalty
Summary
The facility failed to ensure interdisciplinary team (IDT) care conferences were completed for two residents reviewed for comprehensive care planning. Resident 18, who was admitted with diagnoses including Parkinson's disease, kidney disease, and depression, had not had a care conference since 03/29/2022, despite the representative's statement that they had not been invited to a formal meeting for at least the last year. Similarly, Resident 6, admitted with diagnoses including Parkinson's disease, heart failure, and contractures, had not had a care conference since 04/14/2022, with the representative expressing a desire for more frequent meetings to discuss issues. The facility also failed to ensure that IDT care conference meetings included the required team members for two other residents. Resident 14, admitted with Alzheimer's disease and dementia, had a quarterly IDT care conference on 03/15/2024 attended only by the resident and the Social Services Director (SSD), with no other IDT members present. Resident 25, admitted with a right hip fracture, right clavicle fracture, and atrial fibrillation, had an IDT care conference on 03/15/2024 attended only by the resident, their representative, and the SSD, again with no other required IDT members present. Interviews with staff revealed inconsistencies in the understanding and execution of IDT care conferences. Staff E, the SSD, believed it was sufficient to gather information from various departments and document it without their attendance at the meetings. Staff A, the Administrator, and Staff B, the Regional Director of Nursing Services, acknowledged that all required IDT members should attend the care conferences, but this was not being consistently practiced. This lack of proper IDT involvement and failure to hold regular care conferences placed residents at risk for unmet care needs.
Failure to Implement Restorative Therapy Services
Penalty
Summary
The facility failed to ensure restorative therapy services, including the consistent use of braces and splints, were implemented for four residents. Resident 6, diagnosed with Parkinson's disease and contractures, did not consistently receive exercises for their upper and lower extremities. Despite being assessed and ordered a new wheelchair, the resident did not receive the necessary adjustments, leaving them immobile and dependent on staff assistance. The resident's restorative program was not adequately documented or modified to reflect their current status, leading to a decline in their functional abilities and quality of life. Resident 16, who had a stroke resulting in right-side weakness and a hand contracture, did not have a restorative program or a documented wearing schedule for their hand brace/splint. Observations showed the brace/splint was not consistently used, and staff were unaware of the proper schedule for its application. The resident's care plan did not address the decline in their functional abilities, and there was no documentation of a restorative program being implemented. Resident 23, admitted with dementia and muscle weakness, had not been assessed by therapy or placed on a restorative program since their admission. Despite requests from the resident's representative for therapy services, no action was taken. Similarly, Resident 17, who required an ankle-foot brace, did not consistently have the brace applied as per physician's orders. Staff were unaware of the correct process, and the brace was often found on the floor. The facility's failure to implement and monitor restorative programs and the use of braces/splints placed these residents at risk for further decline in their functional abilities and quality of life.
Failure in Enteral Feeding Administration and Documentation
Penalty
Summary
The facility failed to ensure appropriate administration and documentation of enteral feedings and fluid intake via gastrostomy tube (g-tube) for Resident 16. The resident, who had difficulty swallowing, malnutrition, and was unable to speak, received more than 51% of their nutritional needs via the g-tube. Staff N, an LPN, administered fluids and medications to Resident 16 but did not check residuals before flushing the g-tube or ask the resident about symptoms. Additionally, the documentation showed discrepancies in the amount of formula and free water administered, with Resident 16 receiving greater than one and a half times the amount of formula ordered on 27 out of 31 days and 370 ml less free water than required on all 31 days reviewed. Interviews with staff revealed a lack of awareness and adherence to physician orders and proper documentation procedures. Staff N admitted to forgetting to ask the resident about symptoms and was unaware of the need to clear the pump after each shift. The Registered Dietician (RD) and the Regional Director of Nursing Services (RDNS) both indicated that they expected orders to be entered and followed accurately, but were not aware of the inaccuracies in the g-tube orders and documentation. This failure in proper administration and documentation put Resident 16 at risk for dehydration, fluid overload, and weight fluctuations.
Medication Administration Errors
Penalty
Summary
The facility failed to ensure a medication error rate of less than five percent, resulting in an error rate of 28.57%. Eight medication errors were identified for three residents during 28 medication administration opportunities. For Resident 9, the LPN did not prime the insulin pen before administering insulin, despite the resident having a diagnosis of diabetes and requiring insulin based on a sliding scale. The LPN admitted to not priming the needle on this occasion. Similarly, for Resident 5, the LPN did not prime the insulin pen before administration and was unaware of the need to do so. Resident 5 also had a diagnosis of diabetes and required insulin administration based on a sliding scale and physician orders. For Resident 13, the Resident Care Manager administered multiple medications three hours past the scheduled time, acknowledging the delay due to being busy. The observations and interviews revealed that the staff did not follow proper procedures for insulin administration and medication timing. The Regional Director of Nursing Services stated that they expected the nurses to know how to administer insulin correctly and follow the medication pass times and physician orders. The failure to prime insulin pens and administer medications on time placed the residents at risk for side effects and/or reduced or increased medication effectiveness.
Failure to Verify Licensure and Provide Abuse Training
Penalty
Summary
The facility failed to implement two components of their abuse policy, specifically in verifying licensure and providing abuse training. Staff AA, a Nursing Assistant Registered (NAR), continued to work with an expired license for several days, providing care to vulnerable adults without the facility's knowledge. The Administrator and Housekeeping Supervisor/Scheduler were unaware of the expired license, and there was no process in place to ensure licenses were up to date. This lack of oversight allowed Staff AA to work unsupervised with an expired license, which was only discovered later, leading to their removal from the schedule. Additionally, the facility did not provide documented annual abuse and neglect training for five staff members (Staff O, T, U, R, and V). The Infection Preventionist/Staff Development acknowledged that while the required training was offered, there was no process to track or ensure completion, especially for part-time staff. The Regional Director of Nursing Services was also unaware of the inefficiency in tracking the training. This failure to provide necessary training placed residents at risk for unrecognized abuse and unmet care needs.
Failure to Complete Self-Administration Assessment for Resident
Penalty
Summary
The facility failed to ensure a clinically appropriate self-administration of medications assessment was completed by the interdisciplinary team for Resident 14, who was reviewed for safe self-administration of medications. Resident 14, diagnosed with Alzheimer's disease and dementia, was observed with medications left unattended at their bedside on multiple occasions. The resident was found with broken and melted pills, indicating improper medication management. Staff interviews revealed that medications were frequently left in Resident 14's room unattended, and the resident sometimes poured water on the medications or chopped them up, leading to the destruction of the medications and potential missed doses. Staff members, including nursing assistants and nurses, admitted to leaving medications in Resident 14's room, assuming the resident would take them at their own pace. However, there was no documentation of a self-administration assessment until it was brought to the facility's attention by the surveyor. The assessment, completed after the surveyor's intervention, deemed Resident 14 unsafe to self-administer medications. The facility's Regional Director of Nursing Services confirmed that an assessment for appropriateness and safety was part of the process for self-administration of medications and acknowledged that Resident 14 should not have been left with unattended medications.
Failure to Provide Appropriate Length Bed for Resident
Penalty
Summary
The facility failed to provide a comfortable and appropriate length bed for Resident 33, who was admitted with diagnoses including degeneration of the lower spine and left foot drop. The comprehensive assessment indicated that the resident's cognition was intact, required one staff member supervision for transferring, and was independent with bed mobility. Multiple observations showed Resident 33 lying in bed with both feet pushed up against the footboard, causing redness, softness, and wrinkling on the bottom of their left foot. Despite the resident's attempts to adjust their position, they continued to slide down, resulting in their feet pressing against the footboard. During an interview, Resident 33 expressed that the bed did not fit them properly due to their height of 70 inches. The facility's administrator stated that the beds were 80 inches long and suggested that the resident could elevate the bottom of the bed to prevent their feet from touching the footboard. However, the only footboard bed extender available was being used by the resident's roommate, and no immediate solution was provided. This failure to accommodate the resident's needs placed them at risk for discomfort and skin issues.
Failure to Provide Required ABN to Resident
Penalty
Summary
The facility failed to provide a Skilled Nursing Facility (SNF) Advance Beneficiary Notice (ABN) to Resident 149 when their Medicare Part A skilled nursing and rehabilitation services ended. Resident 149, who was admitted with an infection of the left lower leg and venous insufficiency, required limited assistance for activities of daily living and had intact cognition. The resident was not discharged as planned and remained in the facility beyond the last covered day for Medicare Part A without receiving the required ABN, which would have informed them of the potential financial liability for continued services. Interviews with facility staff, including the Business Office Manager, Administrator, and Regional Director of Nursing Services, confirmed that Resident 149 should have received an ABN when their Medicare Part A benefits ended. The staff acknowledged that there were issues with the process of issuing beneficiary notices at the time, leading to the failure to provide the necessary notification to Resident 149. This oversight prevented the resident from making informed financial and care decisions regarding their continued stay in the facility.
Failure to Maintain Homelike Environment and Address Noisy Beds
Penalty
Summary
The facility failed to ensure a quiet, comfortable, and homelike environment for several resident rooms and residents. Observations revealed that multiple rooms had significant physical damage, including scraped paint and missing drywall. Specifically, Room 7 had areas greater than 24 inches by 4 inches and 36 inches by 4 inches with scraped paint and missing drywall. Room 5 had an area greater than 48 inches by 18 inches with similar damage. Room 4 had multiple areas of missing drywall, including a softball-sized hole and other areas with significant damage. Additionally, nutritional supplies were improperly stored in cardboard boxes on the floor in Room 3, posing a risk to residents' safety and cleanliness. Residents 25 and 33 reported that their beds were excessively noisy, which disturbed their sleep and that of their roommates. The noise was confirmed by the surveyor and staff, with the Maintenance Director acknowledging the issue but stating that no alternative beds were available. The Administrator also acknowledged the problem but indicated that there was no current plan for room repairs or bed replacements.
Failure to Resolve Grievance for Missing Hearing Aid
Penalty
Summary
The facility failed to ensure prompt efforts were made to resolve a grievance involving a missing hearing aid for Resident 23. The resident, who was admitted with a diagnosis of dementia and had severely impaired cognition, required extensive assistance for activities of daily living. Despite the facility's policy stating that grievances should be resolved immediately and documented, there was no record of a grievance being logged for the missing hearing aid. The resident's representative reported the missing hearing aid to the Activities Director, who did not fill out a grievance form, assuming someone else had done so. Consequently, the Administrator, who was aware of the missing hearing aid, also failed to follow the grievance procedure, resulting in no tracking or resolution of the issue. Interviews with the resident's representative and staff members revealed that the normal process for handling grievances was not followed. The Activities Director admitted to not filling out the grievance form, and the Administrator acknowledged the failure to adhere to the grievance procedure. This lack of action disallowed the resident their right to a timely grievance resolution and placed them at risk for hearing difficulties and financial concerns due to the unresolved issue of the missing hearing aid.
Failure to Provide Bed Hold Notice at Time of Hospital Transfer
Penalty
Summary
The facility failed to provide a written notice to the resident and/or resident's representative of the facility policy for bed hold at the time of transfer to the hospital. This deficiency was identified for one resident who was reviewed for hospitalization. The facility's policy, dated 10/2018, required that residents and/or their representatives be given a bed hold notice at the time of transfer to the hospital or social leave, along with information on the appeal process if denied readmission. However, this policy was not followed in the case of Resident 9, who was transferred to the hospital on 01/30/2024 without receiving the required bed hold notice. Resident 9, who had a diagnosis of chronic kidney disease and required extensive assistance for activities of daily living, was admitted to the facility on an unspecified date. The comprehensive assessment on 02/04/2024 showed the resident had intact cognition. Despite the facility's policy, there was no documentation indicating that a Bed Hold/Notice of Transfer/Discharge was provided to the resident at the time of transfer. Interviews with the Business Office Manager and the Administrator confirmed that the correct process was not being followed, as the bed hold notice was typically offered a day or two after the transfer, rather than at the time of transfer as required by the policy.
Failure to Accurately Complete PASARR for Resident
Penalty
Summary
The facility failed to ensure that the Pre-Admissions Screening and Resident Review (PASARR) was accurately completed upon or prior to admission for one of the six residents reviewed. Specifically, Resident 33, who was admitted with diagnoses of depression and insomnia, had a PASARR dated 02/09/2024 that did not identify these conditions. This oversight placed the resident at risk of inappropriate placement and not receiving timely and necessary services to meet their mental health and developmental disability care needs. Interviews with staff revealed that the Social Services Director (SSD) was responsible for reviewing and correcting PASARRs on admission. However, in the absence of the SSD, the nursing department was expected to take on this responsibility. Despite these protocols, the PASARR for Resident 33 was not corrected to reflect the resident's diagnoses of depression and insomnia, as evidenced by the resident's medical record and medication administration record showing treatment for these conditions.
Failure to Provide Meal Assistance in Resident's Room
Penalty
Summary
The facility failed to provide necessary assistance with meals to a resident diagnosed with contractures and Parkinson's disease, who required help due to tremors and limited use of their right hand. Despite the resident's preference to eat in their room for comfort and dignity, staff insisted that assistance was only available in the dining room. This led to the resident struggling to eat independently, often dropping food and experiencing frustration and embarrassment during meals. The resident's medical record indicated they needed one staff member's assistance for meal setup or cleanup, and their diet slip specified bite-sized pieces and finger foods. However, observations showed the resident receiving meals that were not appropriately prepared, such as large pieces of roast beef and a casserole that was difficult to cut. Staff interviews revealed a consistent policy of requiring residents to go to the dining room for assistance, citing staffing limitations as the reason for not providing one-on-one help in the resident's room. The resident's representative and the resident themselves expressed concerns about the lack of assistance and the resident's preference to eat in their room. Despite these concerns, staff maintained that assistance was only available in the dining room, leading to the resident's continued struggle with meals. The facility's administrator acknowledged the staffing challenges but did not provide a solution for residents who preferred or needed to eat in their rooms. The Regional Director of Nursing Services stated that residents should be allowed to eat in their rooms with one-on-one assistance, contradicting the facility's practice.
Failure to Follow Physician Orders for Bowel and Pain Management
Penalty
Summary
The facility failed to follow physician orders for bowel and pain management for Resident 25, who was admitted with diagnoses including constipation, a right hip fracture, and a right displaced collar bone fracture. The resident's comprehensive assessment indicated they were dependent on two staff members for bed mobility, transfers, and toileting, and were receiving opioids, which contributed to their constipation. Despite having a bowel management program in place, the facility did not consistently administer the prescribed medications or document their effectiveness. For example, the resident went multiple shifts without a bowel movement, and several steps in the bowel program were either not initiated or not documented properly, leading to ineffective management of the resident's constipation. Additionally, the facility did not adhere to physician orders for pain management. Resident 25 reported increased pain and confusion about their pain medication regimen, stating that their pain medication had been reduced without explanation. The Medication Administration Record (MAR) showed discrepancies in the administration of pain medication, with doses given that did not align with the resident's reported pain levels. Staff interviews revealed inconsistencies in following the prescribed pain management protocol, with some nurses administering medication based on the resident's request rather than the documented pain level. Interviews with staff indicated a lack of clear communication and documentation regarding the resident's bowel and pain management. Alerts in the medical record system were not consistently acted upon, and there was no facility policy for bowel protocols. The facility's failure to follow physician orders and properly document care placed Resident 25 at risk for unmet care needs and negative health outcomes.
Failure to Complete Pre/Post Dialysis Communication Forms and Vital Signs
Penalty
Summary
The facility failed to ensure that pre/post dialysis communication forms and vital signs were completed for a resident requiring dialysis services. The resident, diagnosed with end-stage renal disease, was scheduled for dialysis on Mondays, Wednesdays, and Fridays. However, the medical record showed inconsistent documentation of pre/post dialysis vital signs and a lack of dialysis communication forms for staff to review and monitor the resident's post-dialysis condition. Specifically, there were multiple missed opportunities to complete the communication forms in January, February, and March 2024. Interviews with the resident and staff revealed that vital signs were not consistently monitored after dialysis, and the communication forms were often not completed or returned. The Resident Care Manager acknowledged that vital signs were only being monitored before dialysis and that the communication forms were not being done. The Regional Director of Nursing Services admitted that the correct process was not being followed and that there was no good system in place to ensure compliance with the required procedures.
Failure to Provide Trauma-Informed Care
Penalty
Summary
The facility failed to ensure culturally competent, trauma-informed care for a resident with a history of trauma and loss. The resident, who had a history of depression and insomnia, was admitted with a comprehensive assessment indicating intact cognition and the need for assistance with mobility. Despite the resident's disclosure of past trauma related to their occupation as a firefighter and the loss of a significant other, the facility did not develop a care plan to address these issues. The resident expressed experiencing nightmares and flashbacks, and stated that talking about their trauma helps them cope, yet no care plan focus, goals, or interventions were implemented for trauma-informed care. Interviews with staff revealed that the Social Services Director (SSD) responsible for the resident's assessment had left the facility, and the new SSD had not assessed the resident for trauma. The facility's policy required screening for trauma on admission and the development of a care plan, but this was not followed. The Administrator acknowledged that the new SSD was still in training and could not explain why the former SSD did not create a care plan for the resident's trauma. This oversight put the resident at risk for re-traumatization and a decline in psychosocial well-being.
Failure to Serve Bedtime Snacks
Penalty
Summary
The facility failed to serve a nourishing snack at bedtime for three residents, placing them at risk for hunger, weight loss, and unmet nutritional needs. Resident 1, who required moderate to maximum assistance for activities of daily living (ADLs) and had moderately impaired cognition, reported that they had to ask for a snack, and it depended on which staff was working. Resident 4, who had cerebral palsy and type II diabetes mellitus, required substantial to dependent assistance for ADLs and had intact cognition, stated that they would love a snack before going to sleep but did not always receive one. Resident 17, who had type II diabetes mellitus, kidney disease, and heart disease, required maximum to dependent assistance for ADLs and had intact cognition, also reported not receiving a snack at bedtime consistently and often had to ask for one. Staff interviews revealed that snacks were available but not routinely offered to residents. The Registered Dietician stated that diabetic-friendly snacks were served in the evening, but residents had to ask for them. The Regional Director of Nursing Services was unsure if snacks were being served in the evening, and the Administrator confirmed that staff were not serving snacks at bedtime unless residents asked for them. Review of the Diabetic Administration Records for Residents 4 and 17 showed that they were offered snacks on most days but not consistently every day. The meal service times had been changed, resulting in a greater than 14-hour gap between the evening meal and breakfast, which went unnoticed by the staff.
Improper Disposal of Trash
Penalty
Summary
The facility failed to ensure the proper disposal of trash for the dumpster reviewed for outdoor refuse storage. Observations over several days showed the dumpster with both lids open and unsecured trash bags, including a mattress, which were not contained properly. Interviews with the Maintenance Director, Administrator, and Regional Director of Nursing Services revealed a lack of awareness regarding the requirement to keep the dumpster lids closed, contributing to the unsanitary conditions observed.
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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